ch-83_foot by goldor123


									                                                                                                                            CHAPTER 83

                                                                                                                                     The foot

83.1 Conservative treatment for foot injuries                                  leg walking cast as above.
                                                                                 If his pain is severe and he has only minor injury, or
Because feet are usually hidden inside shoes, injuries to                      his X-ray is negative, a short leg walking cast will also help
them tend to be neglected. You can treat most foot injuries                    him.
conservatively, and only a few need reduction. Fracture of
the body of the calcaneus is the most important one.
                                                                                  DON’T FORGET TO REDUCE SEVERE DISPLACEMENT
Try to diagnose and treat the specific injuries described later.
If you have no X-rays, or diagnosis is difficult, proceed as fol-
   If there is any obvious displacement of the bones of                        83.2 Dislocation of the talonavicular joint
the patient’s foot, correct it, and then apply a short leg
walking cast (81.5), taking care to mould its sole to both the                 The joint between a patient’s talus and his navicular is often
longitudinal and the transverse arches of his foot. Keep him                   strained, and occasionally dislocates, sometimes in associ-
in bed until his pain subsides and then start him walking in                   ation with a dislocation of his forefoot. After some violent
crutches. If you cannot hold the reduction in plaster, fix it                   injury his foot is turned inwards and displaced under his
with Kirschner wire (70.13).                                                   talus, which remains in its normal place in his ankle joint.
   If he has no obvious displacement, fit him with a short                      The displacement of the front of his foot from around his
                                                                               talus leaves it forming a swelling on the dorsum of his an-
                                                                               kle, which presses on the skin and may cause it to necrose
MOULD THE CAST                                                                 rapidly. (A, Fig. 83-2) He is in great pain, and the extreme
TO THE ARCHES                                                                  inversion of his foot makes the diagnosis obvious. Occasion-
                                                                               ally, his foot is displaced laterally instead of medially. Some-
                                                                               times, his cuboid and the head of his calcaneus are fractured
                                                                               at the same time. You will see these fractures best after you
     cast moulded to the transverse                                            have reduced his talonavicular dislocation, but even if they
     and lateral arches                                                        are present, they do not alter treatment.

                                                                                  DISLOCATION OF THE TALONAVICULAR JOINT. Re-
                                                                               duce the dislocation quickly before the skin over the head
                                                                               of the patient’s talus becomes necrotic. If you cannot refer
                                                                               him, anaesthetize him and move his foot back into position.
                                                                               If his foot is unstable, fix it with Kirschner wire (70.13). Splint
                                                                               his ankle, raise it, apply a crepe bandage, and keep him in
                                                                               bed until the swelling is reduced. Then apply a cast with
                                                                               a walking heel, and get him up on crutches. Teach him to
                                                                               walk without a limp, while he is still using crutches. Remove
                                                                               the cast at 3 to 6 weeks. He may need crutches for 6 to 8

                                                                               83.3 Fractures of the dome of the talus
INJURIES. Make a short leg walking cast as usual (81.5), but be sure you       In this injury the patient twists his foot inwards, and shears
mould it to the arches of the patient’s foot. Kindly contributed by Benjamin   a small fragment off the upper surface of his talus. An AP
Mbindyo.                                                                       X-ray shows a small triangular fragment, like a loose body,

83 The foot

at the upper lateral angle of his talus. As his foot returns to                The fracture line runs through the neck of his talus in a coro-
its normal position this fragment may turn upside down.                        nal plane just in front of the anterior margin of his tibia.
                                                                               There are several varieties: (1) There may be no displace-
                                                                               ment. (2) The fragments may angulate so that the posterior
FRACTURE OF THE DOME OF THE TALUS                                              half of his talus is plantar flexed, while its anterior half is
                                                                               dorsiflexed. You can usually reduce these fractures without
If the fragment is the right way up, no treatment is                           too much difficulty by plantar flexing the patient’s foot and
needed.                                                                        holding it in a cast. (3) The posterior half of his talus may be
   If the fragment has turned upside down, refer the pa-                       displaced posteriorly out of its mortice with his talus leav-
tient.                                                                         ing the anterior half in place.
   If you cannot refer him, remove the fragment by opening
his ankle joint. Make an antero–lateral incision just lateral to
the long extensors of his foot so as to avoid his superficial                   FRACTURES OF THE NECK OF THE TALUS
peroneal nerve. Fit him with a short leg walking cast for 10                   DIAGNOSIS Lateral displacement is easily diagnosed, but
to 14 days. Then remove the cast and encourage him to                          you can easily miss an angulation deformity in a lateral X-
walk without a limp as soon as he can.                                         ray, so examine the posterior half of the patient’s subtaloid
                                                                               joint carefully. If its two articular surfaces are not parallel,
                                                                               the fragments have angulated at the fracture line.
83.4 Fracture of the body of the talus
In this rare injury a patient fails from a height on to his heels              TREATING FRACTURES OF THE NECK OF THE TALUS
and crushes the articular surface of his talus. His ankle is
swollen and painful.                                                           NO ANGULATION No reduction is needed for a fracture like
                                                                               that in B, Fig. 83-2. Apply a short leg walking cast from
   FRACTURE OF THE BODY OF THE TALUS If the pa-                                below the patient’s knee to his toes, with his foot in neutral.
tient’s talus is comminuted, there is no advantage in refer-                   Get him up, and teach him to walk bearing weight. Three
ring him, so try to mould the comminuted fragments by ac-                      months later remove the cast.
tive movements. As soon as he can move his ankle without
too much pain, allow him up on crutches, but don’t let him
bear weight on it for 3 months. If it becomes too painful, refer                REDUCING AN ANGULATED
him for an arthrodesis.                                                         FRACTURE OF THE NECK
                                                                                OF THE TALUS
83.5 Fractures of the neck of the talus
These rare fractures are the result of forced dorsiflexion of
the patient’s foot, and may injure his soft tissues severely.

INJURIES OF                               skin here about
THE TALUS                                 to necrose

        A talonavicular
        dislocation                                                                      Before reduction                After reduction, the
                                                                                                                         foot forcibly plantar−flexed
    B                                     C                                                                     4

                                                                                                                3            E

        Fracture of the neck of the       comminuted fracture of the                                                                     6
        talus without angulation          body of the talus

                                                                               Fig. 83.3: REDUCING AN ANGULATED FRACTURE OF THE
Fig. 83.2: SOME INJURIES OF THE TALUS. A, the patient’s talonavic-             NECK OF THE TALUS. A, the fracture before reduction. The body of
ular joint has dislocated, so that his talus forms a swelling on the dorsum    the patient’s talus may also be displaced backwards and rotated. B, the
of his ankle. B, an undisplaced fracture of the neck of the talus. C, a com-   way in which plantar flexion achieves reduction. C, D, and E, the detailed
minuted fracture of the body of the talus.                                     method of reduction. After de Palma, with kind permission.

                                                                                          83.6 Fracture of the body of the calcaneus

   WITH ANGULATION Internal fixation is sometimes possi-             range of plantar and dorsiflexion, he cannot invert or evert
ble.                                                                his heel on his ankle—there is no movement at his subtar
   If his talus is in two parts, refer him for internal fixation.    joint, either active or passive. Trying to move it is painful.
   If you cannot refer him, reduce his fracture by forcibly            The fracture lines may not be easy to see on an X-ray, so
plantar flexing his foot, as in Fig. 83-3.                           take a lateral and a special axial view, and look for widening
   Place a canvas sling (1) around the distal end of the pa-        of his calcaneus. Fractures take many forms and vary from
tient’s thigh, or ask an assistant to hold it.                      small cracks to extensive comminution. Fortunately, an ex-
   Flex his knee to 90◦ (2). Grasp his heel with one hand           act diagnosis of the type of fracture is not necessary, because
and his forefoot with the other (3).                                you can treat them all in the same way.
   Pull his foot forward into full dorsiflexion (4). While you are
pulling forward and maintaining dorsiflexion, strongly evert
his foot (5). This will unlock his sustentaculum tali.              FRACTURE OF THE BODY OF THE CALCANEUS
   While your assistant presses firmly with his thumbs on ei-
ther side of the patient’s Achilles tendon (6), plantar flex his     Don’t try to reduce these fractures. Instead, compress the
foot (7). A crunching noise shows that reduction is occur-          patient’s swollen ankle with a crepe bandage to reduce the
ring.                                                               swelling. Put him to bed for a very short time only (perhaps
   Confirm reduction by taking an X-ray. After reduction, ap-        3 days), until the pain is bearable and he is able to put his
ply a cast from just below the patient’s knee to his toes, hold-    foot to the ground without too much pain.
ing his foot in equinus. Keep him in bed, and make him ex-             Then without weight bearing, and with much encourage-
ercise his muscles inside the cast as much as possible.             ment and careful supervision, encourage active movement
   If you have not been able to reduce his fracture, refer him      of his hip, knee, ankle, and toes for 3 weeks. Follow this by
for open reduction.                                                 active exercise with partial weight bearing using crutches.
   If you have been able to reduce his fracture, l eave the         Cycling is excellent. All this will be painful, especially early
cast on for 5 to 6 weeks. Then remove it, bring his foot into       on, so give him plenty of aspirin. Healing takes time, and im-
the neutral position, and apply another cast for 5 to 6 weeks       provement may continue for 2 years at least. If his fracture
in this neutral postion.                                            is bilateral, early mobilisation will be more difficult and take
   WITH ANTERIOR OR POSTERIOR DISPLACEMENT                          longer.
OF THE FOOT These injuries are rare.                                   CAUTION! If you have to apply a cast to ease the pain,
   If the patient’s foot is displaced forwards, forcibly plan-      and make it easier to treat him as an outpatient, leave it on
tar flex it and push it backwards. Apply a cast with his foot in     for a few days only, and then get him walking without it.
equinus, and continue as above.
                                                                       An occasional patient has enough later disability to need
   If his foot and with it the posterior half of his talus is
                                                                    his subtalar joints fused. Don’t refer him for 6 months or a
pushed backwards, put a Steinmann pin through his cal-
caneus (70.12). Exert traction so as to open up the space
between his calcaneus and his tibia, and push the posterior
fragment forwards into his ankle mortice. Apply a cast in
equinus as above. If closed reduction fails, refer him.              A SIGN OF A
                                                                     FRACTURED CALCANEUM
THE TALUS                                                                                                                 FRACTURED

If some months later, the patient’s FOOT IS STILL
PAINFUL and part of his talus looks abnormally dense,
aseptic necrosis has taken place. This is common, espe-                                         normal hollow
cially after a dislocation, so warn him about it. The frag-                                     beneath
                                                                                                lateral malleolus
ments may unite, even if they look dense on an X-ray. An
arthrodesis may eventually be necessary.

                                                                                                 hollow beneath
83.6 Fracture of the body of the calcaneus                                                       the lateral
                                                                                                 filled out
In this common fracture the patient falls on to his feet, usu-
ally from only quite a small height. Sometimes, both his
calcanei fracture, and his spine too. Always suspect that a
patient might have fractured his calcaneus if he complains
of pain in his foot after landing on his feet. Although his
foot may look fairly normal, you will always find two signs.
   (1) His injured calcaneus is widened, so that as you run
your finger down the outer side of his leg, it passes over the
tip of his lateral malleolus on to his swollen calcaneus in the
same plane. In a normal foot, your finger sinks into a marked
hollow below the lateral malleolus.                                 Fig. 83.4: A SIGN OF INJURY TO THE CALCANEUS is filling out of
   (2) The second sign concerns a patient’s subtalar joint. Al-     the normal hollow under the patient’s lateral malleolus. Kindly contributed
though he can move his ankle through about half its normal          by Peter Bewes.

83 The foot

 FRACTURES OF THE                                      normal angulation      83.9 Fracture subluxation of the
 CALCANEUS                                                                         tarso–metatarsal joint
                                                                              This is a difficult fracture to see on an X-ray, but if you look
                                                                              carefully at the bases of all the patient’s metatarsals, you will
                                                                              see that he has multiple fractures with minor displacements.
                                                             the upper
                                                             surface of
                                                                              This is a severe injury and osteoarthritis often follows, some-
                                                             a normal         times so severely as to need an arthrodesis.
                                                             is angulated
                                                             as above,
                                                             after a
                                                                              FRACTURE SUBLUXATION OF THE
                                                             fracture this    TARSO–METATARSAL JOINT
                                                             is altered       If there is severe displacement of the patient’s tarso–
                                                                              metatarsal joint, attempt to reduce it as best you can.
         mild displacement            severe displacement                        If you cannot reduce it with your hands alone, pass
                                                                              a Kirschner wire through the distal ends of his metatarsals,
Fig. 83.5: TWO FRACTURES OF THE BODY OF THE CALCANEUS.                        hold this in a tensioner, and use it to help you to manipulate
A, with mild displacement. B, with severe displacement. C, the upper          the distal part of his foot. Get this into a good position, and
surface of a normal calcaneus is angulated. A severe fracture destroys this   hold it with crossed Kirschner wires. Remove the tensioner
normal angulation. From Perkins with kind permission.
                                                                              and apply a well–padded cast. If you don’t have Kirschner
                                                                              wires, try to hold his broken bones with a well moulded cast
                                                                              with his forefoot held in plantar flexion. After a week change
83.7 Other fractures of the calcaneus                                         this for a short leg walking cast and crutches. Encourage
                                                                              him to walk normally. Four weeks later change this for a
These are all quite minor injuries. They are not easy to diag-                shoe.
nose, but since they can all be treated by active movements,
this is fortunately unimportant.
  Fracture of the tuberosity of the calcaneus can be diag-                    83.10 Crush fractures of the metatarsals
nosed in a lateral X-ray which may show a fragment prised
up from the posterior angle of the bone. Or, an axial X-ray                   Any crush injury to a patient’s forefoot is serious, and can
may show a vertical fracture. Treat both these injuries by                    disable him. His metatarsals usually break through their
early active movements.                                                       necks, and he may have an open wound. Diagnosis is diffi-
                                                                              cult without an X-ray. These fractures are difficult to reduce,
  Fracture of the sustenstaculum tali is difficult to see in an
X-ray film, displacement is slight, and no reduction is nec-
essary. Encourage the patient to bear weight immediately.
  Fracture of the anterior end of the calcaneus is caused
by severe inversion of the patient’s foot, or a subtaloid dis-
location. A small fragment is pulled off the upper surface of
the front end of his calcaneus. Treat it without reduction by
active movements as above.
                                                                                                          no fracture

83.8 Fractures of the navicular and cuboid

When a patient’s foot is crushed, he may fracture his navic-
ular, or his cuboid; his midtarsal joint may be dislocated, or
his metatarsals fractured. These are serious injuries and he
may have several of them at the same time.

Give the patient a general anaesthetic. Look at his X-rays
and carry out any manoeuvre which you think might reduce                             B
the fragments, especially if there are signs of a dislocation
of his mid–tarsal joint.                                                                                                             normal apophysis
                                                                                                           fracture of the base
   If you cannot reduce his injuries, try to refer him.                                                    of the fifth metatarsal
   If you can reduce them, apply a short leg walking cast                                            callus appears ten days later
(81.5) with his foot in neutral. Keep him in bed with his foot
raised until the swelling has gone. Then encourage him to
walk with crutches, starting with partial weight bearing.                     Fig. 83.6: FRACTURES OF THE METATARSALS. In the march frac-
                                                                              ture A, no injury is visible immediately after the injury, but B, shows
   After 3 weeks remove the cast. Check to see if the pain                    callus appearing 10 days later. C, shows several fractured metatarsals. D,
and swelling have subsided enough for him to start walking                    shows a fracture of the base of the fifth metatarsal. Compare it with the
with crutches and partial weight bearing.                                     normal apophysis E.

                                                                                 83.12 Fracture of the base of the fifth metatarsal

but they usually heal without reduction. If they heal in a           83.12 Fracture of the base of the fifth
grossly displaced position, his foot may be painful perma-                 metatarsal
nently, so do your best to reduce them. His first metatarsal
is a weight bearing bone, so that if it is fractured he is likely    Severe twisting of the front half of the patient’s foot tears
to need a cast.                                                      a fragment bone from the base of his fifth metatarsal. Don’t
                                                                     confuse this fracture with an ununited apophysis, which has
CRUSH FRACTURES OF THE METATARSALS                                   a characteristic smooth comma shape, and is usually bilat-
                                                                     eral. If you are in doubt X-ray his other foot.
If there is obvious gross displacement, anaesthetize the                He will give you a history of having sprained his foot, but
patient, reduce his fracture as best you can, apply a below–         his lateral malleolus is not tender, and there is no tender-
knee walking cast (81.5), and then elevate his leg (Fig. 81-         ness over the front of his calcaneus. Instead, there is marked
1). Take care to mould its sole to both the longitudinal and         tenderness over and underneath the prominence formed by
the transverse arches of his feet as in Fig. 83-1. If you fail       the base of his fifth metatarsal. This is a painful injury, so fit
to correct severe displacement, he will be left with serious         him with a below–knee walking cast for 2 weeks, or longer
disability, so refer him.                                            if necessary.
   If there is no obvious displacement, elevate his leg. As
soon as swelling has subsided, and he is comfortable and
can walk, give him aspirin and strap his foot in a crepe ban-        83.13 Fractures of the phalanges of the toes
dage. If he cannot walk, immobilize his foot in a below–knee
walking cast. After 3 weeks in this encourage him to walk in         A weight falling on to a patient’s toes sometimes breaks
an ordinary shoe.                                                    them. Reduction is unnecessary, but it may be advisable to
                                                                     evacuate a painful subungual haematoma (75.5). These frac-
                                                                     tures are not serious and always unite. Splint his injured toe
DIFFICULTIES WITH CRUSH FRACTURES OF THE                             with zinc oxide strapping to the adjacent normal toe. Pad it
METATARSALS                                                          with a little cotton wool to absorb moisture. As soon as he
If a patient has INTENSE PAIN AND SWELLING, marked                   can get his shoe on, send him back to work. A metal stiff-
stiffness, warm, smooth, glossy skin, bone rarefaction,              ener driven down between the layers of the sole of his shoe
and in extreme cases, trophic ulcers, he has SUDECK’S                will help him to return to work sooner.
ATROPHY which may last several years. It can follow any
crush injury of the foot (or hand), even quite a minor one.
Keep him walking on his foot as best he can, with weight
bearing to tolerance. If he ceases to use it, bone rarefaction
will become severe.

83.11 Fatigue (march) fractures
One of the patient’s metatarsals, usually his second, frac-
tures spontaneously, without any history of injury. He has
localized pain particularly at night, and tenderness over the
fracture site. At first the X-ray shows only a fine transverse
crack, or nothing at all. But 10 days later a mass of callus
appears. Because he may present with pain of gradual on-
set without a history of injury, and because the fracture may
not be visible on an X-ray, you can confuse the callus with a
sarcoma, as in the tibia (81.8). Strap the front part of his foot,
and advise him to put less stress on the fracture.


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