Midfoot Fractures

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Midfoot Fractures

• Jenny Jefferis

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What is a midfoot fracture?

• Fracture of the midfoot involving the
• Tarsometatarsal joint (Lisfranc Fracture)
• Cuneiforms
• Tarsal navicular bone
• Cuboid bone

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What is a Lisfranc Fracture?

• Between the tarsal and metatarsal bones
• The 1st 2nd metatarsal articulates with the
  medial cuneiforms and are the keystones of the
  foot
• Supplies stability between the midfoot forefoot
  during gait

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Lisfranc Fracture

• Frontal view of the foot shows fracture/
  dislocation in the tarsometatarsal joint
  (Lisfranc's joint) with dislocations of the 1st
  through 5th metatarsals

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• Various fractures of the tarsal navicular bone
  include
• Cortical avulsions
• Most common
• Results from twisting forces on the mid foot
• Fracture of the tuberosity
• May involve the post. tibial tendon
• Bony fractures
• Stress fractures

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Tarsal Navicular Fracture

• Frequently have posttraumatic arthritis
  discomfort in all phases of gait
• Requires immobilization in a non-weight bearing
  short leg cast

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Cuboid Fracture

• Known as nutcracker fractures because the cuboid
  is cracked like a nut b/w the 5th metatarsal
  the calcaneous as the forefoot is forced into
  abduction.

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Cuneiform Fracture

• Uncommon
• Usually occur w/ high-energy injuries
• Open reduction internal fixation is recommended

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Mechanism of Injury

• 3 common causes
• Twisting of the forefoot
• Often occur during vehicle accidents when the
  foot is abducted
• Axial loading of a fixed foot
• Occurs when falling on an extremely dorsiflexed
  foot or axial loading from body weight, stepping
  off a curb
• Crushing
• To the dorsum of the foot
• Usually in industrial accidents
• Clinician should be aware of compartment syndrome
  injury to the dorsal pedis artery

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Treatment Goals

• Alignment-
• Restoring the alignment with the cuneiforms
• -Important for normal weight bearing
• -Load distribution of the foot
• -To maintain the medial arch of the foot
• Restoring the length alignment of
• cuneiforms
• cuboid
• navicular

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Treatment Goals

• Stability
• Stable fixation of the navicular cuboid
• Allows effective transfer of weight from the hind
  foot
• Helps with eversion inversion of the subtalar
  jt.
• A stable reconstruction of the Lisfranc joint
• Important in maintaining the medial arch of the
  foot a pn free and secure gait

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Range of Motion
Motion Normal Functional
Ankle Plantar Flexion 45 20
Ankle Dorsiflexion 20-25 10
Foot Inversion 35 10
Foot Eversion 25 10
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Muscle Strength

• Invertors
• Tibialis Anterior
• Tibialis Posterior
• Evertors
• Peroneus Longus
• Peroneus Brevis
• Dorsiflexors
• Tibialis Anterior
• Toe extensors
• Plantar Flexors
• Gastrocnemius
• Soleus
• Tibialis Posterior

Peroneous Longus weakness can result from severe
dislocations of the Lisfranc Fracture because
this muscle inserts on the 1st metatarsal 1st
cuneiform
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Time of Bone Healing

• Tarsometatarsal or Lisfranc Fracture
• 8-10 weeks
• Tarsal Navicular
• 6-10 weeks
• Cuboid Cuneiform Fracture
• 6-10 weeks

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Duration of Rehabilitation

• Tarsometatarsal or Lisfranc Fracture
• 8 weeks- 4 months
• Tarsal Navicular
• Acute Fx6 wks- 4 months
• Delayed union, nonunion, or stress fx 6 wks- 4
  months
• Cuboid Cuneiform Fracture
• 6 wks- 4 months

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Treatment Methods

• Tarsometatarsal or Lisfranc Fx
• Cast
• Biomechanics stress-sharing device
• Mode of Bone Healing Secondary, with callus
  formation
• Indications May be treated w/ a short leg cast
  for 6 wks. May bear weight when pn free.

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Treatment Methods

• Open Reduction Internal Fixation
• Biomechanics stress-shielding device w/ screw
  fixation
• Mode of healing Primary, w/ rigid fixation
• Indications Pt placed in a weight bearing cast
  for 6 wks. Unprotected weigh bearing is not
  recommended until screws are removed at least
  10-12 wks after surgery.

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Treatment Methods

• Closed Reduction Percutaneous Pinning
• Biomechanics Stress-sharing device w/ pin
  fixation
• Mode of bone healing Secondary, w/ callus
  formation
• Indications Kirschner-wire fixation. Placed in a
  non-weight bearing short leg cast after fixation.
  Wires removed at 6 wks, followed by protective
  weight bearing.

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Treatment Methods

• Tarsal Navicular Fx
• Cast
• Biomechanics stress-sharing device
• Mode of bone healing Secondary, w/ callus
  formation
• Indications May be placed in a short leg cast.
• Cortical avulsion fx short leg walking cast, 4-6
  wks.
• Tuberosity fx Short leg walking cast, 4-6 wks.

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Treatment Methods

• Open Reduction Internal Fixation
• Biomechanics Stress-shielding device w/ rigid
  fixation
• Mode of bone healing Primary, w/out callus
  formation
• Indications To avoid severe deformity
  arthritis, must be treated w/ reduction rigid
  fixation

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Treatment Methods

• Cuboid Cuneiform Fx
• Cast
• Biomechanics Stress-sharing device
• Mode of bone healing Secondary w/ minimum callus
  formation
• Indications
• Cuboids closed in a weight bearing cast
• Cuneiforms short leg cast, immobilized because
  of ligamentous damage

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Treatment Methods

• Open Reduction Internal Fixation
• Biomechanics stress-shielding device
• Mode of bone healing primary, w/ rigid fixation
• Indications
• open reduction internal fixation for any amount
  of displacement, followed by a 6 wk. period of
  non-weight bearing.

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Special Considerations of the Fx

• Age
• Joint stiffness particularly w/ navicular fxs
• Active Pts. Also are probe to jt. Stiffness w/ a
  navicular fx
• Articular Involvement
• Posttraumatic arthritis fusion
• Limited pronation supination
• Location or possible
• Open Fractures
• Damage to the dorsal pedis artery
• Open fx must undergo irrigation, debridement,
  intrevenous antibiotics
• Always a possibility of compartment syndrome
• Tendon Ligament Injuries
• Extensor tendons should be inspected for possible
  damage

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Gait

• Stance Phase
• 60 of gait cycle
• Heel Strike
• ? pn from inversion to eversion
• Foot-Flat
• Painful b/c of injured bones of the medial arch
• Mid-Stance
• Painful as foot is moving from neutral to
  eversion
• Push-Off
• Pt may limit plantar flexion
• Cycle is shortened
• Swing Phase
• 40 of gait cycle
• Not affected by any of these fxs b/c foot is not
  in contact w/ ground

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• http//www.youtube.com/watch?v5nokor_ecSI
• http//www.youtube.com/watch?vr8-eG9hc344feature
  related
• http//video.aol.com/video-detail/short-leg-cast/4
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