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10/26/2018 0 Comments

LisFranc Fracture


Introduction
  • Disruption between the articulation of the medial cuneiform and base of the second metatarsal
    • Disruption of the TMT joint complex
    • Injury to 2nd metatarsal àDisruption of other metatarsals
  • May take form of purely ligamentous injuries or fracture-dislocations
    • Ligamentous vs. bony injury pattern has treatment implications
  • More common in males in their 30s 
  • Missed injuries can result in progressive foot deformity, chronic pain and dysfunction
    • Tarsometatarsal fracture-dislocations are easily missed (up to 30% on initial visits) and diagnosis is critical

Mechanism & Pathoanatomy
  • Mechanism = indirect rotational forces and axial load through hyperplantar flexed forefoot 
    • Hyperflexion/compression/abduction moment exerted on forefoot and transmitted to the TMT articulation
    • Metatarsals displaced in dorsal/lateral direction 
    • Think of a running back trying to push through lineman or sprinter
 
Anatomy
  • Midfoot:
    • Medial, Intermediate (Middle), Lateral Cuneiform
    • Navicular
    • Cuboid
  • Lisfranc joint complex consists of three articulations:
    • 1) Tarsometatarsal articulation
    • 2) Intermetatarsal articulation
    • 3) Intertarsal articulations
  • Ligaments
    • Lisfranc ligament  
      • Stabilizes 2nd metatarsal and maintenance of the midfoot arch
      • Interosseous ligament that goes from medial cuneiform to base of 2nd metatarsal on plantar surface 
    • No direct ligamentous attachment between first and second metatarsal

Physical Exam
  • Symptoms
    • Severe pain and inability to bear weight
  • PE
    • Medial plantar bruising with swelling throughout midfoot
    • Tenderness over tarsometatarsal joint
    • Pain with pronation and passive abduction of the midfoot
    • *Instability test
      • Grasp metatarsal heads and apply dorsal force to forefoot while other hand palpates the TMT joints
      • Dorsal subluxation suggests instability
      • If first and second metatarsals can be displaced, global instability is present, and surgery is required
      • When plantar ligaments are intact, dorsal subluxation does not occur with stress exam and injury may be treated nonoperatively
    • Evaluate for compartment syndrome!
 
Imaging
  • Radiographs
    • AP, lateral, oblique views
    • Stress -> may be helpful to show instability when non-weight bearing radiographs are normal and there is high suspicion
    • Weight-bearing with comparison view
    • 5 critical radiographic signsthat indicate presence of midfoot instability
      • 1) Discontinuity of a line drawn from the medial base of the 2nd metatarsal to the medial side of the middle cuneiform (diagnostic)
      • 2) Widening of the interval between the 1st and 2nd metatarsal
        • Fleck sign= bony fragment in 1st intermetatarsal space àAvulsion of Lisfranc ligament from base of 2nd metatarsal (diagnostic)
      • 3) Dorsal displacement of the proximal base of the 1st or 2nd metatarsal  
      • 4) Medial side of the base of the 4th metatarsal does not line up with medial side of cuboid 
      • 5) Disruption of the medial column line (line tangential to the medial aspect of the navicular and the medial cuneiform)
  • CT scan
    • Useful for diagnosis and preoperative planning
  • MRI
    • Can be used to confirm presence of purely ligamentous injury

Treatment
  • Nonoperative
    • Posterior splint and non-weightbearing for sprains and non-displaced fractures
      • No displacement on weight-bearing and stress radiographs and no evidence of bony injury on CT (usually dorsal sprains)
    • Cast immobilization for 8 weeks 
  • Operative
    • ORIF
    • Any evidence of instability (> 2mm shift)     
    • Favored in bony fracture dislocations as opposed to purely ligamentous injuries
    • Primary arthrodesis 
      • Purely ligamentous arch injuries   
      • Primary arthodesis is an alternative to ORIF in patients with any evidence of instability with possible benefits 
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10/25/2018 0 Comments

Patellar Dislocation


Background
  • Typically occurs with trauma to an extended knee with externally rotated foot (quick pivoting in basketball, football and soccer)
  • Acute dislocation occurs with traumatic injury, M=F, may see hemarthrosis
  • Chronic dislocation or patholaxity seen more commonly in women
    • Ehlers-Danlos syndrome
    • Typically, little or no swelling; painless
    • Recurrent subluxation episodes with each flexion movement
  • May occur from a direct blow (ex. helmet to knee collision in football; knee-knee collision in basketball)
    • Usually on noncontact twisting injury with the knee extended and foot externally rotated
    • Patient will usually reflexively contract quadriceps thereby reducing the patella
  • Common associated fractures
    • Medial patella facet
    • Lateral femoral condyle
 
Clinical Features
  • Patella is usually displaced laterally
  • Knee is held in flexion
  • Acute dislocation usually associated with a large hemarthrosis   
    • Absence of swelling supports ligamentous laxity and chronic dislocation mechanism
 
Evaluation
  • Clinical diagnosis
  • May consider pre-reduction x-ray if concern for fracture (not required)
 
Management
  • Reduction = Relocation with lateral pressure on dislocated patella
  • Do NOT need x-rays prior to reduction
    • Consider XR following reduction to rule out fracture or loose body
  • Rarely need any sedation (sub-dissociative dose ketamine ?)
  • Option #1:
    • Mild flexion of hip (20-30 degrees by raising head of bed, not by propping the leg up off the bed) to relax quadriceps
    • Slowly extend and slightly hyperextend the knee and slide patella back into place.
  • Option #2
    • One provider applies slow downward pressure over the quads. This stretches out the muscle and slowly straightens the leg
    • At the same time, second provider pulls gentle traction of the patella outward while rotating the patella back over from lateral to anterior

​Disposition

  • Obtain ortho consult if unable to reduce or fracture/loose bodies seen on post-reduction x-ray
  • Otherwise may be discharged with ortho follow-up in 1-2 weeks
  • Non-Operative:
    • NSAIDS, activity modification, and physical therapy
    • Knee immobilizer for comfort (short-term)
    • Quad strengthening exercises
    • Core and hip strengthening to improve limb positioning and balance (hip abductors, gluteals, and abdominals) 
  • Consider knee aspiration for tense effusion
    • Positive fat globules indicates fracture
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