Foot injuries

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SORE FEET
Dr Dane Horsfall

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Overview
 Common fractures
 Midfoot
 Calcaneus
 5Th Metatarsal
 Cases
 Easily missed injuries
 Classification

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Case: 19yoM with painful R foot
 Waterskiing accident - 3/7 ago - fell at high speed, pain since in
R midfoot and unable to wt bear

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Diagnosis
 Widened gap at base of
1st/2nd Metatarsals with
avulsion # of Lisfranc
Ligament
 Other Ix ?
 Mitch Clark

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CT

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Progress
 Mx Backslab, elevate-high
risk compartment Sx
 Ortho ref - seen in rooms
2/7 later
 Admitted 11/7 later for ORIF
2x screws inserted, 6/52
non wt bearing in backslab

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LisFranc
 Jacques Lisfranc de St Martin 1790-1847 French
Surgeon/Gynae described injury 1815 after War of
the 6th Coalition-falls from horses
 The Lisfranc joint 5 tarso-metatarsal joints.
 The Lisfranc ligament from medial cuneiform to
base 2nd MT
 LisFranc injuries
 Lig rupture
 Lig Avulsion
 Subluxation/Dislocation-assoc # MT
 up to 20% are Lisfranc joint injuries missed

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Diagnosis
 Mechanism-rotation, twisting, fall off
horse, severe axial load- MCA, fall
 Point tenderness over midfoot
 Plantar ecchymosis sign
 Wt bearing xrays

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Types
 LisFranc -Ligament rupture +/- Avulsion +/- #’s

12. + Xray Gap >1mm btw bases 1st/2nd MT MT

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Calcaneal Fractures
 Fall from height onto heels-axial
load
 Associated injuries
 other calcaneal #
 spinal wedge #
 pelvis

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Bohler’s Angle
 Intersection of 2 lines
 Line from post articular
surface calcaneus to
anterior articular process of
calc
 Post art process to sup
angle of calc tuberosity
 Normal 20-40° Abnormal
if < 20°

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Calcaneal #
 Image with CT-often worse #
than appears on plain films-ref
all to ortho
 Calcaneal # without extension
into subtalat jt and minimal
displacement-can consider
conservative Mx-watch for
achilles tendon causing further
displacement of #
 If significant displacement
and/or involvement Subtalar
joint=ORIF

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Horizontal #
 2 types
 Most common-post sup angle of calc
without achilles tendon insertion
involvement “beak” # – from direct
trauma eg kick
 Avuslion # of achilles tendon from
sudden calf muscle contraction
 Thompson Test
 http://www.youtube.com/watch?v=AmDi08rlR3I
 Mx Ortho ref - ORIF

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# Base 5th MT
Jones or not?
 Jones fracture = transverse # of
proximal diaphysis of 5th MT, 10-
20mm from the proximal end. Sir
Robert Jones 1902 while dancing
 “Pseudo Jones” = Avulsion # of the
tuberosity of the base of 5th MT
 Most common lower limb #
 From forceful inversion (“sprained
ankle”)-Peroneus Brevis
 “sprained ankle” palp base 5th MT-
Ottawa foot rules

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Golden Rule:
 If fracture enters or distal to
the intermetatarsal joint =
Jones fracture
 If it enters cubo-metatarsal
joint = Pseudo Jones/Avulsion

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Why differentiate?
 Jones
 high non-union rate Rx due to poor
blood supply and tension from
tendons
 Rx - non wt bearing cast 6/52
 Pseudo Jones
 Cast shoe/CAM walker 4/52

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Jones or Pseudo? 19yo Basketballer –Inversion injury

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Jones or Pseudo?

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Jones or Pseudo? 39yoM fell off chair

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References
 Emedicine -Lisfranc
 Tintinalli et al, Emergency Medicine
 Max Esser and his book-Practical Fracture Management, R
McRae, Max Esser
 Wheeless Textbook of Orthopaedics online