Amy McCandless, DPM

Justin Fleming, DPM

A 45-year-old male is brought to the ED by EMS after jumping from a two story window. The patient was hemodynamically unstable upon arrival to the emergency department and was intubated in the ED.  CAT scans of the abdomen, pelvis, and chest revealed multiple extra-peritoneal hemorrhages, as well as a left sided pelvic fracture. The podiatry service was consulted to evaluate bilateral lower extremity edema and ecchymosis.

PMH: Alcoholism, HTN, Non-ischemic cardiomyopathy, CHF, supraventricular tacchycardia, atrial fibrillation, AICD, subdural hematoma, seizure disorder, hepatitis C

PSH: AICD placement, Hernia repair (umbilical), Right hammertoe repair, Right hip replacement

FMH: Non-contributory

MEDS: Lasix, Xanax, Coreg, Spirolactone, Vasotec, Potassium

ALL: NKDA

SOCIAL: EtOH abuse

ROS: Pt intubated in ICU at time of exam.

VS: BP: 69/60, HR: 86, RR: 18, Temp: 97.4

PE: The patient is sedated and intubated. He presents with palpable pedal pulses that are graded +1/4 at the dorsalis pedis and posterior tibial arteries. Bilateral feet are cool to the touch. Capillary refill time is less than 3 seconds. Unable to assess protective sensation.

Left Lower Extremity: Diffuse non-pitting edema of entire foot. Gross dislocation of the midfoot on the rearfoot. Skin tenting present on the dorsal midfoot. No necrosis or deep open wounds.  Ecchymosis present on dorsalateral foot, lateral ankle, and plantar vault. Superifical abrasions on dorsal surfaces on digits 1-5.

Right Lower Extremity: Diffuse non-pitting edema of entire foot. Ecchymosis present digits 1-5, sub-metatarsal 1-5, and along posterior heel.  No open lesions. No gross dislocations.

Figure 1A & B: Radiographic signs of a traumatic talonavicular dislocation, comminuted cuboid fracture, and a lateral tarsometatarsal joint fracture-dislocation.

CT images of the left foot confirm the findings of a complete talonavicular dislocation, comminuted cuboid fracture and lateral tarsometatarsal joint fracture-dislocation. Additionally the CT images reveal a large amount of comminution noted at the talonavicular joint surface.

Figure 2A & B: CT images demonstrate clinical and radiographic signs of a traumatic talonavicular dislocation, comminuted cuboid fracture, and a lateral tarsometatarsal joint fracture-dislocation.

ASSESSMENT

Talonavicular dislocation, comminuted cuboid fracture and lateral tarsometatarsal joint fracture-dislocation 

PLAN

The decision was made that a staged reconstruction of the patient’s foot injuries would be performed secondary to the significant soft tissue injury.

SURGICAL PROCEDURE

STAGE 1:  Temporary stabilization was achieved via external fixator and percutaneous pinning of the talonavicular joint was performed.

With the patient in the supine position,  4mm pins were placed under fluoroscopic guidance into the 4th/5th metatarsal bases and 1st metatarsal shaft.  Additionally a centrally threaded transcalcaneal shantz pin was placed into the calcaneal tuberosity.  After attempts at closed reduction failed, a midline incision was created over the talonavicular joint.  With longitudinal traction applied through the external fixator the talar head was disimpacted and relocated with a pelvic tenaculum.  A percutaneous wire was used to maintain reduction.  The lateral column was then brought out to length and the fixator was secured.

Figure 3A & B: Utilizing the external fixator the talonavicular joint was reduced and temporarily fixed with a wire. Additionally the lateral column length was restored.

STAGE 2: The patient remained in the external fixator for 2 weeks, at which time his soft tissue envelope was appropriate for definite surgical reconstruction.  A primary talonavicular arthrodesis and ORIF cuboid / lateral tarsometatarsal joint with “bridge plating” was performed.

Following the removal of the external fixator, the midline incision was re-opened and the talonavicular joint was distracted.  Secondary to the severe cartilage damage to the talonavicular joint, the decision was made to perform a primary arthrodesis of the joint. The corresponding articular surfaces and subchondral bone plate was denuded and the joint was anatomically positioned. Two 3.5mm cortical lag screws provided the initial compression.  Remaining bone defects were filled with cancellous allograft. Next, a medium size utility plate was used across the dorsal joint surface in a static mode with locking screws in the navicular and nonlocking screws in the talar neck and head. Next, a lateral utility incision was created to expose the lateral column of the foot.  The cuboid was then disimpacted and the articular surface was restored.  Structural bone was placed to support the anterior facet.  The lateral tarsometatarsal joint was reduced and a large multifragmentary plate was employed to maintain lateral column length and osseous reduction (Fig 5). The external fixator was removed at this time. The wound was flushed and a layered closure of both incisions was performed.

Figure 4A & B: A primary talonavicular arthrodesis and ORIF Cuboid / Lateral tarsometatarsal joint with �bridge plating� was performed.

Post-operatively the patient remained NWB until osseous union of both the arthrodesis and fracture sites. The patient healed without incident and progressed to full weightbearing with good functional outcome.

Midfoot fractures typically have complex injury patterns. This, coupled with the complex anatomy of the midfoot, results in injuries that are difficult for the surgeon to reduce and fixate adequately. To complicate matters, the soft tissue envelope of the foot is unforgiving and often times causes more postoperative set backs than the osseous injury itself. It is imperative with these injuries that both the osseous and soft tissue injuries are assessed and treated accordingly. More often than not, a staged procedure is required to first stabilize the osseous injury while allowing the soft tissue envelope to recover. When attempting reduction and fixation of these fractures, restoration of articular surfaces as well as maintenance of both the medial and lateral columns of the foot leads to the best post-operative outcomes. When imaging studies or intraoperative findings reveal severe comminution, and the joints are deemed non-reconstructable, primary arthrodesis is recommended.  Functional outcomes in these patients are suboptimal with ORIF secondary to the rapid development of post-traumatic arthritis.

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