83. Foot
From Primary Surgery
83.1 Conservative treatment for foot injuries
Because feet are usually hidden inside shoes, injuries to them tend to be neglected. You can treat most foot injuries conservatively, and only a few need reduction. Fracture of the body of the calcaneus is the most important one.
CONSERVATIVE TREATMENT FOR FOOT INJURIES Try to
diagnose and treat the specific injuries described later. If you
have no X-rays, or diagnosis is difficult, proceed as follows:
If there is any obvious displacement of the bones of 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 longitudinal and the transverse arches of his foot. Keep him in bed until his pain subsides and then start him walking in crutches. If you cannot hold the reduction in plaster, fix it with Kirschner wire (70.13).
If he has no obvious displacement, fit him with a short leg walking cast as above.
If his pain is severe and he has only minor injury, or his X-ray is negative, a short leg walking cast will also help him.
DON'T FORGET TO REDUCE SEVERE DISPLACEMENT
83.2 Dislocation of the talonavicular joint
The joint between a patient's talus and his navicular is often strained, and occasionally dislocates, sometimes in association with a dislocation of his forefoot. After some violent injury his foot is turned inwards and displaced under his talus, which remains in its normal place in his ankle joint. The displacement of the front of his foot from around his talus leaves it forming a swelling on the dorsum of his ankle, which presses on the skin and may cause it to necrose rapidly. (A, Fig. 83-2) He is in great pain, and the extreme inversion of his foot makes the diagnosis obvious. Occasionally, his foot is displaced laterally instead of medially. Sometimes, his cuboid and the head of his calcaneus are fractured at the same time. You will see these fractures best after you have reduced his talonavicular dislocation, but even if they are present, they do not alter treatment.
DISLOCATION OF THE TALONAVICULAR JOINT. Reduce the
dislocation quickly before the skin over the head of the
patient's talus becomes necrotic. I! 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 walki
ng 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 weeks.
83.3 Fractures of the dome of the talus
In this injury the patient twists his foot inwards, and shears a small fragment off the upper surface of his talus. An AP X-ray shows a small triangular fragment, like a loose body, at the upper lateral angle of his talus. As his foot returns to its normal position this fragment may turn upside down.
FRACTURE OF THE DOME OF THE TALUS If the fragment is the right way up, no treatment is needed.
If the fragment has turned upside down, refer the patient.
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 peroneal nerve. Fit him with a short leg walking cast for .0 to 14 days. Then remove the cast and encourage him to walk without a limp as soon as he can.
83.4 Fracture of the body of the talus
In this rare injury a patient fails from a height on to his heels and crushes the articular surface of his talus. His ankle is swollen and painful.
FRACTURE OF THE BODY OF THE TALUS If the patient's
talus is comminuted, there is no advantage in referring him,
so try to mould the comminuted fragments by active
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 him
for an arthrodesis.
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. The fracture line runs through the neck of his talus in a coronal plane just in front of the anterior margin of his tibia. There are several varieties: (1) There may be no displacement. (2) The fragments may angulate so that the posterior half of his talus is plantar flexed, while its anterior half is dorsiflexed. You can usually reduce these fractures without too much difficulty by plantar flexing the patient's foot and holding it in a cast. (3) The posterior half of his talus may be displaced posteriorly out of its mortice with his talus leaving the anterior half in place.
FRACTURES OF THE NECK OF THE TALUS
DIAGNOSIS Lateral displacement is easily diagnosed, but you can easily miss an angulation deformity in a lateral X-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.
TREATING FRACTURES OF THE NECK OF THE TALUS
NO ANGULATION No reduction is needed for a fracture like that in B, Fig. 83-2. Apply a short leg walking cast from below the patient's knee to his toes, with his foot in neutral. Get him up, and teach him to walk bearing weight. Three months later remove the cast.
WITH ANGULATION Internal fixation is sometimes possible. If his talus is in two parts, refer him for internal fixation.
If you cannot refer him, reduce his fracture by forcibly plantar flexing his foot, as in Fig. 83-3. Place a canvas sling (1) around the distal end of the patient's thigh, or ask an assistant to hold it. Flex his knee to 90° (2). Grasp his heel with one hand and his forefoot with the other (3).
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.
While your assistant presses firmly with his thumbs on either side of the patient's Achilles tendon (6), plantar flex his foot (7). A crunching noise shows that reduction is occurring.
Confirm reduction by taking an X-ray. After reduction, apply a cast from just below the patient's knee to his toes, holding his foot in equinus. Keep him in bed, and make him exercise his muscles inside the cast as much as possible.
If you have not been able to reduce his fracture, refer him for open reduction.
If you have been able to reduce his fracture, leave the cast on for 5 to 6 weeks. Then remove it, bring his foot into the neutral position, and apply another cast for 5 to 6 weeks in this neutral postion.
WITH ANTERIOR OR POSTERIOR DISPLACEMENT OF THE FOOT These injuries are rare.
If the patient's foot is displaced forwards, forcibly plantar flex it and push it backwards. Apply a cast with his foot in equinus, and continue as above.
If his foot and with it the posterior half of his talus is pushed backwards, put a Steinmann pin through his calcaneus (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.
DIFFICULTIES WITH FRACTURES OF THE NECK OF THE TALUS
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, especially after a dislocation, so warn him about it. The fragments may unite, even if they look dense on an X-ray. An arthrodesis may eventually be necessary.
83.6 Fracture of the body of the calcaneus
In this common fracture the patient falls on to his feet, usually 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.
(2) The second sign concerns a patient's subtalar joint. Although he can move his ankle through about half its normal range of plantar and dorsiflexion, he cannot invert or evert his heel on his ankle-there is no movement at his subtar joint, either active or passive. Trying to move it is painful.
The fracture lines may not be easy to see on an X-ray, so take a lateral and a special axial view, and look for widening of his calcaneus. Fractures take many forms and vary from small cracks to extensive comminution. Fortunately, an exact diagnosis of the type of fracture is not necessary, because you can treat them all in the same way.
FRACTURE OF THE BODY OF THE CALCANEUS
patient's swollen ankle with a crepe bandage to reduce the swelling. Put him to bed for a very short time only (perhaps 3 days), until the pain is bearable and he is able to put his foot to the ground without too much pain.
Then without weight bearing, and with much encouragement and careful supervision, encourage active movement of his hip, knee, ankle, and toes for 3 weeks. Follow this by active exercise with partial weight bearing using crutches. Cycling is excellent. All this will be painful, especially early on, so give him plenty of aspirin. Healing takes time, and improvement may continue for 2 years at least. If his fracture is bilateral, early mobilisation will be more difficult and take longer.
CAUTION ! If you have to apply a cast to ease the pain, and make it easier to treat him as an outpatient, leave it on for a few days only, and then get him walking without it. An occasional patient has enough later disability to need his subtalar joints fused. Don't refer him for 6 months or a year.
83.7 Other fractures of the calcaneus
These are all quite minor injuries. They are not easy to diagnose, but since they can all be treated by active movements, this is fortunately unimportant.
Fracture of the tuberosity of the calcaneus can be diagnosed in a lateral X-ray which may show a fragment prised up from the posterior angle of the bone. Or, an axial X-ray may show a vertical fracture. Treat both these injuries by early active movements.
Fracture of the sustenstaculum tali is difficult to see in an X-ray film, displacement is slight, and no reduction is necessary. 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 dislocation. 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.
83.8 Fractures of the navicular and cuboid
When a patient's foot is crushed, he may fracture his navicular, 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.
FRACTURES OF THE NAVICULAR AND THE CUBOID Give
the patient a general anaesthetic. Look at his X-rays and carry
out any manoeuvre which you think might reduce the
fragments, especially if there are signs of a dislocation of his
mid-tarsal joint.
If you cannot reduce his injuries, try to refer him.
If you can reduce them, apply a short leg walking cast (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. After 3 weeks remove the cast. Check to see if the pain and swelling have subsided enough for him to start walking with crutches and partial weight bearing.
83.9 Fracture subluxation of the 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. This is a severe injury and osteoarthritis often follows, sometimes so severely as to need an arthrodesis.
FRACTURE SUBLUXATION OF THE TARSO-METATARSAL JOINT
If there is severe displacement of the patient's tarso-metatarsal joint, attempt to reduce it as best you can.
If you cannot reduce it with your hands alone, pass a Kirschner wire through the distal ends of his metatarsals, hold this in a tensioner, and use it to help you to manipulate the distal part of his foot. Get this into a good position, and hold it with crossed Kirschner wires. Remove the tensioner and apply a well-padded cast. If you don't have Kirschner wires, t ry to hold his broken bones with a well moulded cast with his forefoot held in plantar flexion. After a week change this for a short leg walking cast and crutches. Encourage him to walk normally. Four weeks later change this for a shoe.
83.10 Crush fractures of the metatarsals
Any crush injury to a patient's forefoot is serious, and can disable him. His metatarsals usually break through their necks, and he may have an open wound. Diagnosis is difficult without an X-ray. These fractures are difficult to reduce, but they usually heal without reduction. If they heal in a grossly displaced position, his foot may be painful permanently, so do your best to reduce them. His first metatarsal is a weight bearing bone, so that if it is fractured he is likely to need a cast.
CRUSH FRACTURES OF THE METATARSALS
If there is obvious gross displacement, anaesthetize the patient, reduce his fracture as best you can, apply a below-knee walking cast (81.5), and then elevate his leg (Fig. 81-1). Take care to mould its sole to both the longitudinal and the transverse arches of his feet as in Fig. 83-1. If you fail to correct severe displacement, he will be left with serious disability, so refer him.
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 bandage. If he cannot walk, immobilize his foot in a below-knee walking cast. After 3 weeks in this encourage him to walk in an ordinary shoe.
DIFFICULTIES WITH CRUSH FRACTURES OF THE METATARSALS
If a patient has INTENSE PAIN AND SWELLING, marked stiffness, warm, smooth, glossy skin, bone rarefaction, and in extreme cases, trophic ulcers, he has SUDEK'S 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, fractures 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 onset 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.
83.12 Fracture of the base of the fifth metatarsal
Severe twisting of the front half of the patient's foot tears a fragment bone from the base of his fifth metatarsal. Don't confuse this fracture with an ununited apophysis, which has a characteristic smooth comma shape, and is usually bilateral. If you are in doubt X-ray his other foot.
He will give you a history of having sprained his foot, but his lateral malleolus is not tender, and there is no tenderness over the front of his calcaneus. Instead, there is marked tenderness over and underneath the prominence formed by the base of his fifth metatarsal. This is a painful injury, so fit him with a below-knee walking cast for 2 weeks, or longer if necessary.
83.13 Fractures of the phalanges of the toes
A weight falling on to a patient's toes sometimes breaks them. Reduction is unnecessary, but it may be advisable to evacuate a painful subungual haematoma (75.5). These fractures are not serious and always unite. Splint his injured toe with zinc oxide strapping to the adjacent normal toe. Pad it with a little cotton wool to absorb moisture. As soon as he can get his shoe on, send him back to work. A metal stiffener driven down between the layers of the sole of his shoe will help him to return to work sooner.
