Talus

Clinical image

Radiograph of a Lisfranc fracture-dislocation. Source: Wikimedia Commons — James Heilman, MD; CC BY 3.0. Image binary is embedded locally in this package; original source and licence are retained.

Calcanium

• I see the lateral view of left ankle showing intra articular fracture of the calcaneum. I would like to know the MOI and time since injury
• I will approach patient using ATLS principles and ensure that the injury is isolated, closed, neurovascularly intact and there is no compartment syndrome, and assess the state of soft tissue. I will actively look for spine fracture and long bone fractures.
• I would like to see the axial view and bordens view.
• My management include
  • Initial
  • Planning
  • Definitive
• Initially, I will give adequate analgesia and immobile in a back slab. Key is proper soft tissue care. That include cryotherapy, foot pump, anti-inflammatory medicines and limb elevation.

Talk

• At this time I will order for a CT scan to know the pattern of injury to bone.

• Comminution , widening of heel and lateral wall blow out all suggest operative fixation but my decision to operate will be based on

  • Patient factors
  • Soft tissue status
  • Fracture pattern

• Final decision will be taken in consultation with the patient

• I will assess the patient for poor prognostic signs

  • DM
  • Smoking
  • Male
  • Manual labour
  • Workers compensation
  • Steroids

• Patients who may benefit from surgical treatment include

  • Gross deformity
  • Open fracture
  • Fracture causing soft tissue compromise
  • Griffine et al BMJ 2014, RCT, no difference in outcome by 2 years

Principle

• Reduce CC and ST joints by reduction of Posterior facet and correction of widening of calcaneum

Compli

• Malunion (I: lateral exostosis, II: +ST arthritis,III: +varus)
• Impingement
• Compartment
• Wound healing
• FHL problem

Lisfranc

• 3 cuniforms and first 2 metatarsals
• Lisfranc ligament: runs from plantar second MT to plantar medial cuniform
• Fleck sign

X Ray

• AP: Medial border of 2nd MT in line with medial border of 2nd cuniform
• Oblique: Medial border of 4th and medial border of cuboid
• Lateral view : no step

Hardcastle

Treatment

• Screw or plate fixation of medial column and k wire fixation lateral column
• Suture anchor
• Arthrodesis
  • Missed or failed ORIF
  • Ly et al
    • Crushed mid foot
    • comminution
    • multidirectional instability
• Mulier et al: Partial fusion