Fracture and Dislocation of Foot

Fractures and Dislocations of the Foot

G. Andrew Murphy Chapter 86

Fractures of the calcaneus .. 4833Mechanism ............................... 4833Radiographic evaluation .......... 4835Classifi cation ............................. 4835Treatment ................................. 4836Decision making in calcaneal

fractures .................................... 4838Open reduction techniques ................ 4839Tongue fracture of the calcaneus ......... 4846Complications and prevention ........... 4847Results ........................................ 4848Late complications .......................... 4848

Talar fractures ....................... 4851Anatomy ................................... 4851Talar head fractures .................. 4853Treatment ..................................... 4853Talar neck fractures .................. 4854Treatment ..................................... 4855Osteonecrosis of the talar body after

talar neck fracture ....................... 4858Talar body fractures ................. 4861

Fractures of the lateral, posterior, or medial process of the talus ............................ 4863

Lateral process fractures ................... 4863Posterior process fractures .................. 4864Medial process fractures .................... 4864Transchondral fractures of the

talus ....................................... 4866

Subtalar dislocations ............ 4867

Midfoot fractures and dislocations ......................... 4870

Fracture-dislocations of the tarsometatarsal articulation (Lisfranc joint) ...................... 4871

Classifi cation ................................. 4873Evaluation and treatment ................. 4873

Metatarsals .............................. 4877Fracture of the proximal

portion of the fi fth metatarsal .............................. 4877

Distal fi fth metatarsal fracture .................................. 4884

Stress fracture of the metatarsals ............................. 4885

Complications ................................ 4885Acute fractures of the central

metatarsals ............................. 4885

Phalangeal dislocations ........ 4887Interphalangeal joint of the

hallux .................................... 4887First metatarsophalangeal

joint ....................................... 4888

Phalangeal fractures ............. 4889

Sesamoid fractures ................ 4890Treatment ................................. 4891Osteochondritis of the

sesamoid ................................ 4892Other conditions of the

sesamoid ................................ 4892

4833

FRACTURES OF THE CALCANEUS

Studies in fracture patterns, soft-tissue management, and outcomes of calcaneal fractures have given a clear under-standing of which injuries are likely to benefi t from early surgical intervention and which are likely to have high rates of complications and poor outcomes. Regardless of the treatment, calcaneal fractures are associated with numerous complications and poor outcomes with signifi -cant long-term quality-of-life issues. van Tetering and Buckley evaluated patients with calcaneal fractures using a validated Short-Form 35 Health Status Survey and com-pared them with normal individuals. They also evaluated the outcomes of calcaneal fractures compared with other orthopaedic injuries and other health issues. van Tetering and Buckley concluded that outcomes in patients with

calcaneal fractures were not as good as outcomes in patients with other orthopaedic conditions and were signifi cantly worse than in patients with other major health issues, including organ transplants and myocardial infarctions.

Mechanism

Calcaneal fractures can be extraarticular (not involving the subtalar joint) or intraarticular (involving the subtalar joint). Extraarticular fractures involving the body, anterior process, or tuberosity should be treated with cast or brace immobilization and non–weight bearing for the fi rst 6 weeks. An exception is the displaced tuberosity avulsion fracture, which serves as the attachment of the Achilles tendon (Fig. 86-1). Open reduction and internal fi xation of this fragment with a large, partially threaded cancellous

Ch086-A03329.indd 4833Ch086-A03329.indd 4833 9/6/2007 10:31:32 AM9/6/2007 10:31:32 AM

4834 Part XIX • The Foot and Ankle

BA

Fig. 86-1 A, Beak fracture does not involve Achilles tendon and can be treated nonoperatively if less than 1 cm of dis-placement is present. B, Avulsion fracture involves insertion of Achilles tendon. Open reduction and internal fi xation are recommended. (From Lowery RBW, Calhoun JH: Fractures of the calcaneus, II: treatment, Foot Ankle 17:360, 1996.)

BA

Dorsal view Plantar view

5

4

2

3

1

1

2

Fig. 86-2 Dorsal and plantar views illustrating common fracture lines in intraarticular fractures of calcaneus. A, Dorsal view: 1, sagittal fracture through posterior facet; 2, lateral wall fracture; 3, fracture line separating remainder of calcaneus from sustentaculum fragment; 4, transverse frac-ture through sinus tarsi; 5, fracture extending into calcaneo-cuboid joint. B, Plantar view: 1, medial wall fracture in which tuberosity fragment shifts distally and laterally with medial overlap; 2, tuberosity fragment has variable fracture line or lines.

Fig. 86-3 Primary fracture line occurs as result of shear force. (From Lowery RBW, Calhoun JH: Fractures of the cal-caneus, I: anatomy, injury, mechanism, and classifi cation, Foot Ankle 17:230, 1996.)

screw is advised to restore the power of the Achilles tendon and prevent a wide heel with the ensuing diffi culties of shoe fi tting. Another extraarticular fracture that may need early intervention is avulsion of the anterior process of the calcaneus by the bifurcate ligament. Minimally displaced fractures of the anterior process are easily missed and should be suspected in a patient who does not recover appropri-ately from a lateral ankle sprain. If the fragment is small or diagnosis is delayed, this fragment can be simply excised.

Intraarticular fractures account for approximately 75% of calcaneal fractures and historically have been associated with poor functional outcome. These fractures are uni-formly caused by an axial load mechanism, such as a fall or a motor vehicle accident, and may be associated with other axial load injuries, such as lumbar, pelvic, and tibial plateau fractures. Cadaver studies, anatomical dissections, and the use of CT have allowed a detailed description of the mechanism of injury and the resulting fracture patterns (Fig. 86-2). The contact point of the calcaneus is situated lateral to the weight bearing axis of the lower extremity. As an axial load force is applied to the posterior facet of the calcaneus through the talus, shear forces are directed through the posterior facet toward the medial wall of the calcaneus (Fig. 86-3). The ensuing fracture (primary frac-ture line) is almost always present and extends from the proximal, medial aspect of the calcaneal tuberosity, through the anterolateral wall, usually in the vicinity of the crucial angle of Gissane. The most variable aspect of this fracture line is its position through the posterior facet of the calca-neus; it can be located in the medial third near the susten-taculum tali, the central third, or the lateral third near the lateral wall.

As the axial force continues, two things happen: the medial spike attached to the sustentaculum is pushed farther toward the medial heel skin, and various secondary fracture lines occur in the region of the posterior facet. Often an anterior fracture extends toward the anterior process and may exit into the calcaneocuboid joint. The additional


Chapter 86 • Fractures and Dislocations of the Foot 4835

CBA

FED

Fig. 86-4 A-F, Essex-Lopresti classifi cation of fractures of calcaneus (see text). (Redrawn from Essex-Lopresti P: The mechanism, reduction technique, and results in fractures of the os calcis, Br J Surg 39:395, 1952.)

25° to 40°

A

B

Fig. 86-5 Böhler angle (see text).

fractures of the posterior facet can be divided into two types, as described by Essex-Lopresti (Fig. 86-4). If the fracture line producing the posterior facet fragment exits behind the posterior facet and anterior to the attachment of the Achilles tendon, the injury is called a joint depression type (see Fig. 86-4B). If it exits distal to the Achilles tendon insertion, it is called a tongue type (see Fig. 86-4C).

As the talus pushes the posterior facet and the underly-ing thalamic fragment into the body of the calcaneus, it also pushes out the lateral wall, closing down the space for the peroneal tendons and occasionally abutting the fi bula. As the force is removed, recoil of the talus occurs, leaving a depressed, thalamic fragment, and the medial spike is retracted into the soft tissues. For this reason, medially open fractures of the calcaneus require deep dissection to expose and irrigate the medial spike thoroughly. Simply excising the skin wound in this injury results in inadequate débridement.

Radiographic Evaluation

Radiographic evaluation of the fracture should include fi ve views. A lateral radiograph is used to assess height loss (loss of Böhler angle) (Fig. 86-5) and rotation of the posterior facet. The axial (or Harris) view is made to assess varus position of the tuberosity and width of the heel. Anteroposterior and oblique views of the foot are made to assess the anterior process and calcaneocuboid involvement. A single Brodén view, obtained by internally rotating the leg 40 degrees with the ankle in neutral, then angling the beam 10 to 15 degrees cephalad, is made to evaluate con-gruency of the posterior facet (Fig. 86-6). For surgeons experienced in the care of these fractures, three radiographs may be suffi cient, but most often CT scans are obtained to evaluate the injury completely. The scans should be ordered

in two planes—the semicoronal plane, oriented perpen-dicular to the normal position of the posterior facet of the calcaneus, and the axial plane, oriented parallel to the sole of the foot (Fig. 86-7).

Classifi cation

With increasing use of CT, more complex classifi cation systems have been developed for these fractures that have been shown to have prognostic value in the treatment of these injuries. Although the Essex-Lopresti system has been used for many years and is useful in describing the location of the secondary fracture line, it does not describe the overall energy absorbed by the posterior facet, shown by comminution or displaced fragments (see Fig. 86-4). Classifi cation systems by Crosby and Fitzgibbons and Sanders have become more widely accepted in evaluation of these fractures (Fig. 86-8). Both classifi cations are based on CT scans and describe comminution and displacement of the posterior facet. The advantage of the Sanders classi-fi cation is its precision regarding the location and number of fracture lines through the posterior facet. Both systems lack descriptions of other important aspects of these frac-tures, however, including heel height and width, varus-valgus alignment, and calcaneocuboid involvement.

Although CT scans have become valuable in the evalu-ation and classifi cation of these fractures, correlation with plain radiographs is mandatory. Ebraheim et al. showed that a CT scan may underestimate sagittal plane rotation



X-ray

10°20°

40°

30°

Fig. 86-6 Brodén view. Three internal rotation views taken in 45 degrees of internal rotation with 10 to 40 degrees of radiographic tube angulation. External rotation view is taken at 45 degrees of external rotation and 30 degrees of radiographic tube angulation. (From Lowery RBW, Calhoun JH: Fractures of the calcaneus, I: anatomy, injury, mecha-nism, and classifi cation, Foot Ankle 17:230, 1996.)

Fig. 86-7 Patient positioning for coronal CT of hindfoot. (Redrawn from Martinez S, Herzenberg JE, Apple JS: Computed tomography of the hindfoot, Orthop Clin North Am 16:481, 1985.)

of the depressed fragment. For this reason, plain lateral radiographs must be used to scrutinize the displacement seen on a CT scan.

Treatment

Closed treatment of intraarticular calcaneal fractures includes closed manipulation and casting, compression dressing and early mobilization, traction-fi xation, manipu-lation as recommended by Böhler, and pin fi xation as rec-ommended by Essex-Lopresti. Closed treatment methods have been successful in some studies. Omoto et al. reported 102 intraarticular calcaneal fractures treated with his closed manipulation technique with long-term follow-up (>7

years average). Satisfactory reductions were obtained in 92 cases, with the remaining 10 requiring open techniques. Aitken reported 75% return to employment using methods similar to those described by Böhler.

Kundel, Brutscher, and Bickel compared the results of 30 patients treated operatively with 33 patients treated nonoperatively. Age, associated trauma, calcaneocuboid joint involvement, Böhler angle (postinjury), workers’ compensation status, percentage of joint depression, and tongue type were compared. The authors specifi cally excluded patients with comminuted fractures. They found that the only statistically signifi cant advantage of operative over nonoperative treatment was the ability of patients to return to their previous occupation. Kundel et al. also noted that patients who had near-anatomical reductions with normal restoration of Böhler angle did better than patients who did not have anatomical reductions, and they concluded that open reduction and internal fi xation of intraarticular calcaneal fractures can be expected to benefi t only patients with near-anatomical reconstruction.

Crosby and Fitzgibbons compared 23 type II intraartic-ular calcaneal fractures treated with open reduction and internal fi xation with 10 type II fractures treated with closed methods. The fractures treated with open reduction and internal fi xation had superior results to the fractures treated by closed means. Thordarson and Krieger had similar results in a small prospective, randomized series with follow-up of only 17 months for operatively treated fractures and 14 months for nonoperatively treated frac-tures. Results were statistically better after open reduction and internal fi xation through the extensile lateral approach than after nonoperative treatment. Essex-Lopresti recom-mended treatment on the basis of displacement and type of fracture as follows: (1) conservative treatment for nondis-placed or minimally displaced fractures with early range of motion, (2) axial fi xation with a metallic pin for tongue-



Type I

Type IV

Type IIA Type IIB Type IIC

Type IIIA Type IIIB Type IIIC

Fig. 86-8 CT classifi cation of intraarticular calcaneal fractures. (From Sanders R, Fortin P, DiPasquale T, et al: Operative treatment in 120 displaced intraarticular calcaneal fractures: results using a prognostic computed tomography scan classifi cation, Clin Orthop Relat Res 290:87, 1993.)

type fractures, and (3) open reduction and internal fi xation for joint depression fractures.

In 2002, Buckley et al. reported the fi rst of a series of articles published in various journals reporting the results of a large, multicenter (four trauma centers) prospective,

randomized, controlled study. Patients with intraarticular calcaneal fractures with more than 2 mm of displacement were randomly assigned to an operative or nonoperative protocol. Nonoperative treatment involved no attempt at reduction, and operative treatment was a standardized



extensile lateral approach (described later in this chapter) and internal fi xation. The fi ndings of this study and others are summarized as follows:

1. As a group, without stratifi cation into various demo-graphic classes, the outcomes after nonoperative treat-ment were not different from the outcomes after operative treatment.

2. Workers’ compensation patients fared more poorly than non–workers’ compensation patients.

3. After excluding the workers’ compensation group, patients with operatively managed displaced intraarticu-lar calcaneal fractures had signifi cantly improved scores over patients with nonoperatively treated fractures.

4. Women had signifi cantly improved scores with opera-tive treatment compared with nonoperative treatment.

5. Subsequent need for hindfoot arthrodesis was more likely in workers’ compensation patients, patients with fractures initially treated nonoperatively, patients with an initial Böhler angle of less than 0 degrees, and patients with Sanders type IV fractures.

6. Complication rates were signifi cantly higher in patients treated operatively (25%) compared with patients treated nonoperatively (18%).

7. Regarding gait satisfaction, younger self-employed patients had improved gait satisfaction. As a group, gait satisfaction was equivalent between operative and non-operative patients.

8. Bilateral fractures were noted to be more depressed (displaced) than unilateral fractures; nonoperatively managed bilateral fractures were more likely to require subsequent arthrodesis; outcomes of operatively and nonoperatively treated bilateral fractures were equivalent.

9. Compared with unilateral fractures, patients with bilat-eral fractures showed overall less subtalar motion on fi nal follow-up.

Although the debate over open or closed treatment of calcaneal fractures may continue for some time, most authors agree that the inability to obtain surgically and maintain an anatomical reduction of the posterior facet is probably associated with a worse outcome than closed non-operative treatment. Open reduction can be obtained through a medial approach (McReynolds, Burdeaux), com-bined medial and lateral approach (Stephenson, Romash), or a lateral approach alone (Benirschke and Sangeorzan, Sanders et al.). Also, several authors have reported success after open reduction followed by immediate arthrodesis.

Decision Making in Calcaneal FracturesGoals common to all types of treatment of calcaneal frac-tures are as follows: (1) restoration of congruency of the posterior facet of the subtalar joint, (2) restoration of the height of the calcaneus (Böhler angle), (3) reduction of the width of the calcaneus, (4) decompression of the sub-

fi bular space available for the peroneal tendons, (5) realign-ment of the tuberosity into a valgus position, and (6) reduction of the calcaneocuboid joint if fractured. Factors to be considered in formulating a treatment plan are as follows.

Age of the Patient Most injuries occur in patients younger than the physiological age of 50 to 55 years. Older patients generally should have closed treatment. Herscovici et al. reported the outcomes of 42 patients who were 65 years old or older and had surgery for calcaneal fractures. They obtained satisfactory results in these patients at a minimum of 2-year follow-up. They reported 12 minor complications and four major complications in the 30 patients available for follow-up.

Health Status An insensate limb caused by either trauma (sciatic or tibial nerve disruption) or disease (diabetes or other neuropathy) is a strong relative contraindication to open treatment. Patients with limited ambulation as a result of other medical conditions likewise should be treated closed.

Fracture Pattern Sanders type I or nondisplaced fractures should be treated closed. Type II and type III fractures can be treated with open reduction. Type IV fractures can be treated either closed or, in experienced hands, with open reduction and immediate arthrodesis.

Soft-Tissue Injury (Open Calcaneal Fractures) As described earlier, fractures that are open medially require more aggressive débridement than simple opening of the wound to wash out the soft tissue. The medial spike should be exposed and débrided. It is better to wait 2 to 3 weeks until the wound is stable before internal fi xation is attempted. Open treatment should not be performed through tight, swollen soft tissues and not in the region of fracture blebs. The report by Levin and Nunley is an excel-lent guide to evaluation and management of more complex soft-tissue problems.

Basic open fracture care principles apply to calcaneal fractures. Most open injuries are caused by penetration of the sustentacular spike through the plantar medial aspect of the heel. These fractures must be treated aggressively with débridement and irrigation. Berry et al. reported that patients with severely comminuted fractures in plantar wounds faired more poorly than patients with minimally comminuted fractures. They reported a low incidence of infection with aggressive soft-tissue management and débridement. Although Aldridge et al. reported a modest complication rate for open calcaneal fractures (11% with Gustilo type II and type III open injuries), Heier et al. reported signifi cantly higher rates of complications, includ-ing osteomyelitis almost exclusively occurring in patients with Gustilo type IIIa or type IIIb open fractures. Their recommendation was to avoid aggressive open reduction



and internal fi xation initially in patients with Gustilo type III open injuries, focusing on aggressive soft-tissue coverage.

Surgeon’s Experience Sanders et al. confi rmed that the learning curve for this fracture is steep. With substantial literature supporting closed methods of treatment, a thor-ough knowledge of the anatomy and clearly defi ned goals are necessary for a successful outcome.

Open Reduction TechniquesThree techniques for operative treatment of calcaneal frac-tures are presented. They are based on substantial outcome studies, showing a satisfactory percentage of good results with reasonably low morbidity. For open reduction tech-niques, either patients are operated on within the fi rst 12 to 24 hours, or, more commonly, surgery is delayed 10 to 14 days to allow soft-tissue swelling to resolve enough for the skin to wrinkle. A bulky Jones dressing is applied. The foot is elevated, ice is applied, and a CT scan is obtained. In a controlled, randomized study, Thordarson et al. evalu-ated the use of a pneumatic intermittent compression foot pump to assist in edema resolution; 13 patients were ran-domly assigned to the foot pump group and 15 patients were assigned to the control group, which received a bulky Jones dressing and elevation. Patients were started on the foot pump no sooner than 24 hours after injury, with the average being 2.3 days. All 13 patients tolerated the foot pump satisfactorily. Statistically signifi cant edema resolu-tion was noted between the two groups at 24, 48, and 72 hours, and the time to surgery was shortened in the foot pump group. No signifi cant differences in wound compli-cations were noted between the two groups. The foot is checked before surgery to ensure that no fracture blebs are present, and that swelling has started to resolve. After 3 weeks, open reduction becomes more diffi cult, but it is possible up to 4 to 5 weeks.

The lateral extensile exposure technique has become very popular, especially among foot and ankle surgeons and traumatologists. Advantages include wide exposure to the subtalar joint allowing more accurate reduction of the facet fragments, ability to decompress the lateral wall, exposure of the calcaneocuboid joint, and suffi cient area laterally for plate fi xation. Disadvantages include inability to assess reduction of the medial wall directly and inability to restore height and length of the calcaneus accurately. More impor-tantly, more soft-tissue dissection and a higher incidence of wound problems and skin necrosis occur with this expo-sure. The latter problem can be decreased, as discussed in the complications section. Fundamentals for success with this approach include careful fl ap elevation, mobilization, and anatomical restoration of the posterior facet; adequate mobilization and reduction of the tuberosity fragment through the primary fracture line; and stabilization with plate and screws.

Multiple orthopaedic manufacturers now produce plates specifi cally for use in lateral exposure and open reduction and internal fi xation techniques. Plates allowing locking of the screws to the plate have become popular for this frac-ture. Theoretically, these plates have the advantage of locking the calcaneal fracture fragments to the plate by the use of these screws. The disadvantage of the plate is its increased thickness and the possibility of subsequent painful hardware, requiring hardware removal. Richter et al. com-pared different plates in an experimental calcaneal fracture model and found that plates that used locked screws pro-vided greater stability under cyclical loading. Thordarson and Latteier reported the use of a low-profi le titanium plate, however, which roughly outlines the shape of the calcaneus. In their clinical series of 42 fractures, there were no cases of hardware breakage, and no loss of reduction occurred. Except in extreme calcaneal fractures, the increased stability provided by locked screws does not warrant the increased thickness of the plate.

If a large defect remains after the procedure, which often is the case, most surgeons recommend the use of autogenous iliac crest bone graft; however, if internal fi xa-tion is secure, and the fracture is stable, the defect may be accepted. Longino and Buckley reported the use of bone graft in the operative treatment of calcaneal fractures and found no signifi cant difference in the maintenance of reduction or subsequent settling of the fracture between fi xation with or without bone graft. They concluded that there was no radiographic or functional benefi t to the use of bone graft. In a cadaver study, Thordarson et al. evalu-ated the use of calcium phosphate bone cement injected into the osseous defect and noted signifi cantly increased stability of the fracture. Thordarson and Bollinger also reported the use of cancellous bone cement augmentation in 15 patients. They had no evidence of soft-tissue reaction or loss of reduction of the fracture. Schildhauer et al. also reported earlier return to weight bearing by patients after using injectable bone cement postoperatively. They reported, however, an 11% infection rate, which they attributed to the skin incisions.

Open ReductionTECHNIQUE 86-1 Benirschke and Sangeorzan

• Administer preoperative antibiotics, and apply a tourniquet.

• Place the patient in a true lateral position, and use the lateral approach (Figs. 86-9 and 86-10).

• Incise the soft tissues sharply, and carry the incision down to the periosteum of the lateral wall (see Fig. 86-9A). The sural nerve may cross the incision at its proximal and its distal end, so take care to retract the nerve.

• Gently retract the fl ap while performing subperiosteal dissection along the lateral wall. Elevate the entire fl ap in one



A

E

D

C

B

3

1

2

Fig. 86-9 A, Lateral view of foot with sural nerve depicted. Solid red line indicates incision. B, Shanz pin placed into tuberosity fragment. Three arrows sequentially indicate relative motion of Shanz pin, with densest arrow indicating greatest displacement. Traction is placed on Shanz pin to bring tuberosity fragment out to length, translated medially, and into slight valgus posi-tion. C, Posterior facet is elevated into its native position. Lateral wall is reduced along outer part of posterior facet. Alignment of tuberosity is maintained by Kirschner wires directed into sustentaculum tali while reduction is completed. D, Lateral view of reduced calcaneus. E, Axial view of fracture reduction. (From Benirschke SK, Sangeorzan BJ: Extensive intraarticular fractures of the foot: surgical management of calcaneal fractures, Clin Orthop Relat Res 292:128, 1993.)

Open ReductionTECHNIQUE 86-1 Benirschke and Sangeorzan—cont’d

piece, and hold it out of the way with two Kirschner wires placed into the talus. The fl ap does not need to be touched again for the remainder of the procedure.

• Expose the entire lateral wall of the calcaneus distally to the calcaneocuboid joint.

• Carry the dissection above and below the peroneal tendons at the level of the calcaneocuboid joint if necessary. This extensile lateral approach exposes the lateral wall of the calcaneocuboid



C

B

A

Fig. 86-10 Reconstruction of calcaneal fracture through extensive lateral approach. A, Preoperative lateral, Brodén, and anteroposterior views showing calcaneocuboid involvement. B, Semicoronal CT scan showing dislocation of peroneal tendons with lateral wall abutment of fi bula, Sanders IIB confi guration, and involvement of calcaneocuboid joint. C, Lateral, Brodén, Harris, and anteroposterior foot views showing satisfactory postoperative reduction with use of compression plate.



eratively. If the fl ap shows uncomplicated healing, and the wound is sealed, early active range of motion is begun at that time. At the second postoperative week, active range of motion of the ankle and subtalar joint is instituted. Patients learn to draw the alphabet with the hallux of their injured limb or make progressively larger circles with their feet. No weight bearing is allowed for 12 weeks. Protection is provided by the use of a removable posterior splint. Weight bearing is instituted at 10 to 12 weeks, and hard-ware can be removed if symptomatic at 1 year.

Occasionally, type IV injuries with severe comminution and cartilage damage of the posterior facet of the calcaneus or posterior facet of the talus can benefi t from immediate arthrodesis after open reduction and internal fi xation of the calcaneal fracture. The advantage of immediate arthrodesis over initial nonoperative treatment followed by late subta-lar fusion includes the earlier return to full functional activities. Buch, Myerson, and Miller reviewed their expe-rience with primary subtalar arthrodesis in 14 patients. They found that all patients had healing of the arthrodesis site between 8 and 12 weeks. Of 12 patients who were employed before the injury, 11 returned to their original occupation at a mean time of 8.8 months after the injury. Minor wound complications occurred in three patients.

Pennal and Yadav reviewed the results in 52 patients treated with either open reduction and internal fi xation or subtalar fusion. They stated that anatomical reduction of the posterior subtalar joint was necessary, and that if this could not be accomplished by open reduction, a subtalar fusion was indicated. Excellent or very good results were achieved in 75% of the primary subtalar fusions and 50% of the secondary subtalar fusions. If the fragments were large, and an operative reduction was achieved, 92% of patients had excellent or very good results. Thompson reviewed 53 patients treated by primary triple arthrodesis and reported that 47 of 53 achieved excellent results. He stated that the talonavicular and calcaneocuboid joints should be included in the fusion because unrecognized damage to these joints is common.

Open ReductionTECHNIQUE 86-1 Benirschke and Sangeorzan—cont’d

joint and posterior facet. Reduction of the tuber-sustentacular fragment is done indirectly.

• When the exposure is completed, perform a stepwise reduction.

• When a fracture line separates the anterior process from the sustentacular fragment, reduce this part fi rst to allow better exposure of the relationship between the medial part containing the sustentacular fragment and the lateral part with the posterior facet and tuberosity (see Fig. 86-9B).

• Reduce the tuberosity to the sustentacular fragment, and perform a provisional fi xation using axially directed Kirschner wires introduced from the heel into the sustentacular fragment.

• With the bone now out to length from these two reduction maneuvers, turn attention to the depression of the posterior facet.

• Refl ect the lateral wall outward to allow an anatomical reduction of the posterior facet (see Fig. 86-9C). Hold this with provisional fi xation using Kirschner wires.

• Obtain intraoperative radiographs to assess overall reduction.

• A large defect often remains in the substance of the calcaneus beneath the reduced posterior facet. If good stability of the fracture and secure internal fi xation are obtained, this defect may be accepted, or bone graft or bone cement can be used to fi ll the void.

• Reduce the lateral wall along the outer edge of the posterior facet, and perform fi xation, which should take advantage of the known anatomy. The thickened bone in the thalamic portion, which supports the posterior facet, provides the most reliable fi xation in most instances.

• Insert small cortical lag screws (3.5 mm) into the sustentacular fragment to maintain the reduction of the posterior facet. Apply a lateral plate that extends from the anterior process of the calcaneus into the most posterior aspect of the tuberosity (see Fig. 86-9D and E). The plate helps to maintain a neutral alignment of the calcaneus. When contouring the plate, be careful not to fi x the heel in varus. Obtain an intraoperative axial view to confi rm neutral alignment before application of the plate. When possible, direct screws from the plate into the sustentacular fragment for maximal fi xation (see Fig. 86-9D and E). Place the most anterior screw into the subchondral bone supporting the calcaneocuboid articular surface. Place the most posterior screw into the thickened bone at the posterior aspect of the calcaneus. Contour the plate into a “frown” shape (concave plantarly), and fi ll the remaining holes.

• Close the fl ap over a deep drain. Apply a short leg splint.

AFTERTREATMENT Closed suction drainage is done for 24 to 48 hours until drainage is less than 25 mL per 8 hours. Remove the short leg splint at 3 to 5 days postop-

Subtalar ArthrodesisTECHNIQUE 86-2

• Carry out open reduction and internal fi xation of the calcaneus as described in the previous section.

• Major bone voids in the posterior side of the calcaneus may require tricortical iliac crest bone graft to restore the normal orientation and height of the calcaneus.

• After internal fi xation, use a burr to remove the cartilage and subchondral bone from the posterior facet of the calcaneus and posterior facet of the talus.

• Use extensive autogenous iliac crest bone graft to fi ll the defect.



• Denude the lateral aspect of the talus to obtain an intraarticular and an extraarticular arthrodesis.

• Fix the arthrodesis with a fully threaded, 6.5-mm cancellous screw.

AFTERTREATMENT The drain is removed on the fi rst postoperative day, and the sutures are removed at 2 to 3 weeks. A short leg cast is applied until evidence of union is apparent, generally between 10 and 12 weeks. A prefab-ricated walking brace is applied, and the patient is gradually allowed to return to full activities.

Combined medial and lateral approaches have been used at the Campbell Clinic for many years with satisfactory results. Advantages include accurate reduction of the sus-tentacular fragment to the medial wall and exposure of the subtalar joint laterally for accurate reduction; problems with wounds also are less likely with this approach. The lateral approach is familiar to most surgeons, and this method of open reduction may be technically easier for orthopaedists who treat only an occasional calcaneal frac-ture. The major disadvantage of this approach is that lateral wall decompression can be more diffi cult, and less space is available for fi xation of the tuberosity fragment to the sustentacular fragment. Also, this approach requires careful exposure and mobilization of the medial neurovascular bundle.

Open ReductionTECHNIQUE 86-3

• Two incisions, one medial and one lateral, are standard, although occasionally one incision may allow enough exposure to reduce the major fragments (Fig. 86-11A to C).

• Place a sandbag beneath the ipsilateral buttock, and apply a tourniquet. Place the patient in a mildly inclined Trendelenburg position, and rest the foot on towels or sheets, which at varying times in the procedure allow the foot to hang freely without support when the towels are moved proximal to the ankle joint.

• Have available a small screw set; a variety of sizes of threaded and nonthreaded pins; and small, malleable reconstruction plates or staples with which the surgeon is familiar.

• Make the lateral incision from the anterolateral corner of the calcaneocuboid joint posteriorly in almost a straight line with the foot held 90 degrees to the ankle and end it 1 to 2 cm anterior to the Achilles tendon.

• Identify the sural nerve in the posterior portion of the incision; it usually lies in a small amount of fat just anterior to the small saphenous vein and overlying the combined sheath of the peroneal tendons. Dissect it distally. It usually divides into medial and lateral branches over the cuboid, but may divide more

posteriorly, making the medial branch especially vulnerable. Try to preserve both main branches, but if exposure of the lateral aspect of the sinus tarsi and calcaneocuboid joint is incomplete, the medial branch, which usually joins with the lateralmost branch of the superfi cial peroneal nerve, can be sacrifi ced without causing signifi cant numbness at the fourth web.

• When the sural nerve and small saphenous vein are retracted, open the inferior peroneal retinaculum on its anterior border where it meets the stem of the inferior extensor retinaculum to expose the anterolateral ridge of the anterior third of the calcaneus, which is the most lateral border of the sinus tarsi.

• Refl ect the origin of the extensor digitorum brevis distally to expose the calcaneocuboid joint. Do not elevate the entire extensor digitorum brevis, but only as much as necessary to expose the calcaneocuboid joint. Leave intact the cervical ligament, and lift off the sinus tarsi only as much of the lateral arm of the inferior extensor retinaculum as is necessary to expose the anterior aspect of the posterior talocalcaneal facet.

• Expose the lateral wall of the calcaneus by sharp dissection or with a thin osteotome or periosteal elevator by fi rst dissecting plantarward beneath the inferior peroneal retinaculum. In other words, return to the initial incision at the junction of the inferior extensor and peroneal retinacula, and refl ect plantarward beneath the peroneus brevis and longus where the latter begins crossing deep to the former. This is the “door” to the anterior two thirds of the lateral surface of the calcaneus. Stay in this plane with the foot held in valgus and equinus. This should take the dissection beneath the lateral calcaneofi bular ligament if the foot is not dorsifl exed to bring this ligament to a more vertical posture. The lateral wall is thin and frequently comminuted. Dark blood (fracture hematoma) should lead into the fracture surfaces between the lateral wall and remaining portion of the calcaneus. Distally, the fracture may enter the calcaneocuboid joint.

• With the foot held in valgus and some degree of equinus, pull the lateral wall laterally with a small but stout toothed retractor.

• Dissect any remaining capsular or periosteal tissue sharply away from the talocalcaneal posterior articular facet.

• Suction or manually remove any further hematoma, and inspect the posterior facet. If inspection is diffi cult, place an Inge retractor into the depths of the sinus tarsi, pressing up on the neck of the talus and down on the sinus tarsi portion of the calcaneus to give a better view of the posterior facet. This is a pivotal point in the procedure, at which time it should be possible to form a good mental image of the fractures through the posterior facet (usually sagittal) and transversely across the junction of the posterior facet articular surface and the proximal border of the sinus tarsi. This latter fracture frequently communicates medially with the oblique fracture that splits off the large anteromedial sustentacular fragment.

• With depression of the posterior facet (in one or more fragments), assess the entire posterior facet (Fig. 86-11D). Reexamine the radiographs as necessary. The posterior facet may


I

H

G

FE

DC

BA

Fig. 86-11 A, Preoperative radiograph. Medial and lateral incisions were chosen in this patient because of his signifi -cant smoking history. B, Planned lateral incision. C, Medial incision. D, Depressed portion of posterior facet, lateral view. E, Anteromedial, sustentacular spike seen through medial wound. Neurovascular bundle is retracted anteriorly. F, Reduction and screw fi xa-tion of posterior facet from lateral side. G, Reduction and fi xation of primary fracture from medial side. H and I, Postoperative radiographs.



• Identify the medial calcaneal branch or branches of the posterior tibial nerve. Pass a Penrose drain around the bundle, and gently retract it anteriorly for further exposure of the posterior border of the bundle. Dissect this until it is lost beneath the abductor hallucis.

• Retract the posterior tibial neurovascular bundle anteriorly (usually one or more medial calcaneal branches must be retracted posteriorly), and expose the medial surface of the calcaneus by lifting the abductor hallucis and fl exor accessory muscles off the calcaneus with a periosteal elevator (Fig. 86-11E).

• Cauterize the medial calcaneal arterial branches.

• Palpate the sustentaculum tali of the calcaneus, and clear all soft tissues from the medial surface of the calcaneus from the sustentaculum to the medial ridge of the calcaneal tuberosity.

• The fracture lines delineating the anteromedial and tuberosity fragments should come into view.

• Pass an instrument or fi nger over the tuberosity fragment, and communicate with the lateral wound. Using an instrument or fi nger, pull down on the tuberosity fragment, disimpacting and dorsifl exing it while holding the ankle in equinus.

• Return to the medial wall of the calcaneus, and inspect the fracture lines again. The tuberosity fragment is displaced laterally and distally and must be pulled posteriorly and translated medially.

• Make a fi nal evaluation of the fracture patterns, and plan the fi xation.

• Through the lateral incision, lift the posterior facet into position and pin it to the sustentacular fragment with two 0.062-inch Kirschner wires. Place these wires just below the articular surface in subchondral bone for good purchase. Pass the wires to the medial side, directed distally about 10 to 20 degrees, and locate them by palpation. Withdraw the wires until they barely penetrate the medial cortex so that they can be used for measuring the length of the fi xation screws if passing a depth gauge is diffi cult.

• Through the medial incision, locate by palpation the fl exor hallucis longus beneath the sustentaculum tali. Starting 3 to 5 mm inferior (plantar) to this tendon, place two 0.062-inch Kirschner wires from anteromedial to posterolateral (usually the angle is about 30 degrees to the longitudinal axis of the calcaneus), holding the fragments reduced manually until the wires are palpated through the lateral incision. They can be used to measure the length of the fi xation screws if brought back to the cortical edge.

• Alternatively, while holding the medial wall reduced manually, direct one or two 3/32-inch pins from the posterolateral aspect of the posterior tuberosity just lateral to the Achilles tendon, and direct the pins upward and medially to engage the sustentacular fragment. This method makes subsequent removal of the pins easy.

Open ReductionTECHNIQUE 86-3—cont’d

be depressed into the cancellous bone of the calcaneus and tilted medially or laterally depending on the position of the foot at impact and the force of axial loading.

• Gently tap a 5- to 6-mm osteotome deep to the depressed fragment, and holding the foot in varus for better exposure, lift the posterior facet into its proper position. Ensure that a second sagittal fracture through the posterior facet medial to the fi rst fracture is not overlooked because, if present, both depressed fragments need elevation and fi xation. Reducing the posterior facet can leave a gap in the cancellous bone beneath the facet; bone grafting of the defect is optional.

• This concludes the initial step of the procedure. No fi xation is used until the medial incision and reduction are accomplished.

• Just posterior to the peroneal tendons, use blunt dissection to reach the superior aspect of the tuberosity of the calcaneus.

• Preserve the calcaneal branches of the sural nerve. A periosteal elevator or digital dissection allows an instrument or a fi nger to slide over the superior aspect of the tuberosity just posterior to the os trigonum of the talus. Later this portal across the tuberosity aids in reducing the tuber-joint angle.

• For the medial incision, tilt the operating table laterally, fl ex the knee, and abduct the hip. Dorsifl ex the foot to 90 degrees at the ankle joint.

• Palpate the most prominent portion of the subcutaneous edge of the tarsal navicular, and 1 cm anterior to this, begin an incision straight posteriorly that crosses the sustentaculum tali. If the sustentaculum cannot be palpated because of swelling, have the incision cross a point 2 cm distal to the subcutaneous tip of the medial malleolus. Continue the incision posteriorly to 1.5 to 2 cm anterior to the Achilles tendon.

• When beneath the dermis, use blunt dissection to identify and tie the communicating veins between the saphenous and plantar (posterior tibial) venous systems.

• Identify the anterior (distal) and posterior (proximal) borders of the fl exor retinaculum (laciniate ligament) that runs from the medial malleolus obliquely plantarward and posteriorly to the posterosuperior border of the calcaneus. The superfi cial fascia of the leg and foot is continuous with the fl exor retinaculum, and this too must be opened the entire length of the incision.

• Dissect the retinaculum anteriorly 1 cm and plantarward to the upper border of the abductor hallucis.

• Identify the neurovascular bundle at the posterior or proximal edge of the fl exor retinaculum. Bluntly delineate the posterior aspect of the bundle, ensuring that the lateral plantar artery, vein, and nerve are included in the dissection. Because the neurovascular bundle lies within the fourth compartment beneath the retinaculum, and the tibial nerve usually divides into its medial and lateral plantar branches beneath this ligament, the bundle should be located proximal to the fl exor retinaculum.



AFTERTREATMENT The extremity is elevated for 72 hours. At 3 weeks, the sutures are removed, and a new cast is applied; this cast is worn for 4 weeks. Non–weight bearing is continued until 8 weeks postoperatively, when a short leg walking cast is applied and is worn for 4 more weeks. We are not convinced that early subtalar joint motion results in any more motion at this joint 1 or 2 years after injury than is obtained by protecting the fracture until it is stable and ready to bear weight. A durable, short leg upright brace can be used for 6 to 9 months after pin removal.

Tongue Fracture of the CalcaneusAlthough the previously described technique works for joint depression and tongue-type fractures, occasionally a tongue-type fracture does not involve additional fracture lines, widening of the lateral wall, or signifi cant displace-ment at the primary fracture line. The tongue fracture in this case can be treated by the axial pin fi xation of Gissane, which was popularized by Essex-Lopresti, who achieved satisfactory results. Tornetta reported his results with this technique in 41 patients with successful outcomes.


• The anteromedial and tuberosity fragments and the posterior facet are reduced, and the tuber-joint angle should be within normal limits.

• Fixation may be with 3.5-mm cortical screws or 4-mm cancellous screws using the lag effect (Fig. 86-11F and G). A small plate or staple can be used, but this is diffi cult if the temporary fi xation pins have been placed too close together or are in the way of optimal plate or staple placement; keep this in mind when placing the wires. Staple fi xation of the medial wall is acceptable, but placing the prongs so that they do not enter the fracture lines and avoiding additional comminution while tapping the staple home can be diffi cult.

• Return to the lateral incision, and conclude the procedure by reducing any remaining fractures. Two or three fractures may need fi xation: the lateral wall, the waist (transverse) fracture at the junction of the middle and anterior thirds of the calcaneus (where the anterior border of the posterior facet meets the sinus tarsi portion of the calcaneus), and possibly a sagittal fracture into the calcaneocuboid joint.

• The lateral wall is paper thin and frequently comminuted. It must be held sometimes only by sutures, but usually a small fragment screw can be used after temporary fi xation has held it “reduced.” Lagging this fragment usually is not recommended because further comminution can result. A washer over the head of the screw sometimes is helpful. A small plate can be used, but this is time-consuming. The calcaneocuboid joint usually requires little manipulation, and a lag screw can effect reduction if the fracture has been cleared of hematoma.

• The fi xation of the posterior two thirds to the anterior third can be diffi cult. Following is one suggested means of fi xation. Reduction should have been obtained when the tuberosity fragment was brought up (extended) into its normal inclination. If not, slide a small elevator or Hohmann retractor under the distal fragment and lift; this usually brings the proximal fragment with it.

• Holding the fracture reduced, drive a 3/32-inch or 1/8-inch Steinmann pin through the depth of the fourth intermetatarsal space posteriorly and slightly medially across the calcaneocuboid joint and then across the fracture and into the tuberosity fragment.

• Cut the pin beneath the skin.

• Take axial and lateral radiographs (Fig. 86-11H and I), lavage the wounds, remove the tourniquet, and close the wounds. Skin staples have not worked as well in these wounds as they do in most areas. Use suction drains if hemostasis is not excellent.

• Wrap large, bulky, gauze dressings from the toes to the tibial tuberosity, and apply a short leg cast.

Axial FixationTECHNIQUE 86-4 Essex-Lopresti

• With the patient prone, make a small incision over the displaced tuberosity of the calcaneus just lateral to the attachment to the Achilles tendon.

• Introduce a heavy Steinmann pin or Gissane spike into the tongue fragment in a longitudinal direction, angling slightly to the lateral side. Use radiographic or image intensifi er control during the insertion of the pin and manipulation of the fracture (Fig. 86-12A).

• With the knee fl exed, reduce the fracture by lifting upward on the pin until the knee clears the table; hold the forefoot at the level of the midtarsal joints with the opposite hand, and avoid creating a cavus deformity by hyperfl exing the forefoot. By this maneuver, the tongue fragment is elevated from its depressed position in the body of the calcaneus.

• Reduce the spreading of the calcaneus by applying pressure on each side of the bone with the heels of the clasped hands. It is important to clear the inferior aspect of the lateral malleolus from contact with any bulging bone fragments that may encroach on the peroneal tendons and produce chronic tenosynovitis.

• Gently rock the calcaneus at this stage to settle the smaller fragments into position.

• Make fi nal radiographs to confi rm the position (Fig. 86-12B).

• Advance the pin or spike across the fracture into the anterior fragment of the calcaneus.



1. Wound problems, particularly with fractures of the cal-caneus, occur more frequently in active smokers. Patients should be advised not to smoke until the wound has healed and should be informed of the consequences of doing so before surgery is planned.

2. Carefully retracting the soft tissues and maintaining a full-thickness fl ap with the extensile approach are crucial.

3. Drains should be used under the lateral fl ap to prevent hematoma formation postoperatively.

4. Sutures should be left in place for 3 weeks, and motion exercises should be avoided during that time to lessen shear forces under the fl ap.

5. Perioperative antibiotics should be used routinely.

Loss of Reduction of Major Fragments Loss of reduction of major fragments can occur if weight bearing is initiated too early. Patients should be kept non–weight bearing for a minimum of 8 weeks to prevent this complication.

Malreduction Accurately restoring the proper valgus alignment of the tuberosity fragment is essential. The patient tolerates varus malrotation poorly. Intraoperative Harris radiographs should be obtained to avoid this complication.

Sural Nerve and Peroneal Tendon Injuries Sural nerve and peroneal tendon injuries are more common with the

DC

BA

Fig. 86-12 Essex-Lopresti reduction of frac-ture of calcaneus by manipulation and pin fi xation. A, Correct position of pin. B, Postoperative radiograph through cast. C and D, Result after 1 year. Patient returned to work as deckhand on barge.

AFTERTREATMENT The foot is carefully padded, and a slipper-type cast is applied, incorporating the protruding portion of the pin or spike. The patient is encouraged to perform supervised exercises of the toes and ankle regularly and, as soon as the pain subsides, subtalar movements. Ambulation without weight bearing is permitted as the swelling subsides. The initial cast and pin usually are removed at 4 to 6 weeks, and a cast is applied from the tibial tuberosity to the toes. If radiographs confi rm union and reconstitution of the depressed cancellous bone beneath the elevated articular surface, weight bearing can be started 8 to 10 weeks after reduction (Fig. 86-12C and D).

Complications and PreventionWound Necrosis, Dehiscence, and Infection Soft-tissue edema and contusion are inherent aspects of calcaneal frac-tures. Operating through such soft tissue entails a fair risk of marginal wound necrosis. Attinger and Cooper pub-lished a comprehensive review of soft-tissue reconstruction for calcaneal fractures when complications are encountered. Folk, Starr, and Early found that after a standard, extensile, L-shaped approach with two-layer fl ap closure, wound complications developed in 25% of patients with 21% requiring surgery for these complications. Using statistical analysis, they identifi ed diabetes, smoking, and open frac-ture as risk factors for wound complications. Although the incidence of mild wound problems is high, serious compli-cations can be minimized in several ways:



extensile approach. The sural nerve should be protected at the proximal and distal extremes of the wound. Peroneal tendons are particularly vulnerable because the fl ap is elevated over a protruding lateral wall, especially if the tendons are dislocated by the wall. Limited periosteal elevation and careful retraction should prevent this complication.

ResultsSignifi cant controversy remains over the results of nonop-erative versus operative treatment. Lack of standardization of results has made it diffi cult to compare studies that have evaluated outcomes. Studies by Day, Essex-Lopresti, Lindsay and Dewar, Lance et al., and Parkes support the principle that if nonoperative treatment is chosen, early mobilization improves long-term results. Although long-term studies by Pozo, Kirwan, and Jackson; Omoto et al.; and others have shown up to 76% good results with early mobilization of displaced intraarticular fractures, other, more recent studies have been considerably more pessimistic. Kitaoka et al. found fair and poor results in 17 of 27 fractures treated in this manner. Crosby and Fitzgibbons, using their classifi ca-tion based on CT scans, showed a worsening of results after closed treatment, with increasing comminution of the pos-terior facet. Twelve of 13 patients with a nondisplaced (type I) fracture achieved good or excellent results with closed treatment at an average follow-up of 3 years; however, unacceptably poor results were found in type II (displaced) and type III (comminuted) fractures treated with a variety of closed methods.

The results after operative treatment also vary, but most authors judge results by the quality of reduction of the posterior facet. Essex-Lopresti stated that 80% of patients younger than 50 years old who had “successful reduction” had satisfactory results. Follow-up studies of treatment using modern techniques are now available.

Burdeaux reported an 80.3% success rate using only an isolated medial approach for primary fracture alignment and stabilization and elevation of the depressed fragment at a mean follow-up of 4.4 years. Melcher et al. reported their results at 3 years and 10 years after extensile lateral approaches with lateral fi xation. At 10-year follow-up, 75% had good or excellent functional results. The subjective results were clearly better at 10-year than 3-year follow-up.

Stephenson, using the combined medial and lateral approach, reported 77% good results at an average follow-up of 3 years. At average follow-up of 10 years, Melcher et al. reported 75% good or excellent results using a lateral approach and plate fi xation. Using postoperative CT scans to evaluate the accuracy of fracture reduction, Hutchinson and Huebner found satisfactory results in 76% and unsatis-factory results in 24%. Unsatisfactory results were corre-lated with failure to obtain or maintain a satisfactory reduction and with workers’ compensation status.

Sanders, using his classifi cation described earlier, reported 120 surgically treated fractures of the calcaneus with a minimum of 1 year of follow-up (average 29 months). In type II fractures, 86% had anatomical reduc-tion of the articular surface on follow-up CT scan. Clinical outcome was good or excellent in 73%, fair in 10%, and poor in 17%. In type III fractures, only 60% had an ana-tomical reduction. Outcome was good or excellent in 70%, fair in 10%, and poor in 20%. For type IV (severely com-minuted) fractures, failure occurred in 73%. A steep learn-ing curve was shown, with signifi cantly greater percentages of good and excellent results in the later years of the study. Using Sanders’ classifi cation, Thordarson and Krieger reported a prospective, randomized study of operative versus nonoperative treatment of type II and type III frac-tures with an average follow-up of 17 months and noted that operative treatment with early mobilization produced superior results compared with nonoperative treatment.

Most authors reported that regardless of the type of treatment, symptoms should improve for at least 2 years and possibly 6 years. Although anatomical reduction of the posterior facet is correlated with better functional out-comes, eventually enough pain develops in some patients to warrant subtalar arthrodesis.

Late ComplicationsRegardless of treatment method, chronic pain develops in some patients, limiting their capacity to work and enjoy life. Late problems leading to a painful outcome include posttraumatic arthrosis of the subtalar joint, lateral subfi bu-lar impingement with or without problems in the peroneal tendon, anterior ankle impingement from loss of the normal plantar fl exed position of the talus, tibial or sural nerve complications, fat pad atrophy, and sympathetic-mediated pain syndrome.

Lateral Decompression of a Malunited Calcaneal Fracture

Patients with chronic lateral subtalar pain should be evalu-ated for two problems: posttraumatic arthrofi brosis or arthrosis and lateral calcaneofi bular impingement. A com-bination of CT and selective subtalar injection of a local anesthetic can be helpful in determining the cause of the pain. Some patients have a congruous subtalar joint, but have impingement or displacement of the peroneal tendons by the extruded lateral calcaneal wall. This excess bone can be removed through a curved lateral incision. Removing this bone allows the peroneal tendons to assume a more normal position inferior to the fi bula and narrows the heel, which assists with shoe fi tting and lessens irritation from the lateral shoe counter. We agree with Braly, Bishop, and Tullos that lateral decompression is useful in carefully selected patients. In Myerson’s review of this procedure in



seven patients, the results were good in one, fair in two, and poor in four. Two patients with fair results and two with poor results were found to have subtalar arthrosis, and three went on to have subtalar arthrodesis. Although this procedure should be reserved for carefully selected patients, it is an important procedure before subtalar fusion.

B C

G

E

F

D

AIncision

Suralnerve

Suralnerve

Inferiorretinaculum

Calcaneofibularligament

Osteotomized fragment

Fig. 86-13 Technique for malunion of calcaneal fracture (Braly, Bishop, and Tullos). A, Incision just plantar to course of peroneal tendons. B, Sural nerve decompression. C, Inferior retinacu-lum incised, and peroneal tenolysis performed. D, Calcaneofi bular ligament is cut to expose lateral calcaneus. E, Lateral calcaneal osteotomy. F, Z-lengthening of peroneal tendons for anterior dislocation. G, Repair or reconstruction of inferior retinaculum with lengthened pero-neal tendons relocated. (Redrawn from Braly WG, Bishop JO, Tullos HS: Lateral decompression for malunited os calcis fractures, Foot Ankle 6:90, 1985.)

TECHNIQUE 86-5 Braly, Bishop, and Tullos

• Place a roll under the ipsilateral hip for greater exposure of the lateral aspect of the foot and ankle. Apply and infl ate a pneumatic thigh tourniquet.

• Make a curved incision just plantar to the course of the peroneal tendons, extending from the posterior aspect of the lateral malleolus to the region of the calcaneocuboid joint

(Fig. 86-13A). If previous subtalar fusion or open reduction has been performed, attempt to use the existing incision.

• Identify and release the sural nerve from surrounding scar tissue to more normal anatomy proximally and distally (Fig. 86-13B).

• Excise any neuromas present, and dissect the nerve back to areas where the potential for external irritation over bony prominences during shoe wear is minimized.

• Incise the peroneal tendon sheath, if intact, taking care not to divide completely the superior retinaculum proximally.

• Perform a tenolysis (Fig. 86-13C).

• With the peroneal tendons and sural nerve retracted, incise the calcaneofi bular ligament (Fig. 86-13D).



Stewart (unpublished data) of this clinic analyzed the results of treatment of fractures of the calcaneus and concluded that most surgeons are unduly pessimistic; regardless of the type of treatment, the functional results after 4 to 5 years are good.

With the realization that symptoms should improve for at least 2 years, and as long as a patient is progressing in activity level and work capability, arthrodesis should be avoided, although the psychosocial complications of pro-longed disability are profound. If a patient fails to progress with conservative treatment (e.g., bracing, antiinfl amma-tory medications), arthrodesis should be done. Myerson found that the longer the interval between the injury and the salvage procedure, the longer the interval until the patient returns to full activity or work.

In patients who are candidates for subtalar arthrodesis, a lateral standing radiograph should be scrutinized care-fully. The talar angle of declination should be evaluated because it measures excursion of the tibiotalar joint in extension (Fig. 86-14). For patients with a depressed talar angle of declination, Carr et al. modifi ed a procedure originally described by Gallie to treat this problem. Although technically demanding, postoperative appearance of the foot and improved ankle dorsifl exion may be impres-sive. Romash described a modifi cation in which the primary fracture line is osteotomized, and the bone block is placed across the posterior facet, leaving the middle and anterior facets in their normal anatomical alignment. We have no experience with his technique.

If calcaneal height is normal or minimally depressed, and there are no anterior ankle joint impingement symp-toms, we prefer in situ subtalar arthrodesis. Amendola and Lammens reported satisfactory union in 15 consecutive patients who had a distraction bone block arthrodesis; 11 of the 15 patients were satisfi ed with the procedure, and the failures were related to transverse tarsal joint arthritis, overcorrection, and refl ex sympathetic dystrophy. Chan and Alexander and Bednarz et al. reported similar results. In general, we prefer to preserve the transverse tarsal joint if no arthrosis is present. Combining the results of the distraction bone block arthrodesis and in situ subtalar arthrodesis in 29 patients, Myerson obtained good results in 18 patients, fair results in fi ve, and poor results in six. Of the fair and poor results, only three were related to hindfoot problems (varus malunion in two and persistent lateral pain in one). The others were related to nerve prob-lems, heel pad or midfoot pain, or alcoholism. Chandler et al. reviewed in situ subtalar arthrodesis for painful sequelae of 19 calcaneal fractures with an average follow-up of 27 months. All patients obtained satisfactory subtalar arthrod-esis. There was no correlation between fi nal outcome and talar angle declination, talar height, or calcaneal width. Peroneal tendon and subfi bular impingement, ankle ten-derness, sural nerve injury, and patient smoking all were statistically associated with lower scores.

TECHNIQUE 86-5 Braly, Bishop, and Tullos—cont’d

• Incise longitudinally the fl oor of the peroneal tendon sheath and the periosteum over the lateral calcaneus.

• With subperiosteal dissection, expose the prominent lateral bony mass of the calcaneus, and excise it (Fig. 86-13E). Do not attempt to reconstruct the calcaneofi bular ligament.

• The amount of bone removed from the calcaneus depends on the degree of lateral impingement of the peroneal tendons and sural nerve evident intraoperatively and on preoperative radiographs. Attempt to narrow the heel, at least laterally, to a more normal width, avoiding violating the subtalar and calcaneocuboid joints during bony resection. Smooth all rough edges with a rongeur and a rasp.

• Repair the refl ected overlying periosteum or tendon sheath over the bed of the ostectomy.

• If any raw cancellous bone is left exposed, apply bone wax for hemostasis.

• Close the wounds in routine fashion, and apply a soft, compressive dressing.

• If the peroneal tendons are dislocated, Braly et al. recommended Z-lengthening of both tendons before locating them behind the lateral malleolus (Fig. 86-13F); we do not routinely lengthen these tendons.

• Repair the retinaculum or reconstruct it using an osteo-periosteal strip from the lateral malleolus, as described by Zoellner and Clancy (Fig. 86-13G), after the ostectomy.

• If peroneal tendon lengthening or relocation and repair or reconstruction of the retinaculum are done, apply a short leg cast, and split it anteriorly in the recovery room.

AFTERTREATMENT Early motion and progressive weight bearing as tolerated are encouraged 2 to 3 days after surgery. If a cast has been applied after tendon lengthening or relo-cation, this is changed to a short leg, nonwalking cast before discharge and is worn for 3 weeks, followed by a short leg walking cast for another 3 weeks. Range-of-motion and strengthening exercises of the ankle are begun, and full activity is allowed approximately 8 to 12 weeks after surgery.

Subtalar Distraction Bone Block Arthrodesis

Deyerle reviewed the long-term results in 50 patients and concluded that subtalar or triple arthrodesis was never nec-essary, either primarily or secondarily, because the natural course of events in severely displaced fractures produced the same amount of immobilization of the subtalar joint after 3 to 5 years. Lindsay and Dewar and O’Connell, Mital, and Rowe reached similar conclusions. Speed and



A

B

C G

D

F

E

Fig. 86-14 Radiographic measure-ments. A, Talocalcaneal height. B, Cuboid-to-fl oor distance. C, Navicular-to-fl oor distance. D, Calcaneal pitch angle. E, Talocalcaneal angle. F, First talometatarsal angle. G, Talar dec-lination angle. (From Buch BD, Myerson MS, Miller SD: Primary subtalar arthrodesis for the treatment of comminuted calcaneal fractures, Foot Ankle 17:61, 1996.)

TECHNIQUE 86-6 Carr et al.

• Position the patient in the lateral decubitus position with the affected side up. Prepare and drape the posterior iliac crest and leg.

• Under tourniquet control, use a longitudinal posterolateral Gallie type of approach to the subtalar joint. Identify the sural nerve in the proximal incision, excise, and bury in muscle; alternatively, protect the sural nerve.

• Subperiosteally expose the lateral calcaneal wall, and excise to a more normal width. This step should ensure peroneal and fi bular decompression.

• Identify the subtalar joint.

• Apply a femoral distractor with half-pins in the medial subcutaneous tibia and medial calcaneus. The medial application helps to correct hindfoot varus.

• Apply distraction, and denude the subtalar joint to subchondral bone. Use a lamina spreader to aid in subtalar joint exposure. Direct attention to any heel varus or valgus at this point, and, if necessary, correct by manipulation. Obtain intraoperative radiographs to ensure correction of the lateral talocalcaneal angle (normal 25 to 45 degrees).

• Measure the subtalar joint gap, and harvest an appropriately sized tricortical posterior iliac crest graft. A block 2.5 cm in height may be required for severe deformities. Two separate pieces may be required to fi ll the gap completely and help prevent late collapse into varus or valgus.

• Release the distraction forces.

• Insert two fully threaded 6.5-mm AO cancellous screws through stab incisions into the heel to fi x the calcaneus and the talus fi rmly. Two screws provide more rigid fi xation and help to prevent rotatory movements around the axis of subtalar motion.

• Obtain fi nal radiographs, lateral and axial views, to confi rm correct positioning.

• Close the wound in layers with interrupted nylon on the skin.

AFTERTREATMENT The patient is kept in a short leg cast for 12 weeks. Weight bearing as tolerated is permitted after 6 weeks.

TALAR FRACTURES

The role of the talus in lower extremity function, the complexity of the anatomy, and the variability of fracture patterns often complicate treatment of talar fractures and often frustrate orthopaedists. To gain full confi dence in the treatment of these injuries, one must have thorough knowl-edge of the osseous and vascular anatomy, have experience with modern methods of fi xation, and be prepared to deal with the complications that often occur with talar injuries.

Anatomy

The vascular anatomy of the talus has been extensively studied by McKeever (1943), Wildenauer (1950), Haliburton et al. (1958), Mulfi nger and Trueta (1970), and Gelberman and Mortensen (1983) (Fig. 86-15). The three major arter-ies of the leg contribute to a rich, extraosseous, anastomotic plexus, supplying blood to the head, neck, and body of the talus. The head and neck regions are richly supplied by the superior neck vessels, branching off the dorsalis pedis artery and the artery of the sinus tarsi. Osteonecrosis of these areas is extremely rare. The tarsal canal is formed by the



Dorsal view of the talusshowing the areas coveredby the following sections

Blood supply tothe medial thirdof the talus

Blood supply tothe middle thirdof the talus

Blood supply tothe lateral thirdof the talus

Blood supply tothe head of the talus

Blood supply tothe middle thirdof the talus

Blood supply tothe posterior thirdof the talus

Medial view of the talusshowing the areas coveredby the following sections

A

B

C

CBA

A

C

CB

A

B

Dorsalis pedisartery branches

Posteriortibialartery

Posteriortuberclebranches

Artery of thetarsal sinus

Tarsal sinus branches

Deltoidbranches



Artery of thetarsal canal

Tarsal sinus branches Artery of the

tarsal canal

Artery of thetarsal canalbranches


Perforatingperoneal artery

Lateral tarsalartery

Perforating peroneal artery

Lateraltarsalartery

Dorsalis pedisartery

Anastomotic arteryfrom deltoid branch

Artery of thetarsal sinus

Tarsal sinusbranchesTarsal sinus branches

Deltoid branches

Deltoid branches

Posteriortibial arteryArtery of the

tarsal canal


Fig. 86-15 Blood supply to talus in sagittal and coronal sections (see text). (Redrawn from Mulfi nger GL, Trueta J: The blood supply of the talus, J Bone Joint Surg 52B:160, 1970.)



sulcus on the inferior surface of the talus and the superior sulcus of the calcaneus and contains the artery of the tarsal canal and the talocalcaneal intraosseous ligament. The tarsal canal runs from posteromedial to anterolateral, where it opens into the tarsal sinus. The talar body is vulnerable because of its blood supply. Related primarily to the degree of displacement of the body, osteonecrosis rates can be 100%. The vascular supply to the talar body can be sum-marized as follows (Fig. 86-16).

The artery of the tarsal canal, which branches off the posterior tibial artery approximately 1 cm proximal to the division into medial and lateral plantar arteries, is the most consistent major supplier of blood to the body of the talus. In the tarsal canal, it sends four to six direct vessels into the body of the talus.

The deltoid artery, which branches off the artery of the tarsal canal and directly supplies blood to the medial one fourth to one half of the talar body, is the second major blood supply to the talar body. Through intraosseous anas-tomoses, it has the potential to supply blood to a much greater area.

The artery of the sinus tarsi, which is more variable in its size and origin, supplies the lateral one eighth to one fourth of the talar body. It is formed by branches of the perforating peroneal artery, the dorsalis pedis (or anterior tibial) artery, or anastomoses between the two. The artery of the sinus tarsi forms an anastomosis with the artery of the tarsal canal and has the potential to supply blood to more of the talus.

The posterior tubercle of the talus is supplied by direct branches from the posterior tibial artery (most common)

or the peroneal artery. Although quite small, because of intraosseous anastomoses, this region also has the potential to supply blood to more of the body.

Talar Head Fractures

Fractures of the head of the talus have been reported to constitute 5% to 10% of talar injuries. Two mechanisms of injury have been suggested in the literature: axially directed loading and compression of the talar head and a dorsal compression fracture of the anterior tibial plafond. A high index of suspicion should be maintained for posttraumatic tenderness in the anterior ankle region because recognition of this fracture can be diffi cult. Plain radiographs may defi ne the fracture clearly, but CT often is necessary for defi nitive diagnosis and evaluation of displacement. The head of the talus with loss of support of the talonavicular joint may be associated with clinical instability of the triple joint complex. Injuries to the calcaneocuboid and subtalar joints are common with this injury.

TreatmentDisplaced fractures of the head of the talus should be treated with open reduction and internal fi xation, using an anteromedial approach, medial to the anterior tibial tendon. Care should be taken not to strip any remaining vascular supply of the head. Stable fi xation of the talar head is accomplished with partially threaded cancellous lag screws or with headless, fully threaded compression screws. Early motion can be started at approximately 2 weeks after surgery, with delayed weight bearing at a minimum of 6

A B

2

1

36 4

5

98

7

7 6

54

3

2

1

Fig. 86-16 A, Schematic drawing of medial ankle and foot showing extraosseous arterial supply to talus. 1, anterior tibial artery; 2, medial recurrent tarsal artery; 3, medial talar artery; 4, posterior tibial artery; 5, posterior tubercle artery; 6, deltoid branches; 7, artery of tarsal canal; 8, medial plantar artery; 9, lateral plantar artery. B, Schematic drawing of lateral ankle and foot with extraosseous arterial supply to talus. 1, anterior tibial artery; 2, lateral talar artery; 3, lateral tarsal artery; 4, posterior recurrent branch of lateral tarsal; 5, artery of tarsal sinus; 6, perforating peroneal; 7, anterior lateral malleolar artery. (From Gelberman RH, Mortensen WW: Arterial anatomy of the talus, Foot Ankle 4:64, 1983.)



weeks. If fi xation is marginal, a short leg cast is employed for 6 weeks with no weight bearing. Osteonecrosis of this segment of the head has been reported to be 10%, and if degenerative arthrosis occurs, talonavicular arthrodesis may be indicated. Arthrodesis of the talonavicular joint is reserved for severe fractures because it eliminates triple joint complex motion. If isolated talonavicular arthrodesis is necessary, shortening the medial column of the foot must be avoided. An inlay tricortical graft described by Adelaar can be used to avoid medial column shortening of the foot and placement of the hindfoot into varus.

Talar Neck Fractures

Many controversies surround the treatment of talar neck fractures, which refl ects the diffi culty of assessment, surgi-cal approaches, fi xation methods, and frequency of postop-erative complications. In 1919, Anderson, having observed 18 patients with talar injuries in the Royal Flying Corps, coined the term aviator’s astragalus. In 1952, Coltart reviewed 25,000 fractures sustained during World War II. He found 228 talar fractures, 106 of which were classifi ed as talar neck fractures. He reported osteonecrosis rates of 35% with subtalar dislocation and 95% with ankle and subtalar dislocation.

Since Coltart’s report, the incidence of osteonecrosis after talar neck injuries has been widely disputed. Although the actual percentage of osteonecrosis varies among inves-tigators, increasing levels of displacement and dislocation progressively disrupt more vasculature and increase the incidence of this complication.

In 1970, Hawkins published a landmark paper on the results of 57 talar neck fractures in 55 patients. His classi-fi cation of talar neck fractures, the most widely used today, is simple, provides guidelines for treatment, and is prog-nostic for development of osteonecrosis and the likelihood of successful outcome (Fig. 86-17). In nondisplaced vertical fractures of the neck (group I fractures), osteonecrosis did not occur, and all fractures united. All 24 displaced frac-tures with subluxation or dislocation of the subtalar joint (group II fractures) united, although osteonecrosis subse-quently developed in 42%. In fractures with dislocation of the subtalar and the ankle joints (group III fractures), non-union occurred in 11%, and osteonecrosis developed in 91%. Also, in Hawkins’ series, an increasing percentage of fair and poor results was noted in group III fractures com-pared with group II fractures. Group III fractures had a fair or poor rating in 75% of the patients. The presence of osteonecrosis also correlated with fair or poor results. Only 12% of Hawkins’ patients who had osteonecrosis had a good or excellent result.

Canale and Kelly at this clinic clinically and radio-graphically reviewed 71 fractures of the neck of the talus in 70 patients with an average follow-up of 12.7 years. Using the Hawkins classifi cation, there were 15 type I

fractures, 30 type II fractures, and 23 type III fractures. An additional type of fracture was described, in which not only the body of the talus was extruded from the ankle mortise, but also the head of the talus was subluxed or dislocated from the navicular articulation. They called this a type IV fracture, and there were three. In two of 13 nondisplaced fractures, osteonecrosis developed, but both had excellent results. The one poor result in a type I frac-ture was caused by severe degenerative changes in the ankle joint secondary to an unrecognized fracture through the dome of the talus. It is important to tell patients, even patients with type I fractures, that subsequent arthritis and a poor result can occur after a nondisplaced fracture. Of the 30 type II fractures, osteonecrosis developed in 50%, and 47% had an unsatisfactory result. Of 23 patients with type III fractures, 52% had an unsatisfactory result, with satisfactory results directly related to anatomical reduction of the fracture and the subtalar dislocation (see Fig. 86-21).

In 1985, Grob et al., Szyszkowitz et al., and Comfort et al. published separate studies in which early open reduction and rigid internal fi xation were used for displaced fractures. In the study by Comfort et al., operative intervention was accomplished in 20 of 28 displaced fractures within 12 hours of injury. Although at least partial osteonecrosis developed in many of the type II fractures and most of the

DC

BA

Fig. 86-17 A, Type I talar neck fracture. B, Type II. C, Type III. D, Type IV. (From Canale ST, Kelly FB Jr: Fractures of the neck of the talus: long-term evaluation of 71 cases, J Bone Joint Surg 60A:143, 1978.)



type III fractures, good or excellent results were obtained in nearly all fractures.

Vallier et al., in a review of 39 patients who had com-plete radiographic data out of a group of 102 talar neck fractures of the talar neck, showed an osteonecrosis rate of 39% in Hawkins type II fractures and 64% in Hawkins type III fractures. In their study, osteonecrosis was associ-ated with comminution of the talar neck and open fracture. Of these patients, 54% developed posttraumatic arthritis also associated with comminution and open fractures. Sanders et al., in their evaluation of functional outcomes after displaced talar neck fractures, found that reconstruc-tive surgery was necessary in 48% within 10 years after injury. In their evaluation of the results of displaced talar neck and body fractures, Lindvall et al. found a high inci-dence of posttraumatic arthritis of the subtalar joint in all patients, even in patients who had an anatomical reduction and stable internal fi xation.

TreatmentAny fracture that involves a joint is a diffi cult problem, and this is especially true of a weight bearing joint. Much of the surface of the talus is covered by articular cartilage. For this reason, almost any fracture of the talus involves a joint surface. More weight per unit of area is borne by the supe-rior surface of the talus than by any other bone. In fractures of the talus, accurate reduction is essential to reestablish the position of its articular surfaces. Any residual irregular-ity of the joint surfaces can produce arthritic changes with resumption of motion and weight bearing. Impacted frac-tures of the head, usually associated with compression frac-tures of the navicular, should be treated nonoperatively. Because of irregularity in the talonavicular joint, pain can persist, and arthrodesis eventually may be necessary for relief.

Care must be taken to search for local and remote asso-ciated fractures. A medial malleolar fracture commonly is associated with a displaced talar neck fracture. As with any axial loading injury, the lumbar spine should be evaluated thoroughly.

Radiographic evaluation of talar neck injuries should include anteroposterior, lateral, and oblique views of the ankle and an anteroposterior view of the foot. Intraoperatively, the view described by Canale, in which the foot is inter-nally rotated 15 degrees and the x-ray beam angled 75% from horizontal, is especially helpful because it profi les the talar neck. This can help prevent malunion and varus.

Although the development of osteonecrosis of the talus may or may not ultimately affect the outcome, most authors agree that varus malunion even of a few degrees is almost uniformly associated with a poor outcome. Because the talar neck is commonly comminuted medially, care must be taken to restore the anatomical alignment of the neck.

Type I Fractures Type I fractures, by defi nition, are non-displaced. A talar neck fracture must be thoroughly evalu-ated before labeling it as a type I. Many fractures, if examined closely by CT scans or tomograms, display subtle displacement. If any doubt exists about the presence of the displacement, one of these tests should be obtained. Alternatively, gentle manipulation under fl uoroscopic control can be used to evaluate the stability of these inju-ries. If the subtalar joint is free of displacement and frag-ments, the fracture should be immobilized in a below-knee cast for 8 to 12 weeks, with weight bearing delayed until trabeculation across the fracture is seen.

Types II, III, and IV Fractures As a rule, displaced fractures of the neck of the talus should be treated with prompt open reduction and internal fi xation because it is diffi cult to obtain an anatomical reduction by closed means. Regarding the timing of surgery, Patel et al. surveyed an expert group of orthopaedic trauma surgeons and found that a high percentage of the surgeons believe that immediate surgery for displaced talar neck fracture often is not indicated. Vallier et al. confi rmed this fi nding when they noted sig-nifi cant differences in outcome between patients treated with prompt reduction and internal fi xation and patients with soft-tissue swelling that was allowed to resolve before defi nitive surgical fi xation.

The anteromedial approach offers good fracture expo-sure and is easily extended for use of a medial malleolar osteotomy. Often the medial neck is the location of the comminution of the fracture, however, and fracture align-ment and reduction can be diffi cult to assess. This area also may offer only limited access for fi xation. We do not hesi-tate to add an anterolateral approach, which may help to assess reduction and to offer a region for screw fi xation. Trillat et al. proposed fi xation from a posterolateral approach into the head of the talus. Lemaire and Bustin and Swanson et al. also used this approach successfully. The best bone for fi xation is located in the lateral talar head, using pos-terior-to-anterior screw placement (Fig. 86-18).

Type III and type IV fractures constitute an orthopaedic emergency for two reasons. First, pressure from the dislo-cated body on the skin and neurovascular structures can lead to skin slough, neurovascular insult, or both. Second, in theory, the only remaining blood supply to the talus, the deltoid branch, may be rotated and occluded, correct-able only through emergency reduction of the body. Open reduction, usually with the help of medial malleolar oste-otomy, generally is necessary (Fig. 86-19). Ziran et al. described the use of the medial malleolar osteotomy for exposure of complex talar fractures. We have found this approach exceptionally useful in type III and type IV frac-tures and in talar body fractures in which access to the fracture is diffi cult through standard incisions.

Consensus on the treatment of a completely extruded talar body is lacking. Because the results of talar body exci-



DC

BA

Fig. 86-18 A, Displaced type II fracture of talar neck. B, Reduced with fi xation using posterior-to-anterior screws. C and D, Negative Hawkins sign and osteonecrosis of talar body 10 weeks postoperatively.

sion with or without tibiocalcaneal fusion are most often poor, we believe that maintenance of the limb length and height of the ankle is important enough to warrant replace-ment of the body. The body should not be replaced in two situations—severe contamination or severe comminution and crushing of the body. Adelaar recommended leaving the talar body out, doing a thorough débridement, and spanning the ankle joint with an external fi xator until a clean wound is obtained. This is followed by either a Blair fusion or a tibiocalcaneal arthrodesis with interposition grafting.

Open Reduction of the Talar NeckTECHNIQUE 86-7

• Expose the head and neck of the talus through an incision, 7.5 to 10 cm long, beginning proximal and just anterior to the medial malleolus, curving distalward and plantarward toward the sole of the foot, and ending on the medial side of the body of the navicular, using the interval between the anterior and posterior

tibial tendons (Fig. 86-20A). Avoid incising the posterior tibial tendon and neurovascular structures inferior to the medial malleolus.

• If the body of the talus is extruded from the ankle mortise, osteotomy of the medial malleolus may make exposure and reduction easier.

• Expose the fracture and the anteromedial aspect of the neck and body of the talus. Preserve intact as much soft tissue as possible around the head and neck of the talus.

• Reduce the fracture, and irrigate the joint to remove bone fragments and debris.

• If an anterolateral approach is necessary, expose the lateral neck through a 5-cm incision over the sinus tarsi, extending toward the base of the fourth metatarsal (Fig. 86-20B). Protect the dorsal intermediate cutaneous nerve in this region.

• After incising the inferior extensor retinaculum, refl ect the extensor digitorum brevis plantarly to expose the fracture.



F

E

D

CBA

Fig. 86-19 Type IV talar fracture. A and B, Injury radiographs showing dislocation of talar body and talar head from talonavicular joint. C and D, After closed reduction and percutane-ous Hoffman pin through tuberosity of calcaneus for leverage. E and F, Lateral and Canale anteroposterior views after open reduction and internal fi xation.

Careful reduction is important because slight varus at the fracture still can produce a malunion that is quite disabling.

• Try to locate interdigitating fracture lines medially or laterally for a guide to reduction, even if a gap remains in the opposite cortex.

• Beginning just posterior to the articular surface of the head on the medial or lateral aspect of the neck, drill two or three small Kirschner wires through the neck and into the body to hold the reduction. Depending on the available space for fi xation, a 4-mm, 4.5-mm, or 6.5-mm partially threaded cannulated screw can be used (Fig. 86-21). In each case, care must be taken to

countersink the screw head to provide a fl at area for seating of the screw head.

• Check the fi nal position with radiographs.

• For placement of posterior-to-anterior screws, use the Henry approach from the lateral side of the Achilles tendon, and develop the interval between the fl exor hallucis longus and the peroneal tendons (see Fig. 86-20C).

• Place the guidewire above the lateral projection of the posterior process, and direct it toward the lateral talar head. Fluoroscopic guidance is essential to avoid the subtalar joint.



CB

A

Anteriortibialtendon

Posteriortibialtendon

Osteotomizedmedial malleolus

Talar dome

Extensordigitorumand peroneustertius

Inferiorextensorretinaculum

Lateralmalleolus

Sinus tarsi

Navicular

Soleus

Suralnerve

Peroneusbrevis

Flexorhallucislongus

Achillestendon

Suralnerve

Flexorhallucislongus

Peroneusbrevis

Posteriorfibulotalarligament

Fig. 86-20 A, Anteromedial approach to ankle. Exposure can be extended from limited cap-sulotomy in interval between anterior and posterior tibial tendons to wide exposure with mal-leolar osteotomy. B, Anterolateral approach to talus. C, Posterolateral approach to talus. (From Mayo KA: Fractures of the talus: Principles of management and techniques of treatment, Tech Orthop 2:42, 1987.)

Open Reduction of the Talar NeckTECHNIQUE 86-7—cont’d

• If the cortex is fragile, as in an elderly patient, or if the fracture is more distal, fi rm fi xation may not be secured by placing a screw obliquely. In such patients, drill two Steinmann pins, 3/32-inch or larger, passing proximally from the navicular into the head of the talus, through the fracture site, and deep into the body of the talus. This usually affords good fi xation. Transfi xing the talonavicular joint in the fracture in this manner is preferable to attempting to countersink screws below the surface of the articular cartilage of the head of the talus.

• If the medial malleolus was osteotomized to improve exposure, reduce it, and fi x it with a malleolar screw.

AFTERTREATMENT The foot is held in a neutral position in a cast, and the ankle is immobilized in a cast from below the knee to the toes, well molded into the arch of the foot. After 6 to 8 weeks, depending on radiographic signs of early union, a walking boot is applied, and weight bearing is permitted. Three months after surgery, if union has progressed satisfactorily, the cast is removed, and an ortho-paedic shoe and scaphoid pad are fi tted and worn for an additional 3 months.

Osteonecrosis of the Talar Body after Talar Neck FractureIn the treatment of fractures and fracture-dislocations of the neck of the talus, satisfactory primary treatment must



B

A

Fig. 86-21 A, Displaced fracture of neck of talus. B, Four years after screw fi xation (see text).

be emphasized, but early recognition and management of osteonecrosis that may follow also must be considered. It can reasonably be predicted that with fractures of the neck of the talus, a very small percentage of nondisplaced frac-tures and a very large percentage of fractures with complete dislocation of the body will be complicated by osteonecro-sis. Between 6 and 8 weeks after injury, osteonecrosis usually can be recognized on a good anteroposterior radio-graph of the ankle made with the foot out of the plaster cast. A thin line of subchondral atrophy along the dome of the talus indicates the presence of vascularity and excludes the diagnosis of osteonecrosis. This (Hawkins sign) has been a useful objective prognostic sign.

Bone grafts across the fracture site in the neck of the talus, primary or early subtalar fusion, and ankle fusion generally have been unsuccessful in speeding the revascu-larization of the body of the talus. Prolonged non–weight bearing in hopes of preventing collapse of the dome of the talus has not been suffi ciently predictable to justify it. In many cases, the talus collapses even though weight bearing is not permitted. When pain develops after osteonecrosis, excision alone of the necrotic body of the talus has not proved useful. We have most often used the Blair type of ankle fusion with a sliding graft from the anterior aspect of the tibia into the viable neck of the talus with excision of the necrotic body (Fig. 86-22). Morris, Hand, and Dunn

stabilized the calcaneus on the tibia by placing a large Steinmann pin up through the calcaneus into the tibia and using a screw through the sliding graft into the tibia. This results in a more normal appearance of the foot, with the extremity not shortened and the relationship of the foot and ankle remaining more physiological. When solid fusion between the tibia and neck of the talus has occurred, some fl exion and extension and inversion and eversion may develop at the subtalar joint because the subtalar joint and subtalar facets have been preserved.

We have obtained arthrodesis of this region using an onlay graft technique through a posterior approach as described by Johnson. This procedure gives a satisfactory arthrodesis rate and maintains the length of the limb and the contours of the malleoli (Fig. 86-23).

C

BA

Fig. 86-22 Blair fusion for comminuted fractures and frac-ture-dislocations of body of talus. A, Line of skin incision. B, Sliding graft removed from distal anterior surface of tibia and comminuted fragments excised. C, Graft embedded in slot in neck of talus. (From Blair HC: Comminuted fracture and fracture-dislocations of the body of the astragalus: operative treatment, Am J Surg 59:37, 1943.)



DC

BA

Fig. 86-23 A and B, Osteonecrosis of talus after talar neck fracture. C and D, After Blair fusion.



displacement or displacement without dislocation, a higher incidence of posttraumatic subtalar osteoarthrosis has been noted after talar body fractures. Nondisplaced talar body fractures have a reported incidence of osteonecrosis of 25%; however, with displacement, the rate of osteonecrosis is 50%. Inokuchi et al. identifi ed these injuries as talar body fractures if the inferior fracture line was proximal to the lateral process of the talus and as talar neck fractures if the inferior fracture line was distal to the lateral process of the talus.

Sneppen et al. classifi ed talar body fractures into fi ve major types: type I, osteochondral or transchondral; type II, coronal-sagittal, horizontal, noncomminuted, shear; type III, posterior tubercle; type IV, lateral process; and type V, crush. The noncomminuted, shear fractures may be in the coronal, sagittal, or transverse plane. Diagnosis should be made with a plain radiograph, although CT may be indicated for complete evaluation of the fracture pattern and displacement. Displaced fractures should be treated with open reduction and internal fi xation. Frequently, these injuries require medial malleolar osteotomy for expo-sure to obtain an adequate reduction. Use of bioabsorbable pins or headless compression screws may be helpful in fi xa-tion. Vallier et al., in an extensive review of the surgical treatment of talar body fractures, confi rmed the morbidity of these injuries. An 88% incidence of osteonecrosis or posttraumatic arthritis was noted on radiographs, and worse results occurred with comminuted and open fractures. These authors found that all patients who had open frac-tures and osteonecrosis experienced collapse of the talar body.

Comminuted fractures of the body of the talus with gross displacement are diffi cult to treat. The long-term result is almost uniformly bad. Accurate replacement of the fragments often is impossible or impracticable. In adults, the results of talectomy usually are poor because of pain on weight bearing, instability, and lack of endurance. The results of calcaneotibial fusion combined with talectomy are superior to the results of talectomy alone because the foot is painless and stable, and enough compensatory move-ment usually develops in the midtarsal joints to enable the patient to walk with a fairly elastic gait and only a slight limp (Fig. 86-24).

Onlay Graft Technique through a Posterior ApproachTECHNIQUE 86-8 Johnson

• Using tourniquet control with the patient in the prone position, make a midline incision protecting the sural nerve.

• Enter the Achilles tendon sheath, and carefully protect it. Divide the Achilles tendon in the coronal plane to allow better exposure of the posterior ankle and subtalar joints.

• After the deep compartment is entered, develop the interval between the fl exor hallucis longus medially and the peroneus longus and brevis laterally.

• Elevate the periosteum from the posterior aspect of the tibia and the dorsal aspect of the tuberosity of the calcaneus. A femoral distractor should be used to assist in the distraction of the ankle and subtalar joints.

• Débride the cartilage from the surfaces of the ankle and subtalar joint with a curet and rongeur.

• Use a 1/2-inch osteotome to create a trough, incorporating the posterior aspect of the tibia, the posterior half of the talar body, the superior portion of the calcaneal tuberosity, and the posterior facet of the calcaneus. This creates one long trough for the onlay graft.

• Harvest cancellous and cortical strips of bone from the posterior superior iliac crest.

• At this point, use the technique for the introduction of an intramedullary arthrodesis nail (see Chapter 3).

• After stabilization of the arthrodesis in a neutral position with the intramedullary nail, apply the bone graft through the entire posterior aspect of the tibia, talus, and calcaneus. We have found the use of an implantable bone stimulator to be valuable in this procedure.

• Place a drain in the deep wound, and repair the Achilles tendon with multiple interrupted 0 braided, absorbable sutures.

• Repair the Achilles tendon sheath with 2-0 braided, absorbable sutures. Close the subcutaneous skin.

AFTERTREATMENT A posterior plaster splint is applied and changed 2 days after surgery to a short leg, non–weight bearing cast. Weight bearing is delayed until there is evi-dence of union at approximately 10 to 12 weeks. A pre-fabricated walking boot is applied, and the patient is gradually able to bear weight and transfer to a shoe, modi-fi ed with a full-length steel shank and rocker sole.

Talar Body Fractures

It is important to distinguish talar body fractures from talar neck fractures. Although the incidence of osteonecrosis is similar between talar neck and talar body fractures without

Calcaneotibial FusionTECHNIQUE 86-9

• Expose the operative fi eld through an anterolateral incision.

• Remove the fragments of the body of the talus.

• In comminuted fractures of the talus several months old, or when the junction of the body and neck is intact, divide the talus with an osteotome into as many pieces as necessary for easy removal. Drive an osteotome through the proximal part of



BA

Fig. 86-24 A, Four years after tibiocalcaneal fusion by compression arthrodesis and autogenous iliac bone graft-ing. B, Sixteen years after fusion, degenerative changes at midtarsal joints are present, but patient is active with mild symptoms.

Calcaneotibial FusionTECHNIQUE 86-9—cont’d

the navicular to remove the proximal articular cartilage and subchondral bone together with the head and neck of the talus.

• Excise the articular surfaces of the tibia and calcaneus. Roughen the medial surface of the lateral malleolus.

• Strip the soft-tissue attachments around both malleoli enough to allow posterior displacement of the foot until the navicular comes in contact with the tibia. It may be necessary to resect a part of both malleoli because the soft tissues collapse like an accordion and resist efforts to appose the calcaneus properly to the tibia.

• Denude the tibia at the point of contact with the navicular.

• While the foot is held at a right angle to the leg or in 5 degrees of dorsifl exion, insert two Steinmann pins transversely through the calcaneus and tibia, as described for arthrodesis of the ankle, and apply Charnley clamps or other external fi xation devices to maintain fi rm contact between the two bones. Fix the navicular to the tibia with a screw.

• Denude bone chips obtained during the operation, and pack them around the junction of the calcaneus, the navicular, and the tibia.

• As an alternative to this technique, the fresh cancellous surface of the neck of the talus can be apposed to the roughened anterior surface of the tibia. The foot is not placed as far posteriorly and looks and functions better.

AFTERTREATMENT With the knee fl exed at 45 degrees, a long leg cast is applied incorporating the Charnley clamps. At 6 weeks, the cast, the Charnley clamps, and the Steinmann pins are removed, and a short walking cast is

applied. After 4 to 6 more weeks, this cast is removed, and the limb is protected for the next 2 to 3 months by a short leg double-upright brace with no joint at the ankle.

Because of the decrease in height and the rigidity of the ankle joint after calcaneotibial fusion, Blair suggested an alternative procedure: the comminuted fragments of the body of the talus are removed, and a sliding graft from the anterior surface of the tibia is inserted into the remnant of the head and neck of the talus in an attempt to obtain fusion across this area (Fig. 86-25). Blair reported these advantages: the position of the foot is unchanged, backward displacement is unnecessary, the extremity is not shortened, the relationships of the foot and ankle remain near-normal, and the weight bearing thrust is placed on more or less normal, undisturbed joint tissue. After this operation, there is still slight fl exion and extension of the foot on the leg, the two subtalar facets and the talonavicular joint allowing a rocking motion.

Fig. 86-25 Ten years after Blair fusion. (Courtesy of Harry Blair, MD.)



C

BA Trigonalprocess

1 2 3 4

Neutral Inversion Eversion

Fig. 86-26 Possible mechanisms of injury in fractures of posterior facet of talus. Probable mechanism is compression. Fragment is sheared off posterior facet by corresponding area of calcaneus as foot is forced into dorsifl exion and slight external rotation. (Redrawn from Dimon JH: Isolated displaced fracture of the posterior facet of the talus, J Bone Joint Surg 43A:275, 1961.)

TECHNIQUE 86-10 Blair

• Expose the ankle through an anterolateral incision. Remove the fragments of the fractured body of the talus, but leave the head and neck fragments undisturbed (see Fig. 86-22). Remove a sliding graft 2.5 cm wide × 5 cm long from the anterior aspect of the distal tibia, and remove the cartilaginous tip from its end. Introduce the graft into a previously prepared hole about 1.8 cm deep in the neck of the talus.

• With the foot plantar fl exed 10 degrees, fi x the proximal end of the graft to the tibia with a screw.

• Pack the cancellous chips around the distal end of the graft.

AFTERTREATMENT A cast is applied from the groin to the toes with the knee in extension and is worn for 4 to 6 weeks. A short leg cast is applied, and protected walking is allowed depending on the appearance of healing on radiographs. Cast immobilization usually is required for 12 to 16 weeks.

Fractures of the Lateral, Posterior, or Medial Process of the Talus

Fractures of the talus may involve the lateral, posterior, or medial process of the body at the insertion of the deltoid (deep portion) ligament. Lateral process fractures probably are more common.

Lateral Process FracturesLateral process fractures have been specifi cally associated with ankle injuries incurred while snowboarding. According to Hawkins, the mechanism of injury is compression and shear stress, as the inverted foot is severely dorsifl exed. Dimon, who called this a fracture of the posterior facet of the talus, suggested that acute dorsifl exion is the mecha-nism of injury. A lateral subtalar dislocation may shear off the lateral process of the talus (Fig. 86-26). A purely inver-sion force probably is not the mechanism of injury because the anterior talofi bular ligament does not attach to the lateral process. The lateral “talocalcaneal ligament” is simply a thickening of the lateral capsule of the subtalar joint. Inversion injuries are so common that, if this mecha-nism of injury were causative, more lateral process fractures should occur than are seen.

The lateral component usually can be recognized easily with CT. An accessory bone, the os trigonum, can occur in continuity with the lateral tubercle of the posterior process of the talus. It can be fused with the lateral tubercle or be a separate fragment (Fig. 86-27). The incidence of os trigonum is 2.7% to 5.7% and is more often bilateral. The posterior talofi bular ligament attaches to the lateral tubercle (Fig. 86-28). The medial tubercle is fractured less often than the lateral. A component of the deltoid ligament

Fig. 86-27 A, Trigonal process, superior view. B, Trigonal process, inferior view. Articular surface is in continuity with that of posterior calcaneal articular surface. C, Variations in size of trigonal process: 1, absent; 2, moderate; 3, medium; 4, large. (Redrawn from Sarrafi an SK: Anatomy of the foot and ankle, Philadelphia, 1983, Lippincott.)



Posterior

Inferior

1Posterolateral

tubercle

Middlecalcaneal

articularsurface

Tarsalcanal

2Sulcus for

flexor hallucislongus

3Posteromedialtubercle

Anteriorcalcanealarticularsurface

Tuberclefor cervicalligament

Sinustarsi

process fractures, which can result in signifi cant long-term disability if not recognized. These fractures often are asso-ciated with subtalar dislocations, but can occur with lesser injuries. If a patient has sustained an ankle sprain and has not improved after 6 to 8 weeks of conventional treatment, the posterior, lateral, or medial talar process may be frac-tured. CT and bone scanning are helpful, and lateral tomography may identify posterior process fractures. A lateral radiograph of the opposite foot for comparison also is helpful. A trial of nonoperative treatment is indicated, but persistence of symptoms and localized tenderness at the posterior process of the talus are indications for excision of the fragment (Fig. 86-29).

Kim et al. reported fi ve patients with avulsion fractures of the medial tubercle and posterior process of the talus. Only two of the fi ve were diagnosed acutely and did well with mobilization and limited weight bearing. The other three fractures were missed, but when discovered they did well with operative excision.

Medial Process FracturesFractures of the medial wall of the body of the talus occur less frequently than lateral process fractures. If CT shows marked displacement, the fragment, usually located just posterior to the medial malleolus, should be excised (Fig. 86-30). Giuffrida et al. described a posteromedial talar facet fracture associated with a medial subtalar dislocation that often is missed on initial postreduction evaluation and frequently is confused with an os trigonum. They empha-sized the fact that patients with medial subtalar dislocations should have additional diagnostic imaging studies, such as coronal CT scan. Prognosis is poor if the fracture is through the medial side of the talar body. A fracture through an incomplete medial facet tarsal coalition, easily seen on CT, can be confused with a medial wall fracture of the body of the talus; however, treatment recommendations are the same.

Fig. 86-28 Posterior aspect of talus. (Redrawn after Sarrafi an SK: Anatomy of the foot and ankle, Philadelphia, 1983, Lippincott.)

inserts on the medial tubercle. There may be a fi brous union of the os trigonum to the lateral tubercle, and the “fracture” occurs through the syndesmotic union.

Lateral process fractures are treated closed, unless they are displaced or involve a signifi cant portion of the talar side of the posterior facet. The amount of displacement and articular involvement is diffi cult to determine. If CT shows less than 3 to 4 mm of displacement (involvement of <10% of the articular surface), we prefer closed treatment in a non–weight bearing cast for 6 weeks followed by 6 weeks in a removable weight bearing cast. During the latter period, subtalar and tibiotalar motion, proprioception, and strengthening exercises are begun. If more than 3 to 4 mm displacement is present, open reduction or excision may be indicated.

Posterior Process FracturesPosterior process fractures often are diffi cult to diagnose. Signifi cant attention has been given to posteromedial

TECHNIQUE 86-11

• Approach the lateral process of the talus through a sinus tarsi incision, beginning at the tip of the fi bula and extending toward the fourth metatarsal base.

• Protect the communicating branch of the sural nerve and dorsal intermediate cutaneous branch, which sometimes crosses the space.

• Retract the peroneus brevis tendon plantarly, and refl ect a portion of the extensor brevis origin dorsally, providing exposure to the lateral subtalar joint.

• Reduce the fracture, and fi x with standard AO screws, countersinking the heads. Alternatively, use full countersinking screws (Herbert [Acumed, Hillboro, Ore], Acutrak [Zimmer, Warsaw, Ind]) (Fig. 86-31).


C

B

A

Fig. 86-29 Posterior process frac-ture of talus. A, Preoperative radio-graph. B, CT scan showing large posterior process and additional fracture. C, Postoperative lateral radiograph after excision. Patient became asymptomatic.

DC

BA

Fig. 86-30 A-C, Medial subtalar disloca-tion with fracture of medial side of body of talus (arrows). Dislocation was not appreciated until anteroposterior radio-graph was obtained after reduction. This probably was impingement or abutment fracture. D, CT scan delineates precise area of fracture. Portion of deep deltoid ligament was attached to fragment. Fragment was excised.



C

BA

Fig. 86-31 Displaced lateral process fracture of talus. A, Preoperative coronal CT scan showing displace-ment of lateral process. B and C, Anteroposterior and lateral views show reduction and stabilization with fully countersinking screws (Acutrak [Acumed, Hillsboro, Ore]).

TECHNIQUE 86-11—cont’d

• If on the preoperative assessment the fracture extends more posteriorly along the lateral subtalar joint, use a posterolateral longitudinal incision between the peroneus brevis laterally and the fl exor hallucis longus medially. The fl exor hallucis longus traverses the subtalar joint between the lateral and medial tubercles of the posterior process of the talus.

• Isolate and protect the sural nerve, and cauterize branches of the peroneal artery. The depth of the wound is surprising, and fat can obscure the dissection. A headlamp is helpful in this dissection.

• Locate the fl exor hallucis longus, and retract it medially from its groove.

• Dorsifl ex the foot to delineate the posterior process, and excise it.

• Flex and extend the hallux while observing the fl exor hallucis longus to ensure that excursion is unhindered.

• If the fracture is through the medial wall of the body of the talus, and there is marked displacement, excise the

fragment usually located just posterior to the medial malleolus.

• Make a short, oblique incision posterior to the medial malleolus, but avoid the posterior tibial and fl exor digitorum longus tendons and the neurovascular bundle.

• If the fragment involves a part of the medial dome of the talus, perform an osteotomy of the medial malleolus to reduce the fragment.

• Apply a bulky compression dressing and a short leg nonwalking cast.

AFTERTREATMENT The compression dressing and short leg walking cast are worn for 3 weeks, then a walking cast is applied and worn for 3 additional weeks.

Transchondral Fractures of the Talus

See Chapter 48 for arthroscopic treatment of transchondral fractures of the talus.



BA

Fig. 86-32 Medial subtalar dislocation. A, Posture of foot. Note prominence of head of talus. B, Radiographic appearance of dislocation. (From DeLee JC, Curtis R: Subtalar dislocation of the foot, J Bone Joint Surg 64A:433, 1982.)

SUBTALAR DISLOCATIONS

In dislocation of the subtalar joint, the calcaneus, cuboid, navicular, and all of the forefoot become displaced from the talus. Most often, the foot is dislocated medial to the talus, although lateral, anterior, and posterior dislocations occur (Fig. 86-32).

Medial subtalar dislocations, without marginal fractures of the calcaneus or talus, almost always are reducible by closed means. Lateral subtalar dislocations frequently are irreducible by closed manipulation, and the most common offending structures blocking reduction are the posterior tibial tendon and osteochondral fracture of the talus (Fig. 86-33).

Long-term results after closed subtalar dislocations without associated fractures generally are good, but subtalar motion may be moderately limited, and walking on uneven surfaces often is awkward. After reviewing 17 subtalar dislocations observed for an average of 35 months, DeLee and Curtis concluded that if an osteochondral fracture is seen on postreduction tomograms, open reduction and internal fi xation or excision of the fragment might reduce the risk of degenerative arthritis. Zimmer and Johnson found frequent subtalar instability when the period of immobilization was shortened and early exercises were instituted. They recommended 6 weeks of cast immobiliza-tion. In a long-term review of severe open subtalar disloca-tions, Goldner et al. found considerably worse results with these injuries as opposed to closed injuries. They reviewed 15 adolescents and adults at an average of 18 years after a type III open subtalar dislocation. Associated injuries included 10 tibial nerve injuries, fi ve posterior tibial tendon

ruptures, fi ve posterior tibial nerve lacerations, 12 articular fractures involving the subtalar joint, three articular frac-tures of the talonavicular joint, three talar dome fractures, and three malleolar fractures. The investigators also found osteonecrosis in the body of the talus in one third of the patients. Approximately half of the patients eventually had some form of arthrodesis procedure.

Bibbo et al., in one of the largest series to date, evalu-ated the results and operative fi ndings of 25 patients with subtalar dislocations and found that medial dislocations accounted for 65% of subtalar dislocations. Open reduction was required in 32%, and the incidence of irreducibility was statistically signifi cantly associated with a high-energy injury. Eighty-eight percent of patients sustained additional injuries to the affected foot and ankle, and systemic injuries occurred in 88% of the patients. After a mean follow-up of 5 years, the American Orthopaedic Foot and Ankle Society (AOFAS) score of the dislocated extremity was signifi cantly lower compared with the uninjured side (71 versus 93). On radiographs at follow-up, 89% of the patients showed subtalar joint abnormalities with 63% of these being symptomatic. Four patients of the 25 eventually required subtalar arthrodesis.

Bibbo et al. emphasized the importance of obtaining a CT scan after reduction of the subtalar dislocation because their patients who had a subtalar dislocation had additional abnormalities identifi ed on CT that were initially missed on plain radiographs. We routinely use CT for further evaluation of these injuries and often fi nd fractures that require treatment because of intraarticular displacement or fragments blocking congruent reduction of the subtalar joint. If a congruent reduction is obtained and proved on



C ED

BA

Fig. 86-33 A, Open lateral subtalar dislocation with fracture of lateral process of talus. B, Arrows mark posterior tibial tendon and disrupted posterior tibial artery. C, Anteroposterior view of same foot distorts lateral portion. D and E, Anteroposterior and lateral views after reduction show medial and lateral columns stabilized to maintain subtalar reduction.

CT scan, and there are no intraarticular fragments or dis-placed bone fragments requiring repair, we routinely treat subtalar dislocations nonoperatively (Fig. 86-34).

Open Reduction of Subtalar DislocationTECHNIQUE 86-12

• Make a longitudinal anterolateral incision 7.5 cm long from just proximal to the ankle joint to the cuboid. Carefully protect the medial and lateral dorsal cutaneous branches of the superfi cial peroneal nerve.

• Retract the extensor digitorum longus and extensor hallucis longus tendons medially and the peroneus tertius tendon laterally, and expose the talus and midtarsal joints.

• Incise the capsule over the head and neck of the talus, and extend the incision into the midtarsus.

• Insert a bone skid or periosteal elevator into the subtalar joint, and by leverage and traction reduce the dislocation of the subtalar and the talonavicular joints. When the dislocation is medial, have an assistant simultaneously abduct and evert the foot; when it is lateral, have the assistant adduct and invert the foot. In a lateral dislocation, the posterior tibial tendon frequently



C

E

D

B

A

Fig. 86-34 A and B, Medial subtalar dislocation with fracture of anterior process of calcaneus and posterior process of talus and proximal metaphysis of fi fth metatarsal. C and D, After closed reduction. E, Three months after injury, fi fth metatarsal fracture has healed; subtalar motion is limited despite normal appearance of joint.

blocks reduction and must be lifted out of the talonavicular joint before reduction is possible. Also, by extending the medial wound seen in lateral subtalar dislocations and lifting the dorsal neurovascular bundle and offending tendons, the dorsal capsule of the talonavicular joint can be incised. With this structure loosened, the navicular may be levered around the head of the talus with a periosteal elevator. This may require a separate anterolateral incision.

• If necessary, hold the reduction with longitudinally placed Steinmann pins across the calcaneocuboid and talonavicular joints for 4 weeks (see Fig. 86-33).

AFTERTREATMENT A cast is applied from the base of the toes to the tibial tuberosity over a bulky compression dress-ing. The cast is bivalved to allow for swelling, and active exercises of the metatarsophalangeal joints are encouraged. At 6 weeks, cast immobilization is discontinued; a lace-up foot and ankle leather corset is applied; active inversion, eversion, dorsifl exion, and plantar fl exion of the foot and ankle are encouraged; and weight bearing is allowed. The corset is worn for 1 month to control edema, and weight bearing to tolerance with crutches is allowed. Full weight bearing should be comfortable by 6 to 8 weeks after injury. Patients must be advised, however, that the foot and ankle



may swell, and the midfoot and hindfoot may feel stiff for several months.

MIDFOOT FRACTURES AND DISLOCATIONS

Fractures of the tarsal navicular can be divided into four types, and all can be treated in a cast with protected weight

bearing as long as fracture displacement is minimal. Displaced fractures of the body of the navicular should be treated with open reduction and internal fi xation, however; the goals are to maintain length of the medial column and to restore articular congruity. Sangeorzan et al. classifi ed navicular body fractures into three types and recommended treatment based on fracture type (Fig. 86-35). In type I fractures, in which the fracture plane is transverse, a satis-factory reduction usually was obtainable. In type II and

BA

C

Fig. 86-35 A, Type I fracture. Dorsal fragment usually consists of less than 50% of body of tarsal navicular. Anteroposterior radiographs show only subtle double cortical shadow at joint line. B, Type II fracture. Talonavicular joint is most often subluxated dorsally and medially with adduction of forepart of foot. C, Type III fracture. Comminuted fracture of body of navicular is associated with disruption of cuneiform-navicular joint, lateral deviation of forepart of foot, and injuries to cuboid or anterior process of calcaneus. (From Sangeorzan BJ, Benirschke SK, Mosca V, et al: Displaced intraarticular fractures of the tarsal navicular, J Bone Joint Surg 71A:1504, 1989.)



type III fractures, reduction was more diffi cult. In each case, an approach was made over the anteromedial hindfoot in the interval between the anterior and posterior tibial tendons. The periosteum of the navicular was not elevated, and the joints were inspected and cleared of debris before fi xation. Fixation usually was obtained with smooth Kirschner wires and small fragment AO screws when the size of the fragment permitted (Fig. 86-36).

If collapse of the navicular occurs with medial column shortening, bone grafting, temporary fi xation to the talus or cuneiforms, or application of a small external fi xator is used for additional fi xation. A prolonged recovery and persistent symptoms are the rule in these injuries.

Navicular stress fractures are frequent causes of arch pain in athletes. Because many of these fractures are not clearly identifi ed on routine radiographs, a high index of suspicion is necessary for accurate diagnosis. Torg et al. reported 21 patients with this injury. Most patients have increasing arch pain with activity. Track athletes seem to be particularly vulnerable. The midfoot may be tender over the navicular, and the foot may be irritable with eversion and inversion stress. Radiographs may be normal initially, but a bone scan frequently is positive, and tomograms, CT, or MRI may confi rm the diagnosis. In an extensive review of 86 proven cases of navicular stress fractures, Khan et al. found that with two exceptions the fractures were located in the sagittal plane, involving the central third of the navicular bone. There were 83 partial fractures and three complete fractures. In their series, non–weight bearing cast immobilization for 6 weeks initially was successful in 86%. Limitation of activity resulted in only a 38% success rate, whereas surgical management with bone grafting and internal fi xation resulted in a 67% success rate. Based largely on their work, Quirk recommended the following treatment:

1. At the time of initial diagnosis, all patients should be placed in a below-knee, non–weight bearing cast for 6 weeks.

2. If tenderness is still located over the navicular after 6 weeks of non–weight bearing immobilization, another cast is applied for 2 weeks.

3. If treatment is successful, the patient is allowed to return to previous activity gradually under supervision.

Quirk also suggested that if open reduction, internal fi xa-tion, and bone grafting are required, a CT scan should be made preoperatively with a marker placed over the fracture line to help identify the area intraoperatively.

Cuboid and cuneiform fractures are rare as isolated inju-ries. These bones frequently are injured as part of a wider injury pattern involving the Lisfranc (most common) or Chopart joint. Cuboid fractures can be classifi ed into avul-sion or compression types. Small avulsions may occur with inversion-type ankle sprains and generally respond to con-servative treatment. Compression, or “nutcracker,” frac-

tures of the cuboid are associated with Lisfranc and midtarsal disruptions. Most are minimally displaced and can be treated in a non–weight bearing cast for 4 weeks followed by weight bearing casts for 4 weeks. A well-molded arch support often is used afterward. For severe displacement with shortening of the lateral column, consideration should be given to open reduction and internal fi xation with bone grafting.

Richter et al., in their evaluation of 155 patients with midfoot fractures and dislocations, found a relative inci-dence of isolated midfoot fractures of 35.5%; Lisfranc fracture-dislocations, 31%; Chopart-Lisfranc fracture-dislocations, 16.8%; and pure Chopart fracture-dislocations, 16%. Dislocations and fracture-dislocations at the Chopart joint are frequent and are associated with high-energy inju-ries, such as traffi c accidents. The incidence of this injury at our institution has been markedly higher, especially since the introduction and routine use of airbags in motor vehi-cles. Patients who may not previously have survived inju-ries now sustain severe blunt force trauma to the feet often resulting in dislocations of the Chopart and Lisfranc joints in addition to other injuries. In this study and a similar study from the same authors, there seemed to be signifi cant improvement in the scores in patients who were treated with early operative intervention and anatomical or near-anatomical alignment and reduction of the joints. The lowest scoring results occurred in patients who had com-bined Chopart and Lisfranc fracture-dislocations. Most often, the exposure of the Chopart joint is a combination of that described for subtalar dislocation with an antero-lateral incision as described for the Lisfranc fracture-dislocation and a dorsomedial incision.

Fracture-Dislocations of the Tarsometatarsal Articulation (Lisfranc Joint)

Injuries of the tarsometatarsal articulation encompass a wide spectrum ranging from mild sprains or subtle sublux-ations to widely displaced debilitating injuries (Fig. 86-37). Myerson reported a 4% incidence per year of tarsometatar-sal injuries in collegiate football players. Players with medial or global tenderness had longer periods of disability than players with isolated lateral tenderness. Aitken and Poulson; Hardcastle et al.; Arntz and Hansen; Sangeorzan, Veith, and Hansen; and Adelaar have published excellent reviews on this subject. In 1986, Myerson et al. published a study of 76 high-velocity tarsometatarsal injuries, noting a direct correlation between better results and anatomical reduction of the fracture-dislocation.

A study by Petje et al. found statistically signifi cant anatomical abnormalities in the normal foot of patients with contralateral Lisfranc fracture-dislocations. This abnormality is best described as a shallow recessed mortise in the second metatarsal, which suggests that patients who do have a Lisfranc fracture-dislocation may have



BA

DC

E

Fig. 86-36 Open reduction and internal fi xation of type III navicular fracture. A and B, Preoperative radiographs. C, Semicoronal CT scan showing comminution of body of navicular. D and E, Postoperative radiographs.



Fig. 86-37 Dorsal view of foot showing contour of tarso-metatarsal joints.

underlying anatomical abnormalities in the feet that might predispose them to contralateral injury.

Teng et al. reported less than satisfactory outcomes in 11 patients with excellent anatomical alignment 41 months after surgical treatment of closed Lisfranc fracture-dislocations. Although objective measures of gait analysis had returned to normal, the investigators concluded that even with seemingly anatomical restoration of normal alignment, many patients did poorly subjectively. Many patients, even with degenerative posttraumatic changes in the joints, have a satisfactory result, however.

Classifi cationClassifi cation of this injury is useful for communication between orthopaedists and for determining the plane of displacement and magnitude of soft-tissue injury. The clas-sifi cation is not prognostic for the result, however. Myerson’s modifi cation of the original classifi cation of Quénu and Küss and Hardcastle et al. is presented because it incorpo-rates more proximal injuries to the medial column of the foot (Fig. 86-38). Subtle injuries through the intercunei-form region and the naviculocuneiform joint probably are more common than previously thought.

Type A Injuries Type A injuries involve displacement of all fi ve metatarsals with or without fracture of the base of the second metatarsal. The usual displacement is lateral or dorsolateral, and the metatarsals move as a unit. These injuries are referred to as homolateral.

Type B Injuries In type B injuries, one or more arti-culations remain intact. Type B1 injuries are medially displaced, sometimes involving the intercuneiform or naviculocuneiform joint. Type B2 injuries are laterally dis-placed and may involve the fi rst metatarsal–cuneiform joint.

Type C Injuries Type C injuries are divergent injuries and can be partial (C1) or complete (C2). These generally are high-energy injuries, associated with signifi cant swelling, and prone to complications, especially compartment syndrome.

Evaluation and TreatmentAny injury resulting in midfoot tenderness and swelling merits a careful physical and radiographic examination. Although grossly displaced fracture-dislocations are obvious on examination, care should be taken with subtle injuries to palpate each articulation for tenderness and swelling, especially the medial cuneiform–fi rst metatarsal joint, which often appears nondisplaced on radiographs. Trevino and Kodros described a “rotation test,” in which stressing the second tarsometatarsal joint by elevating and depressing the second metatarsal head relative to the fi rst metatarsal head elicits pain at the Lisfranc joint. Careful observation of the plantar aspect of the foot may reveal a small ecchy-mosis indicating a signifi cant injury. The inability to bear weight on the foot is another sign of potential instability.

Radiographs must be obtained with the patient bearing weight. If the radiograph reveals no displacement, and the patient cannot bear weight, a short leg cast should be used for 2 weeks, and the radiographs should be repeated with weight bearing. Evaluation should be directed to the fol-lowing areas:

1. The medial shaft of the second metatarsal should be aligned with the medial aspect of the middle cuneiform on the anteroposterior view.

2. The medial shaft of the fourth metatarsal should be aligned with the medial aspect of the cuboid on the oblique view.

3. The fi rst metatarsal–cuneiform articulation should have no incongruency.

4. A “fl eck sign” should be sought in the medial cunei-form–second metatarsal space. This represents an avul-sion of the Lisfranc ligament.

5. The naviculocuneiform articulation should be evaluated for subluxation.

6. A compression fracture of the cuboid should be sought.

Potter et al. and Preidler et al. described MRI of the Lisfranc ligament in the acute setting and if the level of injury cannot be determined by plain radiographs.

Compartment syndrome, although rare and usually seen only with higher energy fracture-dislocations, can cause



Totalincongruity

Partialincongruity

Divergent

Lateral Dorsoplantar

Medial dislocation

Lateral dislocation

Partialdisplacement

Totaldisplacement

Type A

Type B1

Type B2

Type C1 Type C2

Fig. 86-38 Classifi cation of tarsometatarsal fracture-dislocations. (From Myerson M, Fisher R, Burgess A, et al: Dislocations of the tarsometatarsal joints: end results correlated with pathology and treatment, Foot Ankle 6:225, 1986.)



severe, diffi cult-to-treat clawing of the toes and chronic pain. We routinely obtain compartmental pressures in patients who have severe swelling, but individual compart-ments can be diffi cult to assess, and clinical suspicion alone is enough to warrant decompression. We prefer a long medial incision to decompress the abductor hallucis and deep compartments of the foot, including the calcaneal compartment, as described by Manoli (Fig. 86-39A). In addition, two incisions—one between the second and third and one between the fourth and fi fth metatarsals—are used for the dorsal intrinsic compartments (Fig. 86-39B).

The key to successful outcome in Lisfranc injuries is anatomical alignment of the involved joints. Closed, non-displaced (<2 mm) injuries can be treated with a non–weight bearing cast for 6 weeks followed by a weight bearing cast for an additional 4 to 6 weeks. Repeat radio-graphs should be obtained to ensure that no displacement is occurring in the cast. Displaced fractures should be treated operatively (Fig. 86-40). Closed reduction, using fi nger traps and countertraction, can be successful if dis-placement is not severe. Fixation should be used to main-tain the reduction. Steinmann pins (3/32-inch) can be used, especially for the lateral two joints; however, 4-mm can-nulated or 4-mm standard, partially threaded cancellous screws provide excellent fi xation and can be inserted under

image control. Using cannulated screws makes removal easier by employing a guide pin to fi nd the screw head and ultimately to seat with the screwdriver. If the reduction is inadequate, or signifi cant comminution is present, open reduction is preferred, especially in partial (type B) or divergent (type C) patterns.

The literature confi rms that the ability to obtain and maintain an anatomical reduction of a fracture-dislocation is associated with improved outcome over nonanatomical reduction. Kuo et al., in their evaluation of open reduction and internal fi xation in 48 patients with Lisfranc injuries with an average follow-up of 52 months, found that non-anatomical reduction was associated with the presence of posttraumatic arthrosis in 60%. In patients with anatomical reduction, posttraumatic arthrosis occurred in only 16%. No statistical signifi cance was shown in their series regard-less of whether the injury was open or closed, whether all fi ve tarsometatarsals or fewer were injured, whether a cuneiform or cuboid was injured, whether the Lisfranc injury was isolated or associated with multiple injuries, whether the diagnosis was made acutely or delayed, or whether it was a work-related injury.

Degenerative posttraumatic arthrosis can be managed successfully with tarsometatarsal and intermetatarsal arthrodesis as necessary for stabilization of the arthritic

B

A

Medial extension of plantar aponeurosis

Intermuscular septum

Plantar interosseous fascia

Fig. 86-39 A, Cross section of foot showing release of four fascial compartments of forefoot through medial approach (top). Single medial incision for decompression of fascial compartments of foot (bottom). Proximal extension used for decompression of calcaneal compartment and tarsi tunnel. B, Double dorsal longitudinal incisions (left) are used to decompress all four compart-ments (right). (From Lutter LD, Mizel MS, Pfeffer GB, eds: Injuries to the midfoot and forefoot. In Orthopaedic knowledge update: foot and ankle, Chicago, 1994, AAOS.)



AFTERTREATMENT A bulky dressing and posterior splint are applied postoperatively. These are converted to a short leg, non–weight bearing cast at 7 to 10 days postopera-tively. Partial weight bearing may be allowed at 6 to 8 weeks. Laterally placed Steinmann pins are removed at 8 weeks. Medial screws are removed at 4 months. A prefab-ricated walker is used until the medial screws are removed.

Because many of these injuries are initially missed, the question is at what point should open reduction and inter-nal fi xation without arthrodesis still be attempted. We attempt open reduction and internal fi xation without arthrodesis 8 weeks after injury in a patient weighing less than 150 to 160 lb and having little or no comminution. Patients who weigh more are treated earlier with arthro-desis of the medial three joints and rarely, if ever, with arthrodesis of the lateral two joints (Fig. 86-42). Mobility is important in the fourth and fi fth metatarsal–cuboid

DC

BA

Fig. 86-40 Subtle Lisfranc instability. A, Intraoperative fl uo-roscopic radiograph showing fl eck sign at medial cunei-form–second metatarsal articulation. Patient was taken to operating room because standing radiographs in offi ce showed subtle subluxation, swelling, and tenderness and pointed to more serious instability. B, Intraoperative stress radiographs showing subluxation of fi rst through third tarsometatarsal articulations. C, Provisional stabilization with guidewires inserted under fl uoroscopic control. D, Final fi xation with cannulated screws.

joints and reduction of posttraumatic fl atfoot deformity. In a review of 32 patients who had arthrodesis of the tarso-metatarsal joints for intractable pain after traumatic injury of the midfoot, Komenda, Myerson, and Biddinger noted signifi cant improvement in the AOFAS score for the midfoot from 44 points preoperatively to 78 points post-operatively. Mann, Prieskorn, and Sobel reported long-term results of arthrodesis of the midtarsal and tarsometatarsal joints in 40 patients, of whom 17 had posttraumatic arthri-tis. In their series, 93% of patients were satisfi ed with the results at an average follow-up of 6 years.

TECHNIQUE 86-13

• With the patient under a regional or general anesthetic, make a dorsal incision lateral to the extensor hallucis longus tendon over the interval between the base of the fi rst and second metatarsals. At the distal extent of the excision, preserve the most medial branch of the dorsal medial cutaneous nerve.

• Locate and incise the inferior extensor retinaculum.

• Isolate the dorsalis pedis artery and deep peroneal nerve, and use a vessel loop for retraction of these structures medially or laterally to allow inspection of different areas of the Lisfranc joint (Fig. 86-41A).

• Remove any debris from the Lisfranc region between the base of the second metatarsal and the medial cuneiform to allow the space to be reduced. If an intercuneiform screw is needed, insert it under fl uoroscopic guidance from the medial side of the medial cuneiform into the middle cuneiform (Fig. 86-41B).

• Under fl uoroscopic guidance, pass a guidewire from the medial cuneiform into the base of the second metatarsal while holding the reduction with a towel clip.

• Pass a 4-mm cancellous cannulated screw over the guidewire. Reduce any injury and instability to the fi rst tarsometatarsal joint, and hold similarly with a screw from the dorsal aspect of the fi rst metatarsal into the medial cuneiform (Fig. 86-41C). The third metatarsal-cuneiform joint usually is visible through this dorsal incision and can be reduced and fi xed similarly.

• Reduce lateral metatarsocuboid disruptions either closed with smooth 3/32-inch Steinmann pins or open through a parallel incision centered dorsolaterally over the articulations (Fig. 86-41D).

• Close the dorsal skin with interrupted nylon sutures.



DCB

A

Inferior extensorretinaculum

Extensor hallucisbrevis

Extensor hallucislongus

Dorsalis pedisartery

Fig. 86-41 A, Extensile dorsomedial approach to midfoot. Dorsolateral approach to second and third metatarsals (left). Dorsomedial approach to fi rst and second metatarsals (right). B, Medial and middle column fi xation. C, Temporary lateral column fi xation. D, Permanent lateral column fi xation. (From Trevino SG, Kodros S: Controversies in tarsometatarsal injuries, Orthop Clin North Am 26:229, 1995.)

articulation, and posttraumatic arthrosis may cause only mild symptoms in this region.

METATARSALS

Fracture of the Proximal Portion of the Fifth Metatarsal

A great deal of attention has been directed toward the treatment of fractures of the proximal portion of the fi fth metatarsal. As described by DeLee, type I fractures usually are acute and occur at the junction of the shaft and base (Fig. 86-43A to D). Type II fractures occur at the metaph-yseal or diaphyseal junction with clinical or radiographic evidence of a previous injury (Fig. 86-43E). Type III frac-

tures involve fractures of the styloid process (Fig. 86-43F; Table 86-1). Type I and type II fractures, which occur 2 cm or more from the tip of the tuberosity, are caused by vertical or medial-lateral forces. The mechanism of injury for type III or styloid avulsion fractures is an inversion injury to the plantar fl exed foot.

Treatment of type I fractures depends on the type of fracture and the activity demands of the patient. For an acute type IA fracture, an initial non–weight bearing, short leg cast is worn for 6 to 8 weeks followed by a weight bearing cast until union has been achieved. Type IB frac-tures with displacement and comminution can be treated similarly; however, in competitive athletes, consideration should be given to early open reduction and internal fi xa-tion to decrease disability time. Even with non–weight bearing immobilization for 6 to 8 weeks, type I fractures



C

BA

D

Fig. 86-42 Divergent Lisfranc fracture-dislocation. A and B, Preoperative radiographs. Note intercuneiform and naviculo-cuneiform disruption. C and D, Postoperative radiographs. Intracuneiform arthrodesis was performed for stabilization. Patient’s weight was 250 lb.

have a reported nonunion rate of 7% to 28%. The use of electrical and pulsed ultrasound and bone stimulation for these fractures may improve healing of the fracture; however, they cannot take the place of internal fi xation in a high-performance athlete.

In type II fractures with clinical or radiographic evi-dence of chronic injury manifested by partial or complete canal obliteration and sclerosis, non–weight bearing casting may yield satisfactory results. Generally, the period of immobilization and non–weight bearing is approximately 8 weeks. Refracture is common in this category.

Type III fractures generally are treated satisfactorily in a short leg cast for 3 weeks followed by a well-molded arch support. Although nonunions of type III fractures may

occur, they rarely are painful and can be treated with exci-sion of the fragment. Wiener, Linder, and Giattini, in a prospective evaluation of treatment of type III injuries of the proximal fi fth metatarsal, found that the fracture healed in all patients (n = 60) at an average of 44 days, with no fracture taking longer than 65 days. Patients were ran-domly assigned to a soft Jones type of dressing or a short leg cast. They found that the patients treated with a com-pressive soft dressing and allowed to bear weight in a cast boot required a signifi cantly shorter recuperation time and had a better modifi ed foot score than the patients treated with cast immobilization.

Surgery should be considered for type I fractures that are not healing clinically at 8 to 12 weeks. Surgery should



B DC

A

FE

Table 86-1 • Classifi cation of Fractures of the Base of the Fifth Metatarsal

Type Description

I Acute fractures at the metaphyseal-diaphyseal junctionIA NondisplacedIB Displaced or comminuted or bothII Fractures at the metaphseal-diaphyseal junction with clinical or radiographic evidence of previous injury (i.e., pain, sclerosis)III Fractures of the styloid process of the fi fth metatarsalIIIA Without involvement of the fi fth metatarsocuboid jointIIIB With involvement of the fi fth metatarsocuboid joint

From DeLee JC: Fractures and dislocations of the foot. In Mann RA, Coughlin MJ, eds: Surgery of the foot and ankle, 6th ed, St Louis, 1993, Mosby. © Jesse C. DeLee, MD.

Fig. 86-43 Fractures of base of fi fth metatarsal. A, Type IA, acute fracture of proximal diaphysis of fi fth metatarsal. B-D, Type II fractures. E, Type IIIA, fracture of styloid process without articular involvement. F, Type IIIB, fracture of styloid process with joint involvement. (A-D from Zelko RR, Torg JS, Rachun A: Proximal diaphyseal fractures of the fi fth metatarsal—treat-ment of the fractures and their complications in athletes, Am J Sports Med 7:95, 1979; E and F from DeLee JC: Fractures and dislocations of the foot. In Mann RA, Coughlin MJ, eds: Surgery of the foot and ankle, 6th ed, St Louis, 1993, Mosby. © Jesse C. DeLee, MD)

be considered for type II fractures in competitive athletes and others whose occupational demands do not allow pro-longed non–weight bearing immobilization. Open reduc-tion and internal fi xation only rarely are necessary and generally are reserved for displaced intraarticular (type

IIIB) fractures in highly competitive individuals (Fig. 86-44).

For type I and type II fractures that require surgical intervention, two operative treatments have proved suc-cessful: (1) fi xation with a medullary 4.5-mm malleolar screw and (2) corticocancellous inlay bone grafting with clearing of the medullary canal of all sclerotic bone. We and most authors currently use an intramedullary screw technique, but we present both methods, each of which has a satisfactory success rate. Glasgow et al., in a critical review of surgical management of these fractures, found that use of screws other than a 4.5-mm malleolar screw was associated with failure. They attributed the failure of corticocancellous grafting to the use of undersized grafts and incomplete medullary reaming. We have had success using a variety of screw types, including variable pitched compression screws (Fig. 86-45), 5.5-mm and larger can-nulated screws, and noncannulated screws with low-profi le heads. We believe that there are many options for screw fi xation of the fi fth metatarsal, depending on the surgeon’s preference and the size of the canal on the preoperative template; however, using a screw smaller than 4.5 mm is not recommended.



C

BA

Fig. 86-44 A-C, Type IIIB (DeLee) fi fth metatarsal fracture.

Internal Fixation with a Malleolar Screw

As Donley et al. showed, the sural nerve, in particular the dorsolateral branch, lies very close to the insertion point of the screw. This technique should not be performed percutaneously, and suffi cient exposure must be obtained to identify and protect this cutaneous nerve branch.

TECHNIQUE 86-14 Kavanaugh, Brower, and Mann

• Expose the proximal 2 cm of the fi fth metatarsal on its dorsolateral surface.

• Incise the skin only, and observe and protect the two branches of the sural nerve—one dorsal and one straight lateral—that are vulnerable. If the peroneus brevis obscures the portal for the drill, raise a portion of it from the bone.



F

D

E

Fig. 86-44, cont’d D-F, After screw fi xation.

• Use a Kirschner wire to fi nd the medullary canal. This can be diffi cult, and the drill must lie almost parallel to the hindfoot. Starting slightly dorsal to what appears to be the center of the bone also helps.

• Drive a 3.2-mm drill bit into the medullary canal, and confi rm its location by anteroposterior and lateral radiographs (Fig. 86-46A and B).

• Tap the narrow portion of the canal with a 3.2-mm cortical tap and sleeve. This is a self-tapping malleolar screw and should not require tapping, but we have found this step helpful.

• Estimate the length of the screw from the intraoperative radiographs.

• Countersink the entry portal, and insert the screw.

• Verify screw placement with radiographs, and close the wound.

• Exposing a nonunion and applying a small cancellous bone graft may or may not enhance union; if cortical thickening and sclerosis are present, we usually do so (Fig. 86-46C and D).



A

FED

CB

Fig. 86-45 A-C, Type IA (DeLee) fi fth metatarsal fracture in collegiate soccer player. D-F, After fi xation with variable pitch compression screw.



graft is not fi rmly inset, the technique described by Torg et al. is used. A consistent fi nding in the presence of non-union of this fracture is obliteration of the medullary canal by dense, sclerotic bone along the margins of the fracture. Torg et al. suggested that the tendency of this fracture toward nonunion or delayed union or refracture after healing is the result of the formation at the fracture of this poorly organized, sclerotic bone, which impairs healing and the strength of the union. The purpose of their surgical technique is to reestablish the continuity of the medullary canal by removing the sclerotic bone and to facilitate healing of the fracture by inserting an inlay bone graft.

DC

BA

Fig. 86-46 Internal fi xation of fi fth metatarsal fracture. A and B, Position of drill bit confi rmed with anteroposterior and lateral radio-graphs. C, Malleolar screw (6.5 mm) and small iliac cancellous bone graft were used because of cor tical hyper-trophy and history of repeated frac-tures. D, Several months after clinical and radiographic union, screw was removed at patient’s request; screw can remain in place indefi nitely.

AFTERTREATMENT A well-padded, short leg, nonwalk-ing cast, extending to the toes, is applied and is worn for 6 weeks, followed by a walking cast for another 4 to 6 weeks or until the fracture has united. Return to competitive sports is discouraged until the fracture has healed clinically and radiographically, which usually takes 10 to 12 weeks.

Inlay Bone Graft

With the exception of using an iliac corticocancellous bone graft instead of tibial bone and the occasional use of a small fragment screw or one or two small Kirschner wires if the



C

BA Fig. 86-47 Technique of Torg et al. for reduction and grafting of fractures of base of fi fth metatarsal distal to tuberosity (see text). A, Subperiosteal exposure through dorsolateral curvilinear incision; rectangular piece of bone is outlined with four drill holes. B, Piece of bone is excised with osteotome, and sclerotic bone in medullary canal is removed with curet or drill. C, Autogenous cortical graft from distal tibia is contoured and placed in defect. (From Torg JS, Balduini FC, Zelko RR, et al: Fractures of the base of the fi fth metatarsal distal to the tuberos-ity: classifi cation and guidelines for non-surgical and surgical management, J Bone Joint Surg 66A:209, 1984.)

TECHNIQUE 86-15 Torg et al.

• Approach the base of the fi fth metatarsal through a curvilinear dorsolateral incision, and expose the fracture subperiosteally.

• Outline with four drill holes a rectangular piece of bone measuring 0.7 cm × 2 cm, centered over the fracture, and remove this with a sharp osteotome (Fig. 86-47A).

• Curet, drill, or curet and drill the medullary canal until all sclerotic bone has been removed, and continuity of the canal has been reestablished (Fig. 86-47B).

• Through a second incision, remove an autogenous cortico-cancellous bone graft measuring 0.7 cm × 2 cm from the anteromedial aspect of the distal end of the tibia.

• Contour the graft with a high-speed burr so that the cortical portion of the graft fi ts accurately into the rectangular cortical defect and does not protrude into the medullary canal (Fig. 86-47C).

• Close the metatarsal incision in layers.

• To prevent the formation of a stress-riser, place in the tibial defect the section of bone removed from the fracture before closing this incision.

AFTERTREATMENT A non–weight bearing plaster boot is applied and is worn for 6 weeks, followed by 6 weeks in a short leg walking cast.

Distal Fifth Metatarsal Fracture

Spiral fractures of the distal fi fth metatarsal are common and occur frequently in dancers and professional athletes. The mechanism of injury has been reported to be rota-tional, with rolling over on the outer border of the foot while standing on the ball of the foot with the ankle fully plantar fl exed (demi pointe position). O’Malley, Hamilton, and Munyak reviewed their results after open reduction and internal fi xation or closed reduction with percutaneous pinning in 35 dancers with this injury. They found that even in displaced fractures, cast immobi-lization or symptomatic treatment with bandaging and full weight bearing had no long-term consequences. They reported one delayed union and one refracture, both of which subsequently healed. All of the ballet dancers returned to professional performance without limitations, and no patient reported pain with performance at follow-up.



Stress Fractures of the Metatarsals

A variety of factors lead to the development of stress frac-tures of the metatarsals. They occur most commonly in women, especially during the early years of menopause in the phase of rapid bone resorption. Postmenopausal women often are counseled to begin weight bearing exercises to diminish loss of bone mass. Stress fractures also have been noted to occur in athletes, especially ballet dancers and athletes engaged in cutting and jumping sports; amenor-rheic female athletes are of particular concern. Military recruits in their fi rst few weeks of training also are vulner-able to so-called march fractures. Individuals with diabetes and sensory and motor neuropathy, rheumatoid arthritis, Charcot-Marie-Tooth disease, or stroke may be at risk as well.

Patients often note the gradual onset of pain directly over the second metatarsal neck region 2 to 4 weeks after beginning a running or aerobics program. Swelling over the area usually is noted. The diagnosis is suspected on history and physical examination. Initial radiographs made within 2 weeks after the onset of symptoms may be nega-tive, and bone scan or MRI may assist in the diagnosis in questionable cases. Generally, repeat radiographs at 4 to 6 weeks after injury reveal periosteal new bone formation. Differential diagnoses include entrapment neuritis of the superfi cial peroneal nerve, radiating pain from a more proximal tarsometatarsal joint arthrosis, and idiopathic or overuse synovitis of the adjacent metatarsophalangeal joint.

A subset of fractures that may be especially diffi cult to manage include stress fractures of the proximal second metatarsal. O’Malley et al. identifi ed a stress fracture at the base of the second metatarsal in 51 ballet dancers. In all their patients, conservative management with relative rest and boot or cast immobilization resulted in resolution of symptoms. It is important to inform the patient that a stress fracture at the second metatarsal occasionally may result in a slight dorsifl exion malunion and transfer of weight to the third metatarsal, which is at risk for the development of a stress fracture. Surgical intervention rarely is required for stress fractures; however, open reduction and plating may be required if signifi cant bony healing has occurred in a malunion (Fig. 86-48A and B).

AFTERTREATMENT A well-padded cast is applied over a sterile dressing and changed at 3 to 5 days with a wound check, and sutures are removed at 10 to 14 days. Weight bearing is allowed depending on perceived fracture stabil-ity. Pulsing electromagnetic fi eld or ultrasound may be used for high-risk fractures, such as fractures in the base of the fourth or fi fth metatarsal and fractures in patients who smoke or have systemic illnesses.

ComplicationsThe most frequent complication of open reduction and plating is painful, prominent hardware. Generally, this should not be removed earlier than 1 year after surgery, and the mechanical issues that contributed to the fracture in the fi rst place should be treated. Nonunion despite ade-quate fi xation may occur, and if it does, care should be taken to treat all reasons for the nonunion (smoking, poor nutrition, improper shoe gear, and lack of orthotic management).

Acute Fractures of the Central Metatarsals

Relatively few articles in the literature have addressed frac-tures of the central three metatarsals. The mechanism of injury usually is direct, such as a motor vehicle accident, which is reported to be the most common. Alepuz et al. evaluated the fi nal results of 57 patients treated operatively and nonoperatively for central metatarsal fractures and noted numerous poor results (39%). Only 32% of their patients obtained a good result regardless of the type of

Open Reduction and Plating of Lesser Metatarsal Stress FractureTECHNIQUE 86-16

• After regional or general anesthesia, place an ankle tourniquet.

• Make a longitudinal incision over the fractured metatarsal. Identify and protect the dorsal medial (superfi cial peroneal),

dorsal intermediate (superfi cial peroneal), and dorsal lateral (sural) nerves (Fig. 86-48C). For fractures at the base of the second metatarsal, avoid injury to the deep peroneal nerve and dorsalis pedis artery, which lie just medial to the metatarsal.

• Gently elevate the periosteum, and expose the fracture. Use a small curet to remove fi brous tissue if present. Prepare and “freshen” the fracture with a small drill bit.

• If bone graft is to be used, pack it into the fracture at this point. Bone graft (3 to 5 cm2) can be obtained from the calcaneus or the distal tibia.

• Use a small fragment plate for fi xation (Fig. 86-48D). When selecting an implant system, choose a low-profi le design. Locking plates generally are not required. Although contouring of the plate is unnecessary for the second and third metatarsals, some contouring may be required for fractures of the fourth or fi fth metatarsals, especially if metatarsus adductus is present (Fig. 86-48E). Four cortices of purchase on each side of the metatarsal are ideal (Fig. 86-48F and G).

• Close the periosteum over the plate and bone if possible. Close the skin with a few subcutaneous 4-0 or 5-0 nylon sutures if necessary.



G

F

ED

CBA

Fig. 86-48 A and B, Preoperative oblique and anteroposterior radiographs. C, Curettage and preparation of second metatarsal. Note vessel loop around dorsalis pedis and deep peroneal nerve. D, Plating of second metatarsal. E, Exposure of fourth metatar-sal. F and G, Postoperative anteroposterior and lateral radio-graphs. (From Murphy GA: Operative treatment of stress frac-tures of the metatarsals, Op Tech Sports Med 14:239, 2006.)

treatment. Factors cited as contributing to the poor outcome included sagittal plane displacement, open fracture, and severe soft-tissue injury. It has been our experience that mild lateral plane displacement may be tolerated; however, sagittal plane displacement of a metatarsal head either in extension or plantar fl exion or excessive shortening of a metatarsal leads to metatarsalgia and chronic forefoot pain.

For this reason, closed reduction and percutaneous pinning from a dorsal approach is recommended. Occasionally, the displacement is severe enough to require open reduction and internal fi xation. Care must be taken to realign the toe in the sagittal plane, and this assessment is done primar-ily while palpating the levels of the metatarsal heads to ensure they are in the same plane.



PHALANGEAL DISLOCATIONS

Interphalangeal Joint of the Hallux

Dislocation of the interphalangeal joint of the hallux usually is caused by hyperextension, with the distal phalanx posi-tioned dorsal to the proximal phalanx. Tearing of the plantar skin at the interphalangeal joint fl exion crease is common, rendering this an open injury. Most of these dislocations can be reduced closed. If the dislocation is irreducible, two obstacles to reduction may be present: a sesamoid bone or the plantar plate of the interphalangeal joint may be interposed. The fl exor hallucis longus also can be displaced into the joint, but generally is not the primary deterrent to reduction. Finally, at least one collateral liga-ment (usually the tibial) is torn.

Miki, Yamamuro, and Kitai identifi ed two types of interphalangeal dislocations of the hallux. In the fi rst, the plantar plate, ruptured from one or both of its phalangeal attachments (usually proximally), is trapped within the joint; the interphalangeal joint space is widened (Fig. 86-49) and the deformity is minimal, even deceiving. In the second, more common, type, the distal phalanx lies dorsal to the proximal phalanx, locking the joint in hyper-extension. The deformity is obvious. The sesamoid bone within the plantar plate prevents reduction (Fig. 86-50).

Closed reduction under digital block should be attempted. The dislocation can be reduced easily if one or more col-lateral ligaments are torn, and there is no interposition of

BA

Fig. 86-49 A, Anteroposterior radiograph shows marked widening of interphalangeal joint. B, Lateral view shows wide joint space; distal phalanx is not hyperextended. (From Miki T, Yamamuro T, Kitai T: An irreducible dislocation of the great toe: report of two cases and review of the literature, Clin Orthop Relat Res 230:200, 1988.)

Fig. 86-50 Anteroposterior radiograph shows overlapping of proximal phalangeal head and distal phalangeal base. (From Miki T, Yamamuro T, Kitai T: An irreducible dislocation of the great toe: report of two cases and review of the literature, Clin Orthop Relat Res 230:200, 1988.)

a sesamoid or plantar plate. Longitudinal traction is applied fi rst in the axial plane of the deformity, followed by fl exion when the distal phalanx is level with the articular surface of the proximal phalanx. If the radiograph after reduction shows widening of the joint space, the plantar plate still may be interposed, and open reduction is indicated.

Although it had been our experience that interphalan-geal joint dislocations of the lesser toes are reducible by closed methods and do well with buddy taping to the adjacent toe for 3 weeks, Brunet and Tubin reported that nearly all dislocated lesser toe interphalangeal joints in their study required an open reduction. Approximately 30% of dislocated lesser toe metatarsophalangeal joints required open reduction because they were not reducible by closed means. Lesser toe interphalangeal joints that were reduced were virtually asymptomatic at follow-up; however, resid-ual dislocations at the metatarsophalangeal joints were per-sistently painful. In most of their patients, the plantar plate prevented closed treatment by being incarcerated within the joint. These injuries can be reduced through a dorsal midline incision (Fig. 86-51). Open reduction is performed for irreducible dislocations or if joint space widening is obvious on radiograph after closed reduction, even if the toe rests in the proper position clinically (Fig. 86-52).

Open ReductionTECHNIQUE 86-17

• Make a dorsal inverted L–shaped incision with the transverse limb at the joint and the longitudinal limb dorsolateral. Preserve the extensor hallucis longus insertion into the distal phalanx.



Fig. 86-51 Recurrent dislocation of proximal interphalan-geal joint of right fourth toe was treated successfully by resection of head and neck of proximal phalanx and immo-bilization for 3 weeks.

Fig. 86-52 Interphalangeal joint space remains wider than normal after closed reduction; this is an indication for open reduction. (From Miki T, Yamamuro T, Kitai T: An irreducible dislocation of the great toe: report of two cases and review of the literature, Clin Orthop Relat Res 230:200, 1988.)


• On one side of the extensor hallucis longus, identify the plantar plate (identifi cation is easier if the sesamoid is within it), and make a 3- to 4-mm longitudinal incision in it. Reduce the joint with traction.

• If reduction cannot be accomplished, use a probe or small Freer elevator to displace the sesamoid and plantar plate distally, while placing traction on the great toe.

• If the joint is stable, no transarticular pin is needed. If the reduction is unstable, hold the joint reduced, and drill one or two 0.062-inch Kirschner wires longitudinally distal to proximal to rest in subchondral bone at the base of the proximal phalanx.

• Cut the wires off 2 mm outside the skin, and apply a well-padded short leg cast extending past the toes.

AFTERTREATMENT The patient is instructed to rest and elevate the extremity for 3 days with bathroom privileges only and then to begin partial weight bearing with crutches. At 3 weeks, the wires are removed, and weight bearing to tolerance is allowed in a postoperative wooden-soled shoe. Active and active-assisted range of motion of the interpha-langeal joint is begun at that time. At 6 weeks, a wide toe box shoe is allowed.

Marginal wound necrosis and prolonged swelling of the toe are common, but with rest, elevation, reduction of edema, and time, these are not alarming problems. Some permanent limitation of interphalangeal joint motion is common after this injury. Initial radiographs should be reviewed carefully because other injuries to the forefoot are common.

First Metatarsophalangeal Joint

Dislocation of the fi rst metatarsophalangeal joint is rare. The mechanism of injury is hyperextension of the great toe, causing displacement of the proximal phalanx onto the dorsum of the fi rst metatarsal head and neck (Fig. 86-53). The head of the fi rst metatarsal becomes trapped between the fl exor hallucis brevis and abductor hallucis tendons medially, and the lateral head of the fl exor hallucis brevis and adductor tendons laterally. Dorsally, the meta-tarsal head is held by the plantar plate and the deep trans-verse metatarsal ligament. On the plantar surface, the plantar aponeurosis prevents further reduction. The fl exor hallucis longus tendon usually lies lateral to the metatarsal head.

Salamon, Gelberman, and Huffer advocated a transverse plantar approach for open reduction of these complex dis-locations. If this approach is selected, care must be taken to avoid injury to the neurovascular bundles, especially the medial plantar nerve to the great toe, which is superfi cial at this level.

Because of the vulnerability of the neurovascular bundles on the plantar surface of the foot, Yu and Garfi n recom-mended a midline longitudinal dorsal incision over the



BA

Fig. 86-53 Dorsomedial dislocation of fi rst metatarsophalan-geal joint. A, Dislocation could not be reduced by closed means. B, After open reduction, joint was stable.

metatarsophalangeal joint, which permits adequate expo-sure for reduction. The neurovascular bundles are not endangered with this exposure, and scarring on the weight bearing area of the foot is avoided.

Brunet reported 11 complex dislocations of the metatar-sophalangeal joints. Tarsometatarsal joint injuries frequently were present, and more than half of the injuries were open dislocations that required open débridement and relocation. One closed injury required open reduction, but the remain-ing fi ve were reduced by closed methods. One recurrent dislocation was noted in a patient who went back to jogging too soon. At an average of 7 years’ follow-up, all patients except one complained of decreased metatarsophalangeal joint motion, however, not to the extent of signifi cantly reducing endurance to work or exercise. All but one patient had returned to modifi ed or the same type of employment. Many patients had plantar sensitivities; four required the use of a full-time orthosis.

According to Jahss, closed reduction usually is impossi-ble in dorsal dislocations of the great toe in which the intersesamoid ligament is not disrupted (Fig. 86-54). If this ligament is torn with wide separation of the tibial and fi bular sesamoids, or if one of the sesamoids is fractured transversely, the dislocation frequently can be reduced closed. We recommend a midline medial approach.

Open Reduction Using a Midline Medial ApproachTECHNIQUE 86-18

• Make a medial longitudinal incision on the great toe about 5 cm long centered over the fi rst metatarsophalangeal joint. Use sharp dissection through the skin only to avoid injuring any displaced cutaneous nerves.

• Elevate the dorsal fl ap in the same manner as in hallux valgus repair, and assess the magnitude of injury to the collateral ligaments, the plantar plate with the enclosed sesamoids, and the dorsal capsule.

• Use a small Freer or periosteal elevator while hyperextending the great toe and applying traction, and guide the base of the proximal phalanx over the metatarsal head and into the reduced position.

• Repair the collateral ligament (usually the tibial collateral) and dorsal capsule with absorbable sutures.

• Assess the stability of the metatarsophalangeal joint by gentle fl exion and extension and by fl exing and extending the ankle to produce a pull on the long fl exor tendons.

• If the reduction appears unstable, drill a small Kirschner wire across the joint to maintain reduction. It should be removed 3 weeks after surgery.

• Remove the tourniquet, secure hemostasis, and close the skin with nonabsorbable, interrupted sutures.

AFTERTREATMENT Apply a short leg cast that extends distal to the toes over a bulky forefoot dressing that has been applied to hold the toe congruously on the metatarsal head and in 10 to 15 degrees of extension. Partial weight bearing with crutches is allowed during the fi rst 3 weeks, after which time the cast is removed, and full weight bearing is allowed in a wide toe box shoe. Active and active-assisted range of motion of the fi rst metatarsopha-langeal joint is begun, and a toe spacer in the fi rst web space is used for another 3 weeks. Permanent reduction in range of motion of the fi rst metatarsophalangeal joint can be expected, but functional motion should be regained after several months.

PHALANGEAL FRACTURES

Surgical treatment of phalangeal fractures of the toes is rarely required because most phalangeal fractures can be treated successfully by conservative measures. Occasionally, an intraarticular fracture severely displaced into the inter-phalangeal joint of the great toe may require open reduc-tion and internal fi xation to prevent deformity and arthritic changes. The fracture and the joint are exposed, the frac-ture is reduced anatomically, and with a power drill small



Adductor hallucis Transverse headOblique head

Flexorhallucis brevis

Abductor hallucis

SesamoidsJoint capsule

Plantar joint capsuleAttached to proximal phalanxDetached from metatarsal

Fig. 86-54 Anatomy of fi rst metatarsophalangeal joint. Examples of dislocations with disruption of intersesamoid ligament and fracture of tibial sesamoid. (From Jahss MH: Traumatic dislocations of the fi rst metatarsophalangeal joint, Foot Ankle 1:15, 1980.)

0.045-inch Kirschner wires are inserted for internal fi xa-tion (Fig. 86-55). These pins are bent and left outside the skin and generally removed 3 to 4 weeks after surgery when the fracture has stabilized. No cast is required, and protected weight bearing can begin as soon as soft-tissue healing permits.

SESAMOID FRACTURES

Fractures of the hallucal sesamoids most often are seen in an acute setting with dislocations of the metatarsophalan-geal joint after high-energy injuries. Chronic stress frac-tures of the sesamoids, most commonly seen in long-distance runners and ballet dancers, can be diffi cult to diagnose and differentiate from other conditions affecting the hallucal sesamoids. The medial or tibial sesamoid is the more com-monly injured sesamoid because it generally is larger than the fi bular sesamoid and is seated more directly beneath the metatarsal head. The sesamoids are reported to be multi-partite in 5% to 30% of asymptomatic individuals. Although the bipartite sesamoid can be bilateral, a singular sesamoid

BA

Fig. 86-55 Phalangeal fracture. Preoperative (A) and post-operative (B) radiographs.



in the contralateral foot does not absolutely confi rm the presence of fracture and can represent symptomatic syn-chondrosis of the bipartite sesamoid in an injured foot. Fractures and the bipartite condition occur more frequently in the tibial sesamoid.

Two features might distinguish a fracture from a bipar-tite sesamoid. (1) Fractured sesamoid bones tend to be roughly divided into equally sized sections; bipartite sesa-moids tend to have one larger fragment and one smaller fragment. (2) Bipartite sesamoids tend to have smooth, rounded edges; fractured sesamoids tend to have irregular, jagged edges. Simple separation of a synchondrosis of a bipartite sesamoid may have symptoms similar to a frac-tured sesamoid. If the fracture is not widely displaced, the differential diagnosis of a fractured sesamoid includes a painful bipartite sesamoid, osteochondritis dissecans, and osteonecrosis of the sesamoid.

The mechanism of injury to the sesamoids can be either direct, which generally involves an axial loading force on the sesamoid and produces a comminuted multifragmented bone, or indirect, in which the fi rst metatarsophalangeal joint is hyperextended violently, as can be seen most com-monly in football and soccer players. Physical examination usually shows tenderness and swelling in the region of the sesamoid. Limited extension of the great toe and pain with passive extension of the great toe usually are present. The patient may have a shortened stance phase of gait and usually descends stairs with the injured foot leading. Radiographic evaluation should include standard antero-posterior and lateral views.

The forefoot should be in slight pronation while obtain-ing a lateral radiograph to profi le the sesamoids. The medial oblique sesamoid view is helpful in evaluating the tibial sesamoid, and the lateral oblique view is helpful in evaluat-ing the fi bular sesamoid. In addition, the axial sesamoid view can be helpful in showing sclerosis and joint space narrowing associated with osteochondritis of the sesamoid. Tomograms or CT can be of assistance, and radionuclide bone scanning can be invaluable in confi rming the diag-nosis. Chisin et al. recommended caution in interpreting increased bone scan activity because they found that a sig-nifi cant percentage (26% to 29%) of asymptomatic indi-viduals had some increased activity, and the difference between one foot and the other was signifi cant.

Treatment

Widely displaced tibial or fi bular sesamoid fractures gen-erally are associated with either dislocation or traumatic subluxation with spontaneous reduction of the metatarso-phalangeal joint. Disruption of the fl exor brevis musculo-tendinous unit with wide displacement of the sesamoid is not tolerated well by patients. If the sesamoid fragments are of roughly equal size, and the displacement is signifi cant (>5 mm), open reduction with internal fi xation using the

approach described subsequently is necessary. Internal fi xa-tion generally involves use of an 18-gauge wire looped around the proximal and distal poles and placed in a fi gure-of-eight over the sesamoid. Bone grafting from the calca-neus or the supramalleolar area of the distal tibia may be helpful in achieving union.

Minimally displaced or nondisplaced fractures of the sesamoid and stress fractures can be treated initially with cast immobilization, incorporating a toe plate for 3 to 4 weeks. Repeat casting for another 3 to 4 weeks may be necessary if symptoms have not resolved. After this, the toe is protected by placing a lightweight steel shank and a toe rocker in an athletic shoe. Patients who do not respond to this treatment are candidates for operative treatment of the sesamoid. The following options are available for surgical treatment: (1) complete excision of the sesamoid, (2) partial excision of a painful bipartite sesamoid or nonunion of a sesamoid fracture, and (3) cancellous bone grafting to promote union. Although traditionally we have excised the involved sesamoid after failure of conservative treatment, the tibial sesamoid has a signifi cant function in increasing the lever arm and action of the fl exor hallucis brevis muscle and in protecting the fl exor hallucis longus tendon.

We have been gaining experience with excising the smaller fragment of a painful bipartite sesamoid or trying to preserve most of the sesamoid with a nonunion. If a partial sesamoid excision is done, the patient should be informed preoperatively that the remaining sesamoid frag-ment may need to be excised as well. Repairing the fl exor hallucis brevis mechanism is crucial regardless of which treatment method is chosen. Indications for complete sesa-moidectomy are comminuted fractures with no large frag-ments and the loss of articulating cartilage, either on the articular side of the sesamoid or on the overlying surface of the metatarsal head.

Saxena and Krisdakumtorn, in their review of 26 sesa-moidectomies in 24 athletically active patients with a mean follow-up of 86 months, found that athletes were able to return to sports at a mean time of 7.5 weeks, and the remainder of “active” patients returned to activity at 12 weeks. Of 10 fi bular sesamoidectomies, complications included hallux varus in one and postoperative scarring with neuroma-like symptoms in two. Of 16 tibial sesa-moidectomies, hallux valgus deformity developed late in one patient. The authors concluded that despite the func-tional importance of the fi bular and tibial sesamoids, ath-letically active individuals can return to sports 7.5 weeks after sesamoidectomy.

SesamoidectomyTECHNIQUE 86-19

• Make a medial longitudinal incision centered just plantar to midline, and incise the capsule longitudinally in line with the skin.



AFTERTREATMENT The patient is placed immediately into a short leg plaster splint, rendering the entire hallux immobile. The patient remains non–weight bearing for 3 to 4 weeks, at which time a short leg walking cast is applied, again immobilizing the hallux. The cast is removed at 8 weeks. A soft medial longitudinal arch support is pre-scribed and used in conjunction with a fi rm-soled shoe. Active exercises are initiated followed by gentle passive range of motion if symptoms permit. Tomography is per-formed at 10 to 12 weeks to assess bone union because graft healing may remain equivocal for several weeks or months. Tomograms help to monitor progression of healing.

Osteochondritis of the Sesamoid

Osteochondritis of the sesamoid is characterized by a deformed sesamoid with irregular areas of increased bone density modeling a fragmentation. This may be apparent on axial radiograph or CT scan of the sesamoid. According to Richardson, although the exact cause is unknown, trauma probably is the most frequent cause. As in all sesa-moid disorders, nonsurgical treatment consisting of a well under the sesamoid with a lateral forefoot post and full-length steel shank should be used before sesamoidectomy is recommended.

Other Conditions of the Sesamoid

Other conditions associated with sesamoids include sesa-moiditis, which is a poorly understood and fairly vague diagnosis. Surgical treatment should be delayed until all conservative measures have been exhausted. Arthritis, intractable plantar keratoses, and nerve impingement also may be associated with the sesamoid. Readers are referred to the review article by Richardson.

SesamoidectomyTECHNIQUE 86-19—cont’d

• Evaluate the intraarticular portion of the sesamoid for the quality of the cartilage and mobility of the fragments.

• Examine the plantar surface of the metatarsal head for cartilage damage.

• Approach the sesamoid through an extracapsular approach. Protect the proper medial plantar nerve to the hallux, which emerges plantarly at the musculotendinous junction of the abductor hallucis muscle.

• Retract this nerve plantarly.

• Make an incision over the sesamoid, and perform either a complete sesamoidectomy or a partial sesamoidectomy.

• Repair the fl exor brevis defect using 2-0 nonabsorbable polyethylene suture. If a portion of the sesamoid is left, use a 0.045-inch Kirschner wire to secure the fl exor hallucis brevis tendon to the cancellous surface of the remaining sesamoid fragment.

• Repair the capsule with 2-0 absorbable sutures, and close the skin with nylon.

AFTERTREATMENT A short leg cast with a toe plate is applied over a bulky dressing. Weight bearing is delayed for 2 to 3 weeks, followed by weight bearing in a walking brace. Range-of-motion exercises are performed at 2 to 3 weeks, and the resumption of light jogging is allowed at 8 weeks.

Anderson and McBryde reported their experience with autogenous bone grafting for nonunions of the hallux sesa-moid in 21 patients. They reported successful bony union in all but two patients, and most patients obtained pain relief and returned to their preinjury level of activity. These authors advocated bone grafting as opposed to sesamoid excision in select patients.

Bone Grafting of Sesamoid NonunionTECHNIQUE 86-20 Anderson and McBryde

• Make a 5-cm longitudinal skin incision along the medial plantar aspect of the fi rst ray centered in the metatarso-phalangeal joint. Identify the capsule and abductor hallucis tendon, and subsequently divide in line with the skin incision, entering the joint dorsal to the tibial hallucal sesamoid.

• Use retraction to expose the articular surface of each sesamoid.

• Excision is justifi ed when severe cartilaginous destruction is present.

• If the surface is intact, as is usually the case, proceed with bone grafting through an extraarticular approach.

• Through the same skin incision, dissect plantar to the abductor hallucis tendon for extraarticular exposure of the tibial sesamoid. Avoid injury to the plantar digital nerve.

• After sharp periosteal elevation, identify the nonunion within the midportion of the sesamoid. Gross motion at the nonunion site may be seen.

• Avoiding disruption of the articular surface, curet fi brous and necrotic tissue with a small dental curet. The tissue should be saved for microscopic examination.

• Pack the defect with autogenous bone graft, harvested locally through a cortical window in the medial eminence of the fi rst metatarsal head. As a result of the tendinous expansion that surrounds the sesamoid, the proximal and distal fragments remain in close apposition.

• Approximate the periosteal layers, and close the wound with an absorbable suture.



ReferencesCalcaneusAitken AP: Fractures of the os calcis—treatment by closed reduc-

tion, Clin Orthop Relat Res 30:67, 1963.Aktuglu K, Ayodogan U: The functional outcome of displaced

intra-articular calcaneal fractures: a comparison between iso-lated cases and polytrauma patients, Foot Ankle Int 23:314, 2002.

Aldridge JM 3rd, Easley M, Nunley JA: Open calcaneal fractures: results of operative treatment, J Orthop Trauma 18:7, 2004.

Amendola A, Lammens P: Subtalar arthrodesis using interposi-tion iliac crest bone graft after calcaneal fracture, Foot Ankle 17:608, 1996.

Attinger C, Cooper P: Soft-tissue reconstruction for calcaneal fractures or osteomyelitis, Orthop Clin North Am 32:135, 2001.

Barla J, Buckley R, McCormack R, et al: Displaced intraarticular calcaneal fractures: long-term outcome in women, Foot Ankle Int 25:853, 2004.

Bednarz PA, Beals TC, Manoli A: Subtalar distraction bone block fusion: an assessment of outcome, Foot Ankle Int 18:785, 1997.

Benirschke SK, Sangeorzan BJ: Extensive intraarticular fractures of the foot: surgical management of calcaneal fractures, Clin Orthop Relat Res 292:128, 1993.

Berry GK, Stevens DG, Kreder HJ, et al: Open fractures of the calcaneus: a review of treatment and outcome, J Orthop Trauma 18:202, 2004.

Böhler L: Diagnosis, pathology, and treatment of fractures of the os calcis, J Bone Joint Surg 13:75, 1931.

Braly WG, Bishop JO, Tullos HS: Lateral decompression for malunited os calcis fractures, Foot Ankle 6:90, 1985.

Buch BD, Myerson MS, Miller SD: Primary subtalar arthrodesis for the treatment of comminuted calcaneal fractures, Foot Ankle 17:61, 1996.

Buckley RE, Meek RN: Comparison of open versus closed reduction of intraarticular calcaneal fractures: a matched cohort in workmen, J Orthop Trauma 6:216, 1992.

Buckley R, Tough S, McCormack R, et al: Operative compared with nonoperative treatment of displaced intra-articular calca-neal fractures: a prospective, randomized, controlled multi-center trial, J Bone Joint Surg 84A:1733, 2002.

Burdeaux BD: Reduction of calcaneal fractures by the McReynolds medial approach technique and its experimental basis, Clin Orthop Relat Res 177:87, 1983.

Burdeaux BD Jr: Fractures of the calcaneus: open reduction and internal fi xation from the medial side a 21-year prospective study, Foot Ankle Int 18:685, 1997.

Carr JB: Mechanism and pathoanatomy of the intraarticular cal-caneal fracture, Clin Orthop Relat Res 290:36, 1993.

Carr JB: Surgical treatment of the intraarticular calcaneus frac-ture, Orthop Clin North Am 25:665, 1994.

Carr JB, Hansen ST, Benirschke SK: Subtalar distraction bone block fusion for late complications of os calcis fractures, Foot Ankle 9:81, 1988.

Chan SCF, Alexander IJ: Subtalar arthrodesis with interposition tricortical iliac crest graft for late pain and deformity after calcaneus fracture, Foot Ankle Int 18:613, 1997.

Chandler JT, Bonar SK, Anderson RB, et al: Results of in situ subtalar arthrodesis for late sequelae of calcaneus fractures, Foot Ankle Int 20:18, 1999.

Clare MP, Lee WE 3rd, Sanders RW: Intermediate to long-term results of a treatment protocol for calcaneal fracture malunion, J Bone Joint Surg 87A:963, 2005.

Coughlin MJ: Calcaneal fractures in the industrial patients, Foot Ankle Int 21:896, 2000.

Crosby LA, Fitzgibbons T: Computerized tomography scanning of acute intraarticular fractures of the calcaneus, J Bone Joint Surg 72A:852, 1990.

Crosby LA, Fitzgibbons T: Intraarticular calcaneal fractures: results of closed treatment, Clin Orthop Relat Res 290:47, 1993.

Crosby LA, Fitzgibbons TC: Open reduction and internal fi xa-tion of type II intraarticular calcaneus fractures, Foot Ankle 17:253, 1996.

Crosby LA, Kamins P: The history of the calcaneal fracture, Orthop Rev 20:501, 1991.

Csizy M, Buckley R, Tough S, et al: Displaced intra-articular calcaneal fractures: variables predicting late subtalar fusion, J Orthop Trauma 17:106, 2003.

Day FG: Treatment of fracture of the os calcis, Can Med Assoc J 63:373, 1950.

Degan TJ, Morrey BF, Braun DP: Surgical excision for anterior process fractures of the calcaneus, J Bone Joint Surg 64A:519, 1982.

Deyerle WM: Long-term follow-up of fractures of the os calcis: diagnostic peroneal synoviogram, Orthop Clin North Am 4:213, 1973.

Dooley P, Buckley R, Tough S, et al: Bilateral calcaneal frac-tures: operative versus nonoperative treatment, Foot Ankle Int 25:47, 2004.

Ebraheim NA, Biyani A, Padanilam T, et al: A pitfall of coronal computed tomographic imaging in evaluation of calcaneal frac-tures, Foot Ankle 17:503, 1996.

Ebraheim NA, Elgafy H, Sabry FF, et al: Sinus tarsi approach with trans-articular fi xation for displaced intraarticular frac-tures of the calcaneus, Foot Ankle Int 21:105, 2000.

Ebraheim NA, Sabry FF, Haman S, et al: Congruity of the sub-talar joint in tongue fracture of the calcaneus: an anatomical study, Foot Ankle Int 21:665, 2000.

Essex-Lopresti P: Results of reduction in fractures of the calca-neum, J Bone Joint Surg 33B:284, 1951.

Essex-Lopresti P: The mechanism, reduction technique, and results in fractures of the os calcis, Br J Surg 39:395, 1952.

Flemister AS Jr, Infante AF, Sanders RW, et al: Subtalar arthro-desis for complications of intra-articular calcaneal fractures, Foot Ankle Int 21:392, 2000.

Folk JW, Starr AJ, Early JS: Early wound complications of opera-tive treatment of calcaneus fractures: analysis of 190 fractures, J Orthop Trauma 13:369, 1999.

Gallie WE: Subastragalar arthrodesis of the os calcis, J Bone Joint Surg 25:731, 1943.

Geel CW, Flemister AS Jr: Standardized treatment of intra-articular calcaneal fractures using an oblique lateral incision and no bone graft, J Trauma 50:1083, 2001.

Gilmer PW, Herzenberg J, Frank JL, et al: Computerized tomo-graphic analysis of acute calcaneal fractures, Foot Ankle 6:184, 1986.

Hammesfar R, Fleming LL: Calcaneal fractures: a good progno-sis, Foot Ankle 2:161, 1981.

Harding D, Waddell JP: Open reduction in depressed fractures of the os calcis, Clin Orthop Relat Res 199:124, 1985.

Harvey EJ, Grujic L, Early JS, et al: Morbidity associated with ORIF of intra-articular calcaneus fractures using a lateral approach, Foot Ankle Int 22:868, 2001.

Heckman JD: Fractures and dislocations of the foot. In Rockwood CA, Green DP, eds: Fractures in adults, 2nd ed, Philadelphia, 1984, Lippincott.



Heier KA, Infante AF, Walling AK, et al: Open fractures of the calcaneus: soft-tissue injury determines outcome, J Bone Joint Surg 86A:2568, 2004.

Herscovici D Jr, Widmaier J, Scaduto JM, et al: Operative treat-ment of calcaneal fractures in elderly patients, J Bone Joint Surg 87A:1260, 2005.

Howard JL, Buckley R, McCormack R, et al: Complications following management of displaced intra-articular calcaneal fractures: a prospective randomized trial comparing open reduction internal fi xation with nonoperative management, J Orthop Trauma 17:241, 2003.

Huang PJ, Fu YC, Cheng YM, et al: Subtalar arthrodesis for late sequelae of calcaneal fractures: fusion in situ versus fusion with sliding corrective osteotomy, Foot Ankle Int 20:166, 1999.

Hutchinson F III, Huebner MK: Treatment of os calcis fractures by open reduction and internal fi xation, Foot Ankle 15:225, 1994.

Järvholm U, Körner L, Thoren O, et al: Fractures of the calca-neus: a comparison of open and closed treatment, Acta Orthop Scand 55:652, 1984.

Johnson EE: Intraarticuar fractures of the calcaneus: diagnosis and surgical management, Orthopedics 13:1091, 1990.

Jung HG, Yoo MJ, Kim MH: Late sequelae of secondary Haglund’s deformity after malunion of tongue type calcaneal fracture: report of two cases, Foot Ankle Int 23:1014, 2002.

Kingwell S, Buckley R, Willis N: The association between sub-talar motion and outcome satisfaction in patients with displaced intraarticular calcaneal fractures, Foot Ankle Int 25:666, 2004.

Kitaoka HB, Schaap EJ, Chao EY, et al: Displaced intraarticular fractures of the calcaneus treated nonoperatively: clinical results and analysis of motion and ground-reaction and temporal forces, J Bone Joint Surg 76A:1531, 1994.

Kundel K, Brutscher M, Bickel R: Calcaneal fractures: operative versus nonoperative treatment, J Trauma 41:839, 1996.

Lance EM, Carey EJ Jr, Wade PA: Fractures of the os calcis: treatment by early mobilization, Clin Orthop Relat Res 30:76, 1963.

Laughlin RT, Carson JG, Calhoun JH: Displaced intraarticular calcaneus fractures treated with the Galveston plate, Foot Ankle 17:71, 1996.

Letournel E: Open treatment of acute calcaneal fractures, Clin Orthop Relat Res 290:60, 1993.

Leung KS, Yuen KM, Chan WS: Operative treatment of dis-placed intraarticular fractures of the calcaneum: medium-term results, J Bone Joint Surg 75B:196, 1993.

Levin LS, Nunley JA: The management of soft-tissue problems associated with calcaneal fractures, Clin Orthop Relat Res 290:151, 1993.

Lindsay WKN, Dewar FP: Fractures of the os calcis, Am J Surg 95:555, 1958.

Longino D, Buckley RE: Bone graft in the operative treatment of displaced intraarticular calcaneal fractures: is it helpful? J Orthop Trauma 15:280, 2001.

Lowery RBW, Calhoun JH: Fractures of the calcaneus, I: anatomy, injury, mechanism, and classifi cation, Foot Ankle 17:230, 1996.

Lowery RBW, Calhoun JH: Fractures of the calcaneus, II: treat-ment, Foot Ankle 17:360, 1996.

Martinez S, Herzenberg JE, Apple JS: Computed tomography of the hindfoot, Orthop Clin North Am 16:481, 1985.

McReynolds IS: Trauma to the os calcis and heel cord. In Jahss M, ed: Disorders of the foot and ankle, Philadelphia, 1984, Saunders.

Melcher G, Degonda F, Leutenegger A, et al: Ten-year follow-up after operative treatment for intraarticular fractures of the calcaneus, J Trauma 38:713, 1995.

Miller ME: Surgical management of calcaneus fractures: indica-tions and techniques, Instr Course Lect 39:161, 1990.

Monsey RD, Levine BP, Trevino SG, et al: Operative treatment of acute displaced intraarticular calcaneus fractures, Foot Ankle 16:57, 1995.

Myerson MS: Primary subtalar arthrodesis for the treatment of comminuted fractures of the calcaneus, Orthop Clin North Am 26:215, 1995.

Myerson M, Quill GE: Late complications of fractures of the calcaneus, J Bone Joint Surg 75A:331, 1993.

O’Brien J, Buckley R, McCormack R, et al: Personal gait satis-faction after displaced intraarticular calcaneal fractures: 2-8 year followup, Foot Ankle Int 25:657, 2004.

O’Connell F, Mital MA, Rowe CR: Evaluation of modern man-agement of fractures of the os calcis, Clin Orthop Relat Res 83:214, 1972.

Omoto H, Nakamura K: Method for manual reduction of dis-placed intra-articular fracture of the calcaneus: technique, indications, and limitations, Foot Ankle Int 24:724, 2003.

Omoto H, Sakurada K, Sugi M, et al: A new method of manual reduction for intraarticular fracture of the calcaneus, Clin Orthop Relat Res 177:104, 1983.

Paley D, Hall H: Intraarticular fractures of the calcaneus: a criti-cal analysis of results and prognostic factors, J Bone Joint Surg 75A:342, 1993.

Parkes JC II: Injuries of the hindfoot, Clin Orthop Relat Res 122:28, 1977.

Parmar HV, Triffi tt PD, Gregg PJ: Intraarticular fractures of the calcaneum treated operatively or conservatively: a prospective study, J Bone Joint Surg 75B:932, 1993.

Pennal GF, Yadav MP: Operative treatment of comminuted frac-tures of the os calcis, Orthop Clin North Am 4:197, 1973.

Pozo JL, Kirwan EO, Jackson AM: The long-term results of conservative management of severely displaced fractures of the calcaneus, J Bone Joint Surg 66B:386, 1984.

Richter M, Gosling T, Zech S, et al: A comparison of plates with and without locking screws in a calcaneal fracture model, Foot Ankle Int 26:309, 2005.

Robbins MI, Wilson MG, Sella EJ: MR imaging of anteropos-terior calcaneal process fractures, Am J Radiol 172:475, 1999.

Romash MM: Calcaneal fractures: three-dimensional treatment, Foot Ankle 8:180, 1988.

Romash MM: Reconstructive osteotomy of the calcaneus with subtalar arthrodesis for malunited calcaneal fractures, Clin Orthop Relat Res 290:157, 1993.

Romash MM: Calcaneal osteotomy and arthrodesis for malunited calcaneal fracture. In Johnson KA, ed: Master techniques in orthopaedic surgery: the foot and ankle, New York, 1994, Raven.

Sanders R: Intraarticular fractures of the calcaneus: present state of the art, J Orthop Trauma 6:252, 1992.

Sanders R, Fortin P, DiPasquale T, et al: Operative treatment in 120 displaced intraarticular calcaneal fractures: results using a prognostic computed tomography scan classifi cation, Clin Orthop Relat Res 290:87, 1993.

Sanders R, Gregory P: Operative treatment of intraarticular fractures of the calcaneus, Orthop Clin North Am 26:203, 1995.

Sanders R, Hansen ST, McReynolds IS: Trauma to the calcaneus and its tendon. In Jahss MH, ed: Disorders of the foot and ankle, Philadelphia, 1991, Saunders.

Sangeorzan BJ: Salvage procedures for calcaneus fractures, Instr Course Lect 46:339, 1997.

Schildhauer TA, Bauer TW, Josten C, et al: Open reduction and augmentation of internal fi xation with an injectable skeletal cement for the treatment of complex calcaneal fractures, J Orthop Trauma 14:309, 2000.



Scranton PE Jr: Comparison of open isolated subtalar arthrodesis with autogenous bone graft versus outpatient arthroscopic subtalar arthrodesis using injectable bone morphogenic protein-enhanced graft, Foot Ankle Int 20:162, 1999.

Segal D, Marsh JL, Leiter B: Clinical applications of computer-ized axial tomography (CAT) scanning of calcaneus fractures, Clin Orthop Relat Res 199:114, 1985.

Shereff MJ: Radiographic anatomy of the hindfoot, Clin Orthop Relat Res 177:16, 1983.

Simpson LA, Schulak DJ, Spiegel PG: Intraarticular fractures of the calcaneus: a review, Contemp Orthop 6:19, 1983.

Stephenson JR: Displaced fractures of the os calcis involving the subtalar joint: the key role of the superomedial fragment, Foot Ankle 4:91, 1983.

Stephenson JR: Treatment of displaced intraarticular fractures of the calcaneus using medial and lateral approaches, internal fi xation, and early motion, J Bone Joint Surg 69A:115, 1987.

Stephenson JR: Surgical treatment of displaced intraarticular fractures of the calcaneus: a combined lateral and medial approach, Clin Orthop Relat Res 290:68, 1993.

Thompson KR: Treatment of comminuted fractures of the cal-caneus by triple arthrodesis, Orthop Clin North Am 4:189, 1973.

Thordarson DB, Bollinger M: SRS cancellous bone cement aug-mentation of calcaneal fracture fi xation, Foot Ankle Int 26:347, 2005.

Thordarson DB, Greene N, Shepherd L, et al: Facilitating edema resolution with a foot pump after calcaneus fracture, J Orthop Trauma 13:43, 1999.

Thordarson DB, Hedman TP, Yetkinler D, et al: Superior com-pressive strength of a calcaneal fracture construct augmented with remodelable cancellous bone cement, J Bone Joint Surg 81A:239, 1999.

Thordarson DB, Krieger LE: Operative vs. nonoperative treat-ment of intraarticular fractures of the calcaneus: a prospective randomized trial, Foot Ankle 17:2, 1996.

Thordarson DB, Latteier M: Open reduction and internal fi xa-tion of calcaneal fractures with a low profi le titanium calcaneal perimeter plate, Foot Ankle Int 24:217, 2003.

Tornetta P 3rd: Percutaneous treatment of calcaneal fractures, Clin Orthop Relat Res 375:91, 2000.

van Tetering EA, Buckley RE: Functional outcome (SF-36) of patients with displaced calcaneal fractures compared to SF-36 normative data, Foot Ankle Int 25:733, 2004.

Zmurko MG, Karges DE: Functional outcome of patients fol-lowing open reduction internal fi xation for bilateral calcaneus fracture, Foot Ankle Int 23:917, 2002.

Zoellner G, Clancy W Jr: Recurrent dislocation of the peroneal tendon, J Bone Joint Surg 61A:292, 1979.

Zwipp H, Tscherne H, Thermann H, et al: Osteosynthesis of displaced intraarticular fractures of the calcaneus: results in 123 cases, Clin Orthop Relat Res 290:76, 1993.

TalusAdelaar RS: Fractures of the talus, Instr Course Lect 39:147,

1990.Adelaar RS: Complex fractures of the talus, Instr Course Lect

46:323, 1997.Anderson HG: The medical and surgical aspects of aviation, London,

1919, Henry Frowde Oxford University Press.Baumhauer JF, Alvarez RG: Controversies in treatment talus

fractures, Orthop Clin North Am 26:335, 1995.Beals TC, Holmes JR, Manoli A II: Longitudinal Lisfranc frac-

ture-dislocations. Paper presented at the Twenty-seventh Annual Meeting of the American Orthopaedic Foot and Ankle Society, San Francisco, Feb 1997.

Bibbo C, Anderson RB, Davis WH: Injury characteristics and the clinical outcome of subtalar dislocations: a clinical and radiographic analysis of 25 cases, Foot Ankle Int 24:158, 2003.

Bibbo C, Lin SS, Abidi N, et al: Missed and associated injuries after subtalar dislocation: the role of CT, Foot Ankle Int 22:324, 2001.

Blair HC: Comminuted fracture and fracture-dislocations of the body of the astragalus: operative treatment, Am J Surg 59:37, 1943.

Bradshaw C, Khan K, Brukner P: Stress fracture of the body of the talus in athletes demonstrated with computer tomography, Clin J Sports Med 6:48, 1996.

Brand JC, Brindle T, Nyland J, et al: Does pulsed low-intensity ultrasound allow early return to normal activities when treat-ing stress fractures: a review of one tarsal navicular and eight tibial stress fractures, Iowa Orthop J 19:26, 1999.

Brennan MJ: Subtalar dislocations, Instr Course Lect 39:157, 1990.

Canale ST, Belding RH: Osteochondral lesions of the talus, J Bone Joint Surg 62A:97, 1980.

Canale ST, Kelly FB Jr: Fractures of the neck of the talus: long-term evaluation of 71 cases, J Bone Joint Surg 60A:143, 1978.

Cantrell MW, Tarquinio TA: Fracture of the lateral process of the talus, Orthopedics 23:55, 2000.

Coltart WD: “Aviator’s astragalus,” J Bone Joint Surg 34B:545, 1952.

Comfort TH, Behrens F, Gaither DW, et al: Long-term results of displaced talar neck fractures, Clin Orthop Relat Res 199:81, 1985.

Dabezies EJ, Shackleton R: Orthopaedic grand rounds: subtalar dislocation, Orthopaedics 5:348, 1982.

DeLee JC, Curtis R: Subtalar dislocation of the foot, J Bone Joint Surg 64A:433, 1982.

Dhillon MS, Nagi ON: Total dislocations of the navicular: are they ever isolated injuries? J Bone Joint Surg 81B:881, 1999.

Dimon JH: Isolated displaced fracture of the posterior facet of the talus, J Bone Joint Surg 43A:275, 1961.

Ebraheim NA, Padanilam TG, Wong FY: Posteromedial process fractures of the talus, Foot Ankle 16:734, 1995.

Ebraheim NA, Sabry FF, Nadim Y: Internal architecture of the talus: implication for talar fracture, Foot Ankle Int 20:794, 1999.

Ebraheim NA, Skie MC, Podeszwa DA, et al: Evaluation of process fractures of the talus using computed tomography, J Orthop Trauma 8:332, 1994.

Elgafy H, Ebraheim NA, Tile M, et al: Fractures of the talus: experience of two level 1 trauma centers, Foot Ankle Int 21:1023, 2000.

Fitch KD, Blackwell JB, Gilmour WN: Operation for non-union of stress fracture of the tarsal navicular, J Bone Joint Surg 71B:105, 1989.

Fortin PT, Balazsy JE: Talus fractures: evaluation and treatment, J Am Acad Orthop Surg 9:114, 2001.

Frawley PA, Hart JA, Young DA: Treatment outcome of major fractures of the talus, Foot Ankle 16:339, 1995.

Gelberman RH, Mortensen WW: Arterial anatomy of the talus, Foot Ankle 4:64, 1983.

Gissane W: A dangerous type of fracture of the foot, J Bone Joint Surg 33B:535, 1951.

Giuffrida AY, Lin SS, Abidi N, et al: Pseudo os trigonum sign: missed posteromedial talar facet fracture, Foot Ankle Int 25:372, 2004.

Goldner JL, Poletti SC, Gates HS, Richardson WJ: Severe open subtalar dislocations, J Bone Joint Surg 77A:1075, 1995.

Gregory P, DiPasquale T, Herscovici D, et al: Ipsilateral fractures of the talus and calcaneus, Foot Ankle 17:701, 1996.



Grob D, Simpson LA, Weber BG, et al: Operative treatment of displaced talus fractures, Clin Orthop Relat Res 199:88, 1985.

Haliburton RA, Sullivan CR, Kelly PJ, et al: The extra-osseous and intra-osseous blood supply of the talus, J Bone Joint Surg 40A:1115, 1958.

Hawkins LG: Fracture of the lateral process of the talus: a review of thirteen cases, J Bone Joint Surg 47A:1170, 1965.

Hawkins LG: Fractures of the neck of the talus, J Bone Joint Surg 52A:991, 1970.

Heck BE, Ebraheim NA, Jackson WT: Anatomical considerations of irreducible medial subtalar dislocation, Foot Ankle Int 17:103, 1996.

Heckman JD, McLean MR: Fractures of the lateral process of the talus, Clin Orthop Relat Res 199:108, 1985.

Higgins TF, Baumgaertner MR: Diagnosis and treatment of fractures of the talus: a comprehensive review of the literature, Foot Ankle Int 20:595, 1999.

Inokuchi S, Ogawa K, Usami N: Classifi cation of fractures of the talus: clear differentiation between neck and body frac-tures, Foot Ankle Int 17:748, 1996.

Inokuchi S, Ogawa K, Usami N, et al: Long-term follow-up of talus fractures, Orthopedics 19:477, 1996.

Johnson KA, ed: Surgery of the foot and ankle, New York, 1989, Raven.

Johnstone AJ, Maffulli N: Primary fusion of the talonavicular joint after fracture dislocation of the navicular bone, J Trauma 45:1100, 1998.

Karasick D, Schweitzer M: The os trigonum syndrome: imaging features, Am J Radiol 166:125, 1996.

Khan KM, Fuller PJ, Brukner PD, et al: Outcome of conserva-tive and surgical management of navicular stress fracture in athletes: eighty-six cases proven with computerized tomogra-phy, Am J Sports Med 20:657, 1992.

Kim DH, Berkowitz MJ, Pressman DN: Avulsion fractures of the medial tubercle of the posterior process of the talus, Foot Ankle Int 24:172, 2003.

Kim DH, Hrutkay JM, Samson MM: Fracture of the medial tubercle of the posterior process of the talus: a case report and literature review, Foot Ankle Int 17:186, 1996.

Kirkpatrick DP, Hunter RE, Janes PC, et al: The snowboarder’s foot and ankle. Paper presented at the Twenty-seventh Annual Meeting of the American Orthopaedic Foot and Ankle Society, San Francisco, Feb 1997.

Lemaire RG, Bustin W: Screw fi xation of fractures of the neck of the talus using a posterior approach, J Trauma 20:669, 1980.

Lin PP, Roe S, Kay M, et al: Placement of screws in the susten-taculum tali, Clin Orthop Relat Res 352:194, 1998.

Lindvall E, Haidukewych G, DiPasquale T, et al: Open reduction and stable fi xation of isolated, displaced talar neck and body fractures, J Bone Joint Surg 86A:2229, 2004.

McCrory P, Bladin C: Fractures of the lateral process of the talus: a clinical review: “snowboarder’s ankle,” Clin J Sports Med 6:124, 1996.

McKeever FM: Fracture of the neck of the astragalus, Arch Surg 46:720, 1943.

Miller WE: Operative intervention for fracture of the talus. In Bateman JE, Trott AW, eds: Foot and ankle, New York, 1980, Marcel Dekker.

Morris HD, Hand WL, Dunn AS: The modifi ed Blair fusion for fractures of the talus, J Bone Joint Surg 53A:1289, 1971.

Mulfi nger GL, Trueta J: The blood supply of the talus, J Bone Joint Surg 52B:160, 1970.

Nadim Y, Tosic A, Ebraheim N: Open reduction and internal fi xation of fracture of the posterior process of the talus: a case

report and review of the literature, Foot Ankle Int 20:50, 1999.

Patel R, Van Bergeyk A, Pinney S: Are displaced talar neck fractures surgical emergencies? A survey of orthopaedic trauma experts, Foot Ankle Int 26:378, 2005.

Quirk R: Stress fractures of the navicular, Foot Ankle Int 19:494, 1998.

Ries M, Healy WA Jr: Total dislocation of the talus: case report with a 13-year follow-up and review of the literature, Orthop Rev 17:76, 1988.

Ritsema GH: Total talar dislocation, J Trauma 28:692, 1988.Rockett MS, Brage ME: Navicular body fractures: computerized

tomography fi ndings and mechanism of injury, J Foot Ankle Surg 36:185, 1997.

Sanders DW, Busam M, Hattwick E, et al: Functional outcomes following displaced talar neck fractures, J Orthop Trauma 18:265, 2004.

Sanders R: Displaced intra-articular fractures of the calcaneus, J Bone Joint Surg 83A:1438, 2001.

Sangeorzan BJ, Benirschke SK, Mosca V, et al: Displaced intraar-ticular fractures of the tarsal navicular, J Bone Joint Surg 71A:1504, 1989.

Sneppen O, Christensen SB, Krogsoe O, et al: Fracture of the body of the talus, Acta Orthop Scand 48:317, 1977.

Swanson TV, Bray TJ, Holmes GB: Fractures of the talar neck, J Bone Joint Surg 74A:544, 1992.

Szyszkowitz R, Reschauer R, Seggl W: Eighty-fi ve talus frac-tures treated by ORIF with fi ve to eight years of follow-up study of 69 patients, Clin Orthop Relat Res 199:97, 1985.

Thordarson DB, Triffon MJ, Terk MR: Magnetic resonance imaging to detect avascular necrosis after open reduction and internal fi xation of talar neck fractures, Foot Ankle Int 17:742, 1996.

Torg JS, Pavlov H, Cooley LH, et al: Stress fractures of the tarsal navicular: a retrospective review of twenty-one cases, J Bone Joint Surg 64:700, 1982.

Trillat A, Bousquet G, Lapeyre B: Displaced fractures of the neck or of the body of the talus: value of screwing by posterior surgical approach, Rev Chir Reparatrice Appar Mot 56:529, 1970.

Tucker DJ, Feder JM, Boylan JP: Fractures of the lateral process of the talus: two case reports and a comprehensive literature review, Foot Ankle Int 19:641, 1998.

Vallier HA, Nork SE, Barei DP, et al: Talar neck fractures: results and outcomes, J Bone Joint Surg 86A:1616, 2004.

Vallier HA, Nork SE, Benirschke SK, et al: Surgical treatment of talar body fractures, J Bone Joint Surg 86A:180, 2004.

Viladot A, Lorenzo JC, Salazar J, et al: The subtalar joint: embry-ology and morphology, Foot Ankle 5:54, 1984.

Wildenauer E: Die Blutversorgung der Talus, Z Anat 115:32, 1950.

Zimmer TJ, Johnson KA: Subtalar dislocations, Clin Orthop Relat Res 238:190, 1989.

Ziran BH, Abidi NA, Scheel MJ: Medial malleolar osteotomy for exposure of complex talar body fractures, J Orthop Trauma 15:513, 2001.

MidfootAitken AP, Poulson D: Dislocations of the tarsometatarsal joint,

J Bone Joint Surg 45A:246, 1963.Anderson LD: Injuries of the forefoot, Clin Orthop Relat Res

122:118, 1977.Arntz CT, Hansen ST Jr: Dislocations and fracture dislocations

of the tarsometatarsal joints, Orthop Clin North Am 18:105, 1987.



Boden BB, Osbahr DC: High-risk stress fractures: evaluation and treatment, J Am Acad Orthop Surg 8:344, 2000.

Buzzard BM, Briggs PJ: Surgical management of acute tarso-metatarsal fracture dislocation in the adult, Clin Orthop Relat Res 353:125, 1998.

Coss S, Manos RE, Buoncristiani A, et al: Abduction stress and AP weightbearing radiography of purely ligamentous injury in the tarsometatarsal joint, Foot Ankle Int 19:537, 1998.

Curtis MJ, Myerson M, Szura B: Tarsometatarsal joint injuries in the athletes, Am J Sports Med 21:497, 1993.

DeLee JC: Fractures and dislocations of the foot. In Mann RA, ed: Surgery of the foot, 5th ed, St Louis, 1986, Mosby.

DePalma L, Santucci A, Sabetta SP, et al: Anatomy of the Lisfranc joint complex, Foot Ankle Int 18:356, 1997.

Fitch KD, Blackwell JB, Gilmour WN: Operation for nonunion of stress fracture of the tarsal navicular, J Bone Joint Surg 71B:105, 1989.

Goosens M, De Stoop N: Lisfranc’s fracture dislocations: etiol-ogy, radiology and results of treatment, Clin Orthop Relat Res 176:154, 1983.

Hardcastle PH, Reschauer R, Kutscha-Lissberg E, et al: Injuries to the tarsometatarsal joint: incidence, classifi cation and treat-ment, J Bone Joint Surg 64B:349, 1982.

Heckman JD: Fractures and dislocations of the foot. In Rockwood CA Jr, Green DP, eds: Fractures in adults, 2nd ed, Philadelphia, 1984, Lippincott.

Johnson JE, Johnson KA: Dowel arthrodesis for degenerative arthritis of the tarsometatarsal (Lisfranc) joints, Foot Ankle 5:243, 1986.

Kavanaugh JH, Brower TD, Mann RV: The Jones fracture revis-ited, J Bone Joint Surg 60A:776, 1978.

Komenda GA, Myerson MS, Biddinger KR: Results of arthro-desis of the tarsometatarsal joints after traumatic injury, J Bone Joint Surg 78A:1665, 1996.

Kuo RS, Tejwani NC, DiGiovanni CW, et al: Outcome after open reduction and internal fi xation of Lisfranc joint injuries, J Bone Joint Surg 82A:1609, 2000.

Lu J, Ebraheim NA, Skie M, et al: Radiographic and computed tomographic evaluation of Lisfranc dislocation: a cadaver study, Foot Ankle Int 18:351, 1997.

Mann RA, Prieskorn D, Sobel M: Midtarsal and tarsometatarsal arthrodesis for primary degenerative osteoarthrosis or osteoar-throsis after trauma, J Bone Joint Surg 78A:1376, 1996.

Monteleone GP Jr: Stress fractures in the athlete, Orthop Clin North Am 26:423, 1995.

Mulier T, Reynders P, Sioen W, et al: The treatment of Lisfranc injuries, Acta Orthop Belg 63:82, 1997.

Myerson M: The diagnosis and treatment of injuries to the Lisfranc joint complex, Orthop Clin North Am 20:655, 1989.

Myerson MS: The diagnosis and treatment of injury to the tarsometatarsal joint complex, J Bone Joint Surg 81B:756, 1999.

Petje G, Steinböck G, Landsiedl F: Arthrodesis for traumatic fl at foot, Acta Orthop Scand 67:359, 1996.

Potter HG, Deland JT, Gusmer PB, et al: Magnetic resonance imaging of the Lisfranc ligament of the foot, Foot Ankle Int 19:438, 1998.

Preidler KW, Brossmann J, Daenen B, et al: MR imaging of the tarsometatarsal joint: analysis of injuries in 11 patients, Am J Radiol 167:1217, 1996.

Quénu E, Küss G: Étude sur les luxations du metatarse (luxations métatarsotarsiennes) du diastasis entre le 1er and le 2e metatar-sien, Rev Chir 39:281, 1909.

Resch S, Stenström A: The treatment of tarsometatarsal injuries, Foot Ankle 11:117, 1990.

Richter M, Thermann H, Huefner T, et al: Chopart joint frac-ture-dislocation: initial open reduction provides better outcome than closed reduction, Foot Ankle Int 25:340, 2004.

Richter M, Wippermann B, Krettek C, et al: Fractures and fracture dislocations of the midfoot: occurrence, causes, and long-term results, Foot Ankle Int 22:392, 2001.

Ross G, Cronin R, Hauzenblaz J, et al: Plantar ecchymosis sign: a clinical aid to diagnosis of occult Lisfranc tarsometatarsal injuries, J Orthop Trauma 10:119, 1996.

Sangeorzan BJ, Veith RG, Hansen ST Jr: Salvage of Lisfranc’s tarsometatarsal joint by arthrodesis, Foot Ankle 10:193, 1990.

Shereff MJ: Compartment syndromes of the foot, Instr Course Lect 39:127, 1990.

Shereff MJ: Fractures of the forefoot, Instr Course Lect 39:133, 1990.

Teng AL, Pinzur MS, Lomasney L, et al: Functional outcome following anatomic restoration of tarsal-metatarsal fracture dis-location, Foot Ankle Int 23:922, 2002.

MetatarsalsAdelaar RS: The treatment of tarsometatarsal fracture-disloca-

tions, Instr Course Lect 39:141, 1990.Alepuz ES, Carsi VV, Alcántara P, et al: Fractures of the central

metatarsal, Foot Ankle Int 17:200, 1996.Boden BP, Osbahr DC: High-risk stress fractures: evaluation and

treatment, J Am Acad Orthop Surg 6:344, 2000.Brukner P, Bennell K: Stress fractures in female athletes: diag-

nosis, management, and rehabilitation, Sports Med 6:419, 1997.

Brunet JA: Pathomechanics of complex dislocations of the fi rst metatarsophalangeal joint, Clin Orthop Relat Res 332:126, 1996.

Brunet JA, Tubin S: Traumatic dislocation of lesser toes, Foot Ankle Int 18:406, 1997.

Brunet JA, Wiley JJ: The late results of tarsometatarsal joint injuries, J Bone Joint Surg 69B:437, 1987.

Clapper MF, O’Brien TJ, Lyons PM: Fractures of the fi fth meta-tarsal: analysis of a fracture registry, Clin Orthop Relat Res 315:238, 1995.

Curtis MJ, Myerson M, Szura B: Tarsometatarsal joint injuries in the athlete, Am J Sports Med 21:497, 1993.

Donahue SW, Sharkey NA: Strains in the metatarsals during the stance phase of gait: implications for stress fractures, J Bone Joint Surg 9A:1236, 1999.

Donley BG, McCollum MJ, Murphy GA, Richardson EG: Risk of sural nerve injury with intramedullary screw fi xation of fi fth metatarsal fractures: a cadaver study, Foot Ankle Int 20:182, 1999.

Faciszewski T, Burks RT, Manaster BJ: Subtle injuries of the Lisfranc joint, J Bone Joint Surg 72A:1519, 1990.

Fam AG, Shuckett R, McGillivray DC, et al: Stress fractures in rheumatoid arthritis, J Rheumatol 10:722, 1983.

Frey C, Andersen GD, Feder KS: Plantarfl exion injury to the metatarsophalangeal joint (“sand toe”), Foot Ankle Int 17:576, 1996.

Glasgow MT, Naranja RJ, Glasgow SG, et al: Analysis of failed surgical management of fractures of the base of the fi fth meta-tarsal distal to the tuberosity: the Jones fracture, Foot Ankle Int 17:449, 1996.

Hesp WELM, Van der Werken C, Goris RJA: Lisfranc disloca-tions: fractures and/or dislocations through the tarsometatarsal joints, Injury 15:261, 1983.

Josefsson PO, Karlsson M, Redlund-Johnell I, et al: Closed treat-ment of Jones fracture: good results in 40 cases after 11-26 years, Acta Orthop Scand 65:545, 1994.



Josefsson PO, Karlsson M, Redlund-Johnell I, et al: Jones fracture: surgical versus nonsurgical treatment, Clin Orthop Relat Res 299:252, 1994.

Kavanaugh JH, Brower TD, Mann RV: The Jones’ fracture revis-ited, J Bone Joint Surg 60A:776, 1978.

Kaye RA: Insuffi ciency stress fractures of the foot and ankle in postmenopausal women, Foot Ankle Int 4:221, 1998.

King RE: Dislocation of the tarsometatarsal joints, Bull Hosp Jt Dis 47:190, 1987.

Maenpaa H, Lehto MU, Belt EA: Stress fractures of the ankle and forefoot in patients with infl ammatory arthritides, Foot Ankle Int 9:833, 2002.

Manoli A: Compartment syndromes of the foot: current con-cepts, Foot Ankle 10:340, 1990.

Moshirfar A, Campbell JT, Molloy S, et al: Fifth metatarsal tuberosity fracture fi xation: a biomechanical study, Foot Ankle Int 24:630, 2003.

Muscolo L, Migues A, Slullitel G, et al: Stress fracture nonunion at the base of the second metatarsal in a ballet dancer: a case report, Am J Sports Med 6:1535, 2004.

Myerson M: The diagnosis and treatment of injuries to the Lisfranc joint complex, Orthop Clin North Am 20:655, 1989.

Myerson M, Fisher R, Burgess A, et al: Dislocations of the tar-sometatarsal joints: end results correlated with pathology and treatment, Foot Ankle 6:225, 1986.

O’Malley MJ, Hamilton WG, Munyak J: Fractures of the distal shaft of the fi fth metatarsal: “dancer’s fracture,” Am J Sports Med 24:240, 1996.

O’Malley MJ, Hamilton WG, Munyak J, et al: Stress fractures at the base of the second metatarsal in ballet dancers, Foot Ankle Int 17:89, 1996.

Pietropaoli MP, Wnorowski DC, Werner FW, et al: Intramedullary screw fi xation of Jones fractures: a biomechanical study, Foot Ankle Int 20:560, 1999.

Prieskorn D, Graves S, Yen M, et al: Integrity of the fi rst meta-tarsophalangeal joint: a biomechanical analysis, Foot Ankle Int 16:357, 1995.

Quill GE: Fractures of the proximal fi fth metatarsal, Orthop Clin North Am 26:353, 1995.

Resch S, Stenström A: The treatment of tarsometatarsal injuries, Foot Ankle 11:117, 1990.

Rosenberg GA, Sferra JJ: Treatment strategies for acute fractures and nonunions of the proximal fi fth metatarsal, J Am Acad Orthop Surg 8:332, 2000.

Sammarco GJ: The Jones fracture, Instr Course Lect 42:201, 1993.

Sangeorzan BJ, Veith RG, Hansen ST: Salvage of Lisfranc’s tar-sometatarsal joint by arthrodesis, Foot Ankle 10:193, 1990.

Shah SN, Knoblich GO, Lindsey DP, et al: Intramedullary screw fi xation of proximal fi fth metatarsal fractures: a biomechanical study, Foot Ankle Int 22:581, 2001.

Torg JS, Balduini FC, Zelko RR, et al: Fractures of the base of the fi fth metatarsal distal to the tuberosity: classifi cation and guidelines for non-surgical and surgical management, J Bone Joint Surg 66A:209, 1984.

Torg JS, Pavlov H, Cooley LH, et al: Stress fractures of the tarsal navicular: a retrospective review of twenty-one cases, J Bone Joint Surg 64A:700, 1982.

Trevino SG, Kodros S: Controversies in tarsometatarsal injuries, Orthop Clin North Am 26:229, 1995.

Vuori JP, Aro HT: Lisfranc joint injuries: trauma mechanisms and associated injuries, J Trauma 35:40, 1993.

Weinfeld SB, Haddad SL, Myerson MS: Metatarsal stress frac-tures, Clin Sports Med 16:319, 1997.

Wiener BD, Linder JF, Giattini JFG: Treatment of fractures of the fi fth metatarsal: a prospective study, Foot Ankle Int 18:267, 1997.

Yue JJ, Marcus RE: The role of internal fi xation in the treatment of Jones fractures in diabetics, Foot Ankle Int 17:559, 1996.

Zelko RR, Torg JS, Rachun A: Proximal diaphyseal fractures of the fi fth metatarsal—treatment of the fractures and their com-plications in athletes, Am J Sports Med 7:95, 1979.

PhalangesHojyo F, Nagata K, Narahara T, et al: Two cases of irreducible

dislocation of the interphalangeal joint of the great toe with interposition of sesamoid bone, J Orthop Surg 34:820, 1983.

Jahss MH: Traumatic dislocations of the fi rst metatarsophalangeal joint, Foot Ankle 1:15, 1980.

Jahss MH: Chronic and recurrent dislocations of the fi fth toe, Foot Ankle 1:275, 1981.

Katayama M, Murakami Y, Takahashi H: Irreducible dorsal dis-location of the toe: report of three cases, J Bone Joint Surg 70A:769, 1988.

Kursunoglu S, Resnick D, Goergen T: Traumatic dislocation with sesamoid entrapment in the interphalangeal joint of the great toe, J Trauma 27:959, 1987.

Lewis AG, DeLee JC: Type-I complex dislocation of the fi rst metatarsophalangeal joint: open reduction through a dorsal approach, J Bone Joint Surg 66A:1120, 1984.

Miki T, Yamamuro T, Kitai T: An irreducible dislocation of the great toe: report of two cases and review of the literature, Clin Orthop Relat Res 230:200, 1988.

Nelson TL, Uggen W: Irreducible dorsal dislocation of the inter-phalangeal joint of the great toe, Clin Orthop Relat Res 157:110, 1981.

Salamon PB, Gelberman RH, Huffer JM: Dorsal dislocation of the metatarsophalangeal joint of the great toe: a case report, J Bone Joint Surg 56A:1073, 1974.

Sarrafi an SK: Anatomy of the foot and ankle, Philadelphia, 1983, Lippincott.

Yu EC, Garfi n SR: Closed dorsal dislocation of the metatarso-phalangeal joint of the great toe, Clin Orthop Relat Res 185:237, 1983.

SesamoidsAnderson RB, McBryde AM: Autogenous bone grafting of

hallux sesamoid nonunions, Foot Ankle Int 18:293, 1997.Aper RL, Saltzman CL, Brown TD: The effect of hallux sesa-

moid resection on the effective moment of the fl exor hallucis brevis, Foot Ankle 15:462, 1994.

Aper RL, Saltzman CL, Brown TD: The effect of hallux sesa-moid excision on the fl exor hallucis longus moment arm, Clin Orthop Relat Res 325:209, 1996.

Brown TIS: Avulsion fractures of the fi bular sesamoid in associa-tion with dorsal dislocation of the metatarsophalangeal joint of the hallux: report of a case and review of the literature, Clin Orthop Relat Res 149:229, 1980.

Burman MS, Lapidus PW: The functional disturbances caused by the inconstant bones and sesamoids of the foot, Arch Surg 22:936, 1931.

Chisin R, Peyser A, Milgrom C: Bone scintigraphy in the assess-ment of the hallucal sesamoids, Foot Ankle Int 16:291, 1995.

deBritto SR: The fi rst metatarso-sesamoid joint, Int Orthop 6:61, 1982.

Fleischli J, Cheleuitte E: Avascular necrosis of the hallucal sesa-moids, J Foot Ankle Surg 34:358, 1995.

Glass B: Fractured fi bular sesamoid: a case report, J Foot Surg 19:19, 1980.

Helal B: Surgery of the forefoot, Br J Med 1:276, 1977.



Helal B: The great toe sesamoid bones: the lux or lost souls of Ushia, Clin Orthop Relat Res 157:82, 1981.

Hussain A: Dislocation of the fi rst metatarsophalangeal joint with fracture of fi bular sesamoid, Clin Orthop Relat Res 359:209, 1999.

Inge GAL, Ferguson AB: Surgery of the sesamoid bones of the great toe: an anatomical and clinical study with a report of 41 cases, Arch Surg 27:466, 1933.

Irwin AS, Maffulli N, Wardlaw D: Traumatic dislocation of the lateral sesamoid of the great toe: nonoperative management, J Orthop Trauma 180:2, 1995.

Jahss MH: The sesamoids of the hallux, Clin Orthop Relat Res 157:88, 1981.

Kaiman ME, Piccona R: Tibial sesamoidectomy: a review of the literature and retrospective study, J Foot Surg 22:286, 1983.

Morris JM: Biomechanics of the foot and ankle, Clin Orthop Relat Res 122:10, 1977.

Nuber GW, Anderson PR: Acute osteomyelitis of the metatarsal sesamoid, Clin Orthop Relat Res 167:212, 1982.

Richardson EG: Hallucal sesamoid pain: causes and surgical treatment, J Am Acad Orthop Surg 7:270, 1999.

Saxena A, Krisdakumtorn T: Return to activity after sesamoid-ectomy in athletically active individuals, Foot Ankle Int 24:415, 2003.

Van Hal ME, Keene JS, Lange TA, et al: Stress fractures of the great toe sesamoids, Am J Sports Med 10:122, 1982.

Weiss JS: Fracture of the medial sesamoid bone of the great toe: controversies in therapy, Orthopedics 14:1003, 1991.

Zinman H, Keret D, Reis ND: Fracture of the medial sesamoid bone of the hallux, J Trauma 21:581, 1981.


Fracture and Dislocation of Foot

Documents