Fractures of the bones of the feet

FRACTURES OF THE BONES OF THE FEET GORDON

MACKAY

MORRISON,

M.D.,

P.A.C.S.

Visiting SurgicaI Staff, Boston City and Faulkner Hospitals BOSTON,

MASSACHUSETTS

T

HE common fractures of the bones of the feet will be deaIt with in this articIe, and IittIe or no attempt wiI1 be made to speak of the unusuaI or rare fractures seIdom seen. Owing to the fact that the foot is subject not only to the trauma of strain, but is aIso pecuIiarIy IiabIe to injury from crushing and the impact of faIIing objects, there resuIt a great variety of injuries that cannot be classified nor deaIt with here. Certain generaIities shouId be carried in mind by the reader to avoid necessity of repetition. For instance, those fractures with sufficient displacement to cause tissue tension, threatening skin sIough and subsequent sepsis require very prompt attention. The fractures which are compounded need equahy speedy treatment-in fact, those not handIed within four hours show a rapid rise in the incidence of sepsis. In those requiring open operative treatment, skin incisions shouId be made with carefu1 thought to avoiding the more important weight bearing and pressure points of the foot. PainfuI scars beneath the great toe joint, or under the calcis are to be avoided if possibIe. Early motion is to be sought, but Iet us remember to provide adequate and proIonged protection to certain types of fractures with prevention of such sequeIae as acute foot strain, metatarsaIgia, valgus deformity and its accompanying spastic ffat foot.

phaIangea1 joint. Diagnosis is made by x-ray. The sesamoid under the great toe is probably the commonest and most liable to cause troubIe. It may be bipartite or doubIe type ossification centre-two together, resembIing a fracture. Treatment: Conservative or operative. Anterior arch support taking the weight off the tender area may be tried for a reasonabIe Iength of time-a month or twobut if this faiIs, remove sesamoid placing the incision as advantageousIy as possibIe to avoid painfu1 scar. This painfu1 scar business must be kept in mind in a11 operative procedures on the feet, just as carefuIIy as we figure out incisions on the fingers and hands to avoid interference with function and comfort. Bipartite sesamoids are often mistaken for chip fractures and might be important in lega cases. Repair as shown by x-ray is usuaIly fibrous, seIdom true bone union. PHALANGES

Fractures of phaIanges are often unnoticed. They may be caused by a rotary twist or by “stubbing the toes,” but most often by dropping heavy objects on the toes. True bone repair often does not occur in the dista1 phaIanges. A fibrous union takes pIace with a fairIy uniform good resuIt, usuaIIy minus pain. A very few fractures of the phalanges remain painfu1, requiring amputation of part or the whoIe toe. Treatment: PIantar spIint or pIaster sole extending out beyond the ends of the toes. Traction is hard to maintain, and seIdom necessary. A pIaster mouId or gutter may be appIied over sheet wadding, giving IateraI and pIantar support to straighten

SESAMOIDS

Fractures of these smaI1 cartiIaginous masses are usually not important. They may be acquired from a weight bearing twist of the foot, a fall Ianding on the baI1 of the foot or from a crushing weight as a rock dropping on the great toe metatarso721

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a toe in bad position. This is incorporated into the pIaster sole or boot. About four weeks minimum, or better, six weeks, had

FIG. I. Incision for remova of sesamoid beneath great toe.

best eIapse before direct weight bearing is aIIowed. DisIocation of a11 toes, as from stepping up on a curb and slipping back, the toes taking a11 the weight bearing, does occur! ManipuIation and plaster with toes in semifIexion in we11 padded cast cares for a condition that is crippIing unIess we11 handled. METATARSAL

FRACTURES

The most important injury is that to the fifth metatarsa1 near the proxima1 end. Sometimes these do not unite and are tender on waIking, since they take a large share of the weight bearing on the outside of the foot. Causes: Sharp inversion of the foot commonIy caIIed “turning the ankIe.” Weight is thrown suddenIy on the outer side of the foot: tendon attachments and body weight cause fracture by cross Ieverage over the fuIcrum of the firmIy attached base. Hence the break is aIways and constantIy just in front of this base. DispIacement is mostIy sIight, if present at aI1. This injury is easy to miss, so x-ray this type of accident as you do a11 other suspected damage to bones eIsewhere in the body.

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Treatment: PIantar spIint or pIaster sole for six weeks minimum, without weight bearing. It is we11 to warn the patient that a bone graft may be necessary in a fracture of the proxima1 end of the fifth metatarsa bone. Fractures of the metatarsals, other than the fifth aIready mentioned, usuaIIy respond to manipuIation and manual traction. A plantar spIint or pIaster soIe worn for four to six weeks cares for the majority. Certain complicated fractures of these bones, muItipIe in nature, do occur, as in a faI1 in which one Iands on the baI1 of the foot. Two, three or four bones may be partiaIIy avuIsed from their beds-usuaIIy at the proxima1 ends. Manipulation may restore position, but often an open operation with pinning by wire or naiIs may be required. FoIIowing operation, proIonged fixation in pIaster shouId be maintained for six weeks or more. RemovaI of naiIs or wires may be required after patient resumes waIking on foot. Motions and pressure tend to Ioosen metallic substances in the foot more than elsewhere in the body. It is seldom necessary to shorten the metatarsa1 to repIace its end back in pIace. We have in mind, in this relation, only those injuries with a tearing out of the bone ends from their norma reIations. The second metatarsal, and the Iongest of its name, fits at its proximal end into a recess formed by the three cuneiforms. Fractures at its proxima1 end may, and often do, invoIve one or more cuneiform bones. This may be a cIean crack through number one, two or three cuneiform, but usuaIIy it resuIts in a crushing and mass damage in this articuIating area. Conservative treatment is usuaIIy satisfactory here. A pIaster boot is required for onIy six weeks, but disabiIity is of many months’ duration. It is extremeIy important in metatarsa1 fractures that in the IateraI x-ray fiIm there be no anterior or posterior anguIation of the bone. This is far more important cIinicaIIy than a deviation to right or left, as seen by antero-posterior view. A hard knuckIe of bone pressing down against

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tendon or other soft tissue may necessitate an osteotomy at a later date. Or the reverse, an anterior projection may cause either dysfunction of foot statics or a pressure prominence irritated constantly by the shoe. The occasional metatarsal fracture may progress better if a small plate and screws are used, similar to those used in certain metacarpal fractures by Otto Hermann. Preservation of a proper anterior or in treat“ transverse ” arch is important ment of severe metatarsal injury. This shouId be’constantly kept in mind. CUNEIFORM

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CUBOID

This bone is usually injured by a crushing injury or by a rotary twist to mid-tarsal

FRACTURES

These are relatively rare as isolated fractures. Cracks through these cuneiforms should be protected for adequate time by immobilization in plaster or by padded plantar sphnt without weight bearing. 2. Varus dispIacement of forefoot with broken scaphoid.

FIG.

INJURY

TO

NAVICULAR

(S~APHOID)

This brings to mind injury to the mediotarsal, commonly phrased “mid-tarsal” joint. This is serious, even though “merely a sprain.” A sprained mid-tarsal joint can prove to be one of the most crippling injuries in the foot. It usually requires three to six months to rehabilitate the injured mid-tarsal region. Adequate support of the longitudinal arch is essential for many months. Varus displacement of the forefoot with broken scaphoid driven medially may occur and it seems to be a too little-known entity. The mechanism is that of varus strain, by which the astragalus smashes the scaphoid and moves outward; the foot is inverted and rotated in about the vertical axis. (Fig. 2.) This is a very serious accident often misinterpreted and called simply a scaphoid fracture. The position of the foot must be restored. The scaphoid fragments must be moulded into pIace. UncommonIy open operation is necessary to obtain a good result. The ordinary “ cracked scaphoid ” is without displacement and if put at rest for six weeks generally results well.

joint; seldom is there displacement of fragments. A plaster boot to be worn four to six weeks, followed by leather or felt arch support, and corrective exercises, is the treatment indicated. TALUS

OR

ASTRAGALUS

Fractures of the astragalus are indeed major injuries. A common type is one having a crack running from the neck down through the body back and down the OS calcis. This may mean a block of astragalus torn loose and usually displaced backward or outward. Since the subastragaloid joint accounts for most of the Iateral motion of the ankle, it is important that any gross displacement of astragaloid parts be corrected to proper ahgnment and that weight bearing be withheld for many weeks in the more severe injuries. In certain rotary or twisting types of trauma, dispracement of the astragalus may require open operation.

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Prompt replacement is essentia1 to prevent skin slough and subsequent sepsis! This apphes to most of the fractures of the body.

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is thrown outward with even a very sIight IateraI dispIacement of the astragalus and some degree of spastic ffat foot is bound to

e FIG. 3. Fracture of astragaIus.

An attempt shouId be made to save this bone, even if severeIy smashed and compounded, since its Ioss Ieaves a foot not much good. There has been some tendency to remove compounded astragaIi with resuits that we beIieve are unnecessariIy bad -much worse than in those cases where we have seen the bone Ieft in. The fracture through the neck itseIf, breaking off the head and dispIacing it upward, may sometimes be manipuIated back into position. At other times it must be operated upon. Quite frequentIy one observes a periosteal tear, usuaIIy smaI1, from the side or front of the astragaIus accompanying a sprained ankIe. This may or may not be termed a fracture, but if it is so caIIed, this injury must be considered the most common of the astragaIus fractures. Since the astragalus supports the tibia, and fits in the joint mortise formed by the malIeoIi, even the sIightest dispIacement of astragaIus must be corrected and maintained in perfect position. Forced eversion or inversion of the foot causes the upper squarish part of the astragaIus to pry apart the joint mortice and usuaIIy spreads this mortice to a greater or Iesser degree. There is a widening of space between the astragaIus and the media1 malIeolus, with Ioss of proper weight bearing Iines, even in certain sprained ankIes. It is worth noting that the weight bearing Iine

FIG. 4. Spreading of joint mortice.

resuIt from this vaIgus position. Avoid it! To make cIearer this weight bearing line: a line dropped through the midpoint of tibia in an antero-posterior fiIm shouId aIso drop through the mid point of superior surface. Again, the astragaIus, the sIightest IateraI or outward dispIacement of astragalus in vaIgus is far more harmfu1 to function than the same degree of dispIacement in varus because it results in spastic flat foot strain, one of the saddest cIinica1 end-resuIts. A properIy appIied pIaster boot, with foot dorsiffexed and neutra1 as to eversion or inversion, shouId have manua1 pressure appIied beneath the externa1 maileolus, and we11 padded counter pressure above the interna malIeoIus as the cast hardens, forcing and maintaining the astragalus into near contact with the media1 maIIeoIus. This position alIows proper hearing of the joint capsuIe and tibio-IibuIar Iigaments maintaining that al1 important weight bearing Iine. Adequate realignment of parts-by manipuIation or if necessary by open operation-moulded pIaster boot, and proIonged protection give fairIy good results. Such a pIaster boot mouIded under the IongitudinaI arch shouId be kept on for four to six weeks foIIowed by a Ieather or feIt inner sole for partial weight bearing for the next four weeks.

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and the condition of the skin is good, then an immediate reduction may be done. The most common type you wiI1 meet is This procedure is not usuaIIy practicabIe. PiIIow and sides splints, or pressure dressthe IateraIIy mushed and crumpIed variety, accompanied by compression fracture of ing with eIevation of the part for three or four days is good treatment. Skin preparathe spine in not a few instances. The next most ordinary fracture of OS tion of the whole foot for a day or two the foot ready for operative makes caIcis is the avuIsion type: the AchiIIes manipuIation. tendon insertion hoIds, tearing out a chunk After aspetic draping a Kirschner wire of bone, often trianguIar in shape. This may be put through the OS calcis, from the may be replaced by open operation, but inside outward, to prevent the wire carromsuch a procedure tends to produce a badIy ing off the straight Iine with puncture of the humped up area of bone at the fracture edges. We have had better results in a pIantar vesse1 which may cause aneurysm. The writer has seen onIy one such accident smaI1 series of such accidents by removing most of the fragment of bone and tacking but the resuIt was bad. Or, through a smaI1 skin incision on either side of the heel, down the tendon by sutures. The foot tongs may be inserted to provide grip for shouId then be put up in partial pIantar the manua1 traction and remodeIIing to ffexion for three weeks’ time. Any period wire or Ionger than three weeks may resuIt in foIIow. In either case, whether tongs are used, they come out before the contracture of AchilIes tendon and resulting equinus. PIantar ffexion is a dangerous operation is over. ProIonged traction gets you nowhere as compared to a strong hard position for any kind of ankIe or foot Iesion pul1 downward and backward over the and must be used guardedIy. Since we are deaIing with the commoner edge of the tabIe. One of the operator’s types of fractures-here those of the OS feet had best be pIaced against the table for sufficient puI1 to accompIish reduction. caIcis-Iet us go on to the situation usuahy During the reduction the foot must be heId met. in pIantar Aexion; otherwise the puI1 is A person faIIs from a Iadder or verandausuaIIy a distance of six to ten feet, somewasted on the tendo-AchiIIes. times much higher-landing on the feet. A sand bag pIaced under the draping is The upward thrust of soIid ground or ce- now used on which to pIace the foot resting ment crushes the hee1 bone into mushy on the sand bag beIow the inner maIIeoIus. A foIded towe suffrcientIy thick is Iaid substance, spreading it out mediaIIy and just beIow the externa1 maIIeoIus. With IateraIIy, mostly IateraIIy. The normaI depression beneath the external maIIeoIus impacting bIows from a heavy maIIet, the disappears, in part if not entireIy. And OScaIcis may be moulded so as to reproduce this occurs before sweIIing contributes its the normal depression beIow the external share of obIiteration of normally depressed maIIeoIus into which the finger may sink area. This observation, together with the to norma distance. history of a faI1 Ianding on the feet, may In other words, the externa1 maIIeoIus make the diagnosis simple. Any compIaint again becomes normaIIy prominent. And of backache in the region of the tweIfth the IateraI buIging of bone, usuaIIy greater dorsa1 or first or second Iumbar vertebra than that on the inner side, is corrected as shouId be cause for fiIms to be taken of both sides more nearIy approximate one another. Keeping the hee1 off the tabIe, this region for compression fracture. Usually such Iesions show sweIIing of the wire or tongs is removed, steriIe dressthe hee1 fairIy promptIy and are not seen in ings, sheet wadding and pIaster boot aptime to do immediate reduction. If the plied. Pressure manuaIly appIied below the maIIeoIi as the cast hardens, heIps to prepatient is presented before the foot swehs, FRACTURES

OF THE

OS CALCIS

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vent any possibIe dispIacement of the bone and tends to Iimit excessive caIIus growth. After six to eight weeks in pIaster, a shoe

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DECEMBER, 193,

equaIIy exceIlent procedure is that of Otto Hermann. By this method, mouIding by maIIet and Forrester clamp precedes the

FIG. 6. OS caIcis with chunk out.

FIG. 5. A common

0s calcis fracture.

attachment with thumbscrew pressing an inverted half-moon shaped pad below the externa1 maIIeolus, is appIied. This pressure, worn as snugIy as is comfortabIe, wiI1 prevent the heaping of bone which tends to occur in this commonest type of OScaIcis fracture. Raising the inner side of the hee1 three-sixteenth of an inch is desirable. LateraI motion is satisfactory by this method in the majority of cases. The technique described was worked out and deveIoped at the Boston City HospitaI by the writer’s associate, F. J. Cotton. An

downward and backward manuaI traction through use of tongs correcting the deformity present. Pressure pads beneath the maIIeoIi and under the pIaster, severa changes of the cast and meticuIous foIIow-up, has resulted in an exceilent series of end-resuIts in Hermann’s hands. By either method a painIess foot and Iateral motion sufficient to accommodate the owner on rough cobbIestones or uneven ground, has been accomplished as a rule. However, the surgeon may not fee1 any apoIogy for the end-resuIt if the patient can waIk comfortabIy on a smooth floor, and yet be unabIe to trave1 with comfort over rough country. The author wishes to express his appreciation with thanks for the drawings by his associate, Frederic Jay COttOIl,

M.D.