o Radiography: joint effusion, intra-articular fx, debris formation, dislocations, osteochondral fragmentation; bone resorption: phalangeal “hour glassing,” metatarsal “pencil sharpening.”

o Histology: osseous debris embedded into synovium

o Scenario: continued WB ➝ vicious cycle of repetitive trauma, further joint laxity & distention, deformity, increased inflammation & hyperemia ➝ bone resorption ➝ more susceptible to fracture

· Stage II Coalesence

o Healing phase

o Radiography: absorption of osseous debris, fusion of fragments, sclerosis of bone ends.

· Stage III Reconstruction

o Radiographically: bone ends & major fragments become rounded; revascularization reduces degree of sclerosis

o Scenario: revascularization and remodeling of bone ends as body’s attempt to restore joint architecture

Sanders & Frykberg

I. IPJs and Phalanges; MTPJs & Metatarsals

II. TMT Joints

III. NC Joints, TN & CC Joints

IV. Ankle Joint

V. Calcaneus

Burns

Open Fractures: Gustilo & Anderson

· Type I: Clean wound <1 cm long, little soft tissue damage with no crushing component, simple transverse or short oblique fracture with minimal comminution

· Type II: laceration >1 cm with no extensive soft tissue damage, moderate amount of comminution, simple transverse or short oblique fracture with minimal comminution

· Type III: wound >5cm with extensive soft tissue damage to muscle, skin, and neurovascular structures. Associated with severe crush component and severely comminuted fracture. Marked contamination. Examples include farm injuries, gunshot wounds, traumatic amputations, and open fractures >8 hours old.

o Type IIIA: adequate soft tissue coverage of fracture with limited periosteal stripping

o Type IIIB: extensive soft tissue injury with periosteal stripping, considerable bone exposure.

o Type IIIC: associated with arterial injury. Reported amputation rate of 25-90%

Principles of Treatment:

· All open fractures should be treated as an emergency

· Evaluate patient for other life threatening injuries

· Appropriate antibiotic therapy

· Tetanus prophylaxis

· Adequate debridement and irrigation

· Stabilization of fracture

· Early cancellous bone grafting

· Appropriate wound coverage

· Rehabilitation

Antibiotic Therapy:

Considered therapeutic, not prophylactic.

· Type I: cephalosporin

· Type II: cephalosporin +/- aminoglycoside

· Type III: cephalosporin + aminoglycoside

Farm injuries: Penicillin G

Irrigation:

· Type I: 1-2 L saline

· Type II-III: 2-4 L saline

All Type III wounds should be checked again in 24 to 48 hours

Wound Coverage:

Primary Closure: Indicated in Type I and the majority of Type II open fractures

Delayed Primary Closure: Defined as closure of the wound within 3-10 days. Indicated for Type III open fractures

First MTPJ Dislocation: Jahss

Jahss

Mechanism: 1^st MTPJ hyperextension (motor vehicle accident, falls from heights, sports injuries)

Clinical presentation:

· Hallux is dorsally sublexed at the MTPJ with the first metarsal head prominent plantarly

· Pain is elicited on attempted ROM and palpation of the involved joint

· Extensor apparatus is in a contracted state and the flexor apparatus is tightened

· Flexed attitude of HIPJ may be present

· Deformity may be subtle because of masking caused by the swelling that follows the injury

· Type I

o Transverse capsular rupture plantar to metatarsal head/neck with the proximal phalanx, plantar capsule, and sesamoids displaced dorsally on metatarsal head

o Retrograde plantar directed force of phalanx drives met head in a plantar direction, HIPJ becomes fixed in plantarflexion

o Intersesamoidal ligament remains intact, sesamoids do not fracture

· Type IIA

o Dorsal dislocation of proximal phalanx with intersesamoidal ligament rupture and sesamoid subluxation to each side of the metatarsal head; sesamoids do not fracture

· Type IIB

o Dorsal dislocation of proximal phalanx, sesamoids displaced medial and lateral to metatarsal head

o Transverse avulsion fracture of one of the sesamoids

· Type IIC

o Intersesamoidal ligament rupture

Treatment:

· Type I: usually irreducible on closed reduction, the metatarsal head being incarcerated by the conjoined tendons with their intact sesamoids

· Type II: seamoid disruption usually permits closed reduction. Mayo block, distraction, and pushing the proximal phalanx into a congruous relation with the metatarsal head. Repair soft tissue insult with suture. Correction is maintained with a slipper cast or BK cast for 3-4 weeks, then a surgical shoe for an additional 3 weeks. Resistant deformity requires surgical repair. Type IIB injury should be cased BK for 6 weeks NWB

Fifth Metatarsal Fractures: Stewart; Torg; Chapman

Stewart

· Type I: Classic Jones fracture. Occurs at diaphyseal-metaphyseal junction or distal limit of 4^th-5^th metatarsal joint. Considered extraarticular.

· Type II: intraarticular fracture of the 5^th met base

· Type III: Extraarticular avulsion fracture of the styloid process

· Type IV: Intraarticular comminuted fracture.

· Type V: Extraarticular avulsion of epiphysis, children only. Longitudinal fragment.

Torg

Based on radiographic examination

· Type I

· Type II

· Type III

Tarsometatarsal (Lisfranc’s) Fracture-Dislocation: Hardcastle (Quenu & Kuss)

Hardcastle

· Type A: total or homolateral incongruity

· Type B: partial or isolateral incongruity

o Type B1: medial displacement

o Type B2: lateral displacement

· Type C: divergent

Navicular Fractures: Watson-Jones

Watson-Jones

· Type I: Tuberosity fracture

· Type II: Dorsal lip fracture

· Type III: Transverse body fracture with dorsal fragment dislocation

Transchondral Talar Dome Fractures: Berndt-Hardy

· Stage I: subchondral bone compression

· Stage II: partially detached osteochondral fragment

· Stage III: completely detached, non-displaced fragment

· Stage IV: displaced osteochondral fragment

DIAL a PIMP: Dorsiflexion Inversion AnteroLateral; Plantarflexion Inversion PosterioMedial

Treatment

· Stage I, II, III-medial: 6-12 weeks of BK NWB cast immobilization

· Stage III-lateral, IV: fragment excision, crater curettage, drill hole fenestration to subchondral bone (aid in revasculartion and stimbulate fibrocartilage). Followed by 6-12 weeks of BK NWB cast immobilization.

· All stages should be rehabilitated with early passive NWB ROM

Talar Neck Fractures: Hawkins, Canale & Kelly

The purpose of this classification is not only to describe the extent of the injury but also to allow the physician to confidently predict the prevalence of avascular necrosis.

· Type I: nondisplaced vertical fracture of talar neck

· Type II: displaced vertical fracture of talar neck with dislocation of STJ

· Type III: displaced vertical fracture of talar neck with dislocation of STJ, AJ

· Type IV: displaced vertical fracture of talar neck with dislocation of STJ, AJ, TNJ

Blood supply:

· Head & Neck: artery of sinus tarsi (from perforating peroneal and DP artery)

· Body: artery of tarsal canal (from PT and deltoid branch)

· Posterior talus: calcaneal branches

Incidence and prognosis

Type	Incidence	Blood Supply Interruption	AVN of Body
I	20%	a. sinus tarsi	Rare (0-15%)
II	42%	a. sinus tarsi & tarsal canal	42% (15-50%)
III	34%	a. sinus tarsi, tarsal canal, deltoid branches	91% (90-100%)
IV	4%	all arteries	>91% + AVN of head

Mechanism:

· Forced dorsiflexion and hyperextension of the foot

· Injuries typically the result of high impact trauma

Treatment:

· Type I: NWB cast 6-8 weeks

· Type II-IV: attempt closed reduction, ORIF if unsuccessful. Anteromedial approach with screw fixation through head and neck of talus perpendicular to fracture line.

Hawkin’s Sign: subchondral radiolucency around fracture site, indicating revascularization, detectable 6-8 weeks following injury

Talar Body Fractures: Sneppen

· Group I: Transchondral or compression fracture of the talar dome (including osteochondritis dessicans of the talus)

· Group II: Coronal, sagittal, or horizontal shearing fractures involving the entire talar body. (caused by severe dorsiflexion with compressive forces. Body of the talus must be sandwiched between the tibia and calcaneus. Rare injury).

o Type 1: Coronal or Sagittal fracture

§ IA: nondisplaced

§ IB: displacement of trochlear articular surfaces

§ IC: displacement of trochlear articular surface with associated STJ dislocation

§ ID: total dislocation of talar body (displacement of STJ & AJ)

o Type II: Horizontal fracture

§ IIA: nondisplaced, dividing the talar body into superior and inferior halves

§ IIB: displaced, superior portion shifts on the inferior portion

· Group III

o Fracture of posterior tubercle of talus. Steida’s process of Shepherd’s fracture; Os trigonum syndrome. Note that the lateral tubercle of the posterior process of the talus has a secondary center of ossification.

o Caused by severe plantarflexion of the foot

o Pain in posterior ankle causing limited ROM, which can often be reproduced with FHL movement

· Group IV:

o Fracture of the lateral process of the talus

· Group V:

o Crush fracture of talar body

Treatment:

· Group I, II

o Non-displaced: BK NWB cast 6-8 wks

o Dispalced: close reduce or ORIF, BK NWB cast 6-8 wks, followed by 6-8 wks BK WB cast if no signs of AVN, delayed/non-union

· Group III

o Injectional therapy local/steroid every 3 wks, BK WB cast 6 wks, or surgical excision of lateral tubercle

Fractures of the Calcaneus: Sanders; Rowe; Essex-Lopresti

Sanders

· Type I: nondisplaced articular fracture of posterior facet (regardless of number of fracture lines)

· Type II: 1 fracture line across posterior facet creates 2 fragments; 3 fracture types based on fracture line locations

o II-A ➝ most lateral fx line

o II-B ➝ central fx line

o II-C ➝ most medial fx line

· Type III: 2 fracture lines across posterior facet create 3 fragments, with depression of the central fragment

o II-AB ➝ lateral + central fx line

o II-AC ➝ lateral + medial fx line

o II-BC ➝ central + medial fx line

· Type IV: 3 fracture lines create 4 or more fragments (comminution)

o ABC ➝ lateral, central, + medial fx line

Treatment

· Type I: NWB cast 6-8 wks

· Type II-IV: ORIF via lateral hockey stick (Palmer) incision to maintain peroneal tendons and sural nerve in flap)

Rowe

Primarily utilized for extra-articular fractures.

Rowe Extra-Articular: closed reduction if stable; ORIF if displaced, unstable

· Type IA: calcaneal tuberosity fracture

o Medial: more common, heel everted on fall, abductory force

o Lateral: heel inverted on fall, adductory force

· Type IB: sustentaculum tali fracture

o Tenderness on hallux movement because of FHL course

o Mechanism: excessive eversion on fall from height, force on medial foot with valgus heel

· Type IC: anterior superior process fracture (intra- or extra-articular)

o Most common, often improperly diagnosed as ankle sprain

o Mechanism: avulsion via bifurcate ligament, plantarflexion force on supinated foot

· Type IIA: beak fracture of posterosuperior tuberosity

o Mechanism: direct trauma

· Type IIB: tendo Achilles avulsion fracture of post-sup tuberosity

o Mechanism: violent contraction of gastroc-soleus, foot fixed

· Type III: calcaneal body fracture (extra-articular)

o Most common extra-articular type, talus impacts calcaneus

o Mechanism: fall from height with heel valgus or varus

Rowe Intra-Articular: ORIF necessary

· Type IV: fracture involving STJ without joint depression

o Mechanism: fall from height

· Type V: comminuted with central or severe depression

o Mechanism: fall from height

Essex-Lopresti

Describes intra-articular fractures (tongue type and joint depression)

Mechanism:

1. Vertical fall ➝ tongue type

2. Posterior fall ➝ joint depression

Fall from height ➝ talus driven into calcaneus ➝ creation of 1° fracture line extending from apex of Critical Angle of Gissane to the plantar cortex of calcaneus

2° fracture line depends on the direction of force:

· Verticle force ➝ 2° fracture line extends posteriorly from 1° line to the posterior calcaneal cortex producing tongue type fractures

· Posteior force ➝ 2° fracture line extends posteriorly from 1° line and exits on the superior aspect of the calcaneus, surrounding the posterior facet and causing it to impact the body of the calcaneus, exploding it medially and laterally into fragments

Lateral Ankle Ligamentous Injuries: O’Donoghue; Dias

O’Donoghue

Grade

Clinical Presentation

Grade I

Partial tear of ligament

· Mild tenderness

· Mild swelling

· Slight/no functional loss (WB/ambulate with minimal pain)

· No mechanical instability (negative stress exam)

Grade II

Incomplete tear of ligament with moderate functional impairment

· Moderate pain

· Moderate swelling

· Mild/moderate ecchymosis and tenderness over involved structures

· Some loss of motion/function (pain on WB and ambulation)

· Mild/moderate instability (mild positivity in clinical exam)

Grade III

Complete tear with loss of ligament integrity

· Severe swelling (> 4 cm diameter about the fibula)

· Severe ecchymosis

· Loss of function/motion (unable to WB/ambulate)

· Mechanical instability (moderate to severe positivity on stress exam)

Dias

· Grade I: Partial rupture of CFL

· Grade II: Complete rupture ATFL

· Grade III: Complete rupture ATFL, CFL, +/- PTFL

· Grade IV: Complete rupture all lateral ligaments and partial failure of deltoid ligament

Diagnostic Procedures

· X-Ray Scout films: AP ankle, lateral ankle, mortise ankle, AP foot

· Inversion Stress (talar tilt): 5° increase in talar tilt indicates loss of CFL integrity when compared with contralateral ankle

· Anterior Drawer Sign: 4 mm increase in anterior displacement of talus indicates loss of integrity of ATFL

· Always evaluate uninjured foot for lack of symmetry

AITFL/PITFL Avulsion Fractures: Tillaux-Chaput; Wagstaffe; Volkmann

Tillaux-Chaput

Chaput’s tubercle is the anterolateral tubercle of the tibia and of the inertion points for the AITFL

Mechanism: Lauge-Hansen SER-I, PAB-II, PER-II

The Tillaux fracture is a subtype of of Salter-Harris III classification of epiphyseal fractures, described as in isolated fracture of the lateral distal tibial epiphysis avulsed by the anterior tibiofibular ligament

Wagstaffe

Wagstaffe’s tubercle is the anterior portion of the lateral malleolus and the other insertion site of the AITFL

Mechanism: Luage-Hansen SER-I, PAB-II, PER-II

Volkmann

Volkmann’s tubercle is the posterior lip of the tibia and the attachment site of the PITFL. The posterior lip is commonly referred to as the third or posterior malleolus.

Mechanism: Lauge-Hanse SER-III, PER-IV

Ankle Fractures: Danis-Weber; Lauge-Hansen

Danis-Weber

Based solely on fracture of lateral malleolus.

· Type A) – fracture line below the level of the inferior tibial-fibular syndemosis

o Fracture line ➝ Supination aDduction (SAD) mechanism

· Type B – fracture line at the level of the inferior tibial-fibular syndesmosis

o Straight oblique fracture line ➝ Pronation aBduction (PAB) mechanism

o Spiral oblique fracture line ➝ Supination External Rotation (SER) mechanism

· Type C – fracture line above the level of the inferior tibial-fibular syndesmosis

o Straight oblique fracture line ➝ Pronation Dorsiflexion mechanism

o Spiral oblique fracture line ➝ Pronation External Rotation (PER) mechanism

Lauge-Hansen

Concepts

· The first term describes the position of the foot, the second term describes the direction of the pathologic force on the talus)

· Staged classification: if a fracture is at stage 3, then stages 1 and 2 also had to occur with their associated soft tissue and osseous damage

· Consider rotational injuries as clockwork patterns; consider aBduction/aDduction injuries as direct blows

Clarification

· SER-II is most common; PER is most destructive

· Verify stage and mechanism by looking for manifestations of the next stage to ensure it has not occurred

· PAB-I could also be PER-I, II, or III ➝ ankle mortise and high fibular films are necessary to rule out associated injuries (diastasis, Maisonneuve)

· In absence of additional findings, SER-II and PAB-III must be differentiated by appearance of fibular fracture line

· SER-II, SAD-I, PAB-I, PER-II without fracture lines are simply ankle sprains

Supination aDduction ➝ SAD (direct blow injury)
SAD-I	Straight transverse fracture of lateral malleolus at or below level of AJ or rupture of lateral collateral ligaments
SAD-II	Oblique fracture of the medial malleolus (directed inferolateral-superomedial)

Supination External Rotation ➝ SER (clockwork)
SER-I	Rupture of AITFL or Tillaux-Chaput (tibia) / Wagstaffe (fibula) avulsion
SER-II	Spiral oblique fracture of lateral malleolus at level of AJ (posterior spike on LAT x-ray)
SER-III	Rupture of PITFL or posterior tibial lip (malleolus) fracture – small fragment (Volkmann’s)
SER-IV	Straight or transverse fracture of medial malleolus or rupture of deltoid ligament

Pronation aBduction ➝ PAB (direct blow injury)
PAB-I	Straight transverse fracture of medial malleolus or rupture of eltoid ligament
PAB-II	Rupture of both AITFL and PITFL without diastsis
PAB-III	Straight oblique fracture of the lateral malleolus at the level of the AJ (directed infermedial-superior lateral – lateral spike on AP x-ray)

Pronation External Rotation ➝ PER (clockwork injury)
PER-I	Straight transverse fracture of medial malleolus at or below level of AJ or rupture of deltoid ligament
PERI-II	AITFL rupture with tear of interosseous membrane or Tillaux-Chaput / Wagstaffe (much less common)
PER-III	Spiral oblique fracture of fibula above level of of AJ (posterior spike) (fracture begins where interosseous membrane rupture stops)
PER-IV	Posterior tibial lip (malleolus) fracture – large fragment (Volkmann’s) or rupture of PITFL

Pilon Fractures: Reudi-Allgower, AO; Ovadia-Beals

Pilon = intra-articular distal tibial metaphysis

Mechanism:

· High-impact injury

· Most commo mechanism is axial compression

· Talar dome is driven into ankle mortise

· Less common mechanism is a rotational mechanism with foot pronated and dorsiflexed

Repair:

1. Restore length of fibula

2. Reconstruct the tibial articulation using the “key” fragment and talus as template

3. Fill in defects with cancellous bone graft

4. Apply buttress plate to medial tibial to prevent late tibial varum deformity

Reudi-Allgower

Most commonly used classification

· Type I: Cleavage fracture of distal tibia without major dislocation of articular surface

· Type II: Significant fracture and dislocation of the joint surface without comminution

· Impaction and comminution of the distal tibia

AO-ASIF

AO group modification of Reudi-Allgower system.

· Type A: intra-articular fracture without major incongruency – Reudi-Allgower Type I

o A1: metaphysial simple fx

o A2: metaphyseal wedge fx

o A3: metaphyseal complex fx

· Type B: intra-articular fracture with significant incongruency – Reudi-Allgower Type II

o B1: pure split fx

o B2: split-depression fx

o B3: multifragment depression fx

· Type C: intra-articular fracture with displacement – Reudi-Allgower Type III

o C1: articular simple, metaphyseal simple fx

o C2: articular simple, metaphyseal multifragment fx

o C3: multifragment fx

Ovadia-Beals

Most recent system, but Reudi-Allgower/AO-ASIF still more popular

· Type I: non-displaced articular fracture

· Type II: minimally displaced articular fracture

· Type III: displaced articular fracture with several large fragments

· Type IV: displaced articular fracture with multiple fragments and large metaphyseal defect

· Type V: displaced articular fracture with severe comminution

Epiphyseal Fractures: Salter-Harris

Salter-Harris

Concepts:

· Physis = radiolucent cartilaginous growth plate

· Injury prognosis determined by disturbance of physeal blood supply (based on fracture type)

o Good: physis separation from metaphysis

o Poor: fracture cross physis

o Worse: fracture cross physis completely covered by articular cartilage

· Types I & II: extra-articular fx, best prognosis

· Types III * IV: intra-articular fracture, poor prognosis unless physis & congruent joint surface restored

· If blood supply undisturbed fracture will heal in 3 weeks

· Physis is weaker than bone, tendon, ligaments, joint capsule

· Force mechanisms of injury: shear, avulsion, bending, axial compression

· High index of suspicion of joint sprain, dislocation, long bone involvement

· Always attempt to determine the mechanism of injury – key aid for diagnosis

· Indirect trauma most common mechanism of ankle injury in children

· Age and force determines pattern of ankle fracture:

o Types I & II – shear force – young children

o Types III & IV – bending/compression force – older children

Treatment:

· Types I & II: closed reduction

· Types III & IV: ORIF – restoration of joint congruency essential; do not compress physis

o Smooth K-wires may cross physis if no more than 7% of physis is destroyed

o Opening wedge osteotomies may be indicated if varus/valgus deformity persists

o Fixation must always be removed

Types:

Type

Notes

Subtypes

Type I

complete separation of epiphysis from metaphysis

· Shear or avulsion force, no fracture

· Growing cells remain with physis, undisturbed

· Minimal displacement because of thick periosteum (facilitates reduction)

· Radiographic diagnosis often difficult – rely on clinical symptoms and exam

· Excellent prognosis (except for Type IC)

· IA: complete separation of epiphysis from metaphysis between layers of chondrocyte hypertrophy and calcification

· IB: separation through layer of degenerative cartilage

· IC: crush injury damaging one side of physis, premature osseous bridge may result secondary to cell damage

Type II

fracture line through physis, exiting out metaphysis

· Most common acute physeal injury

· Shear or avulsion force

· Triangular-shaped metaphyseal fragment: Thurston-Holland’s sign

· Periosteal hinge facilitates reduction

· Children >10 years

· Prognosis good if physeal vessels intact

· IIA: metaphyseal fragment attached to epiphysis, periosteum intact on concave side of fracture but torn on convex side

· IIB: Metaphyseal fragment is free, periosteum torn both sides

· IIC: thin layer of metaphysis present across physeal fragment

· IID: compression against physis at point fracture exits metaphysis

Type III

fracture from articular surface to weak zone of physis and along plate to the periphery

· Bending/compressive force (some shear force)

· More common in older children

· Accurate reduction essential to restore congruity of tibial plafond

· Prognosis good if physeal vessels intact

· IIIA: as described by Type III

· IIIB: small layer of growing cells avulsed with epiphysis

Type IV

fracture from articular surface through epiphysis, across physeal plate, and exits through metaphysis

· Bending/compressive force

· More common in older children accurate reduction essential to restore physeal function and congruent articular surface (prevent arthroses/growth arrest)

· Prognosis poor unless physis and joint restored

· IVA: as described by Type IV

· IVB-D: involve multiple fragments of epiphysis/metaphysis

Type V

severe crushing force through epiphysis, destroys a portion of or the entire physis

· Relatively uncommon

· Etiology may be non-traumatic – osteomyelitis, aseptic necrosis

· Requires high index of suspicion (often misdiangoised)

· No visible fracture, physeal displacement unusual

· May exist with another type and go unrecognized

· Poor prognosis: premature plate closure typically results

Type VI

Avulsion of perichondral ring (physeal periphery)

Type VII

epiphyseal fragment avulsion fracture without physis

Tarsal Coalitions: Articular Classification System

Downey

Etiologic classification

· Congenital: Leboucq’s theory suggests that tarsal coalition results from the failure of the differentiation and segmentation of primary mesenchyme. Leonard concluded that tarsal coalition was a unifactorial disorder with autosomal dominant inheritance, allowing this theory to be the most widely accepted.

· Acquired: tarsal coalition can result from arthritis, infection, trauma, neoplasms, and is most commonly seen in the older patient.

Articular Classification

Step 1: Division of tarsal coalitions into extra- and intra-articular

· Extra-articular Coalitions

o Calcaneonavicular

o Cubonavicular

· Intra-articular Coalitions

o Talocalcaneal

§ Middle

§ Posterior

§ Anterior

§ Combination

o Talonavicular

o Calcaneocuboid

o Naviculocuneiform

Step 2: Articular Classification System

· Juvenile (Osseus Immaturity)

o Type I: Extra-articular coalition

§ A – no secondary arthritis

§ B – secondary arthritis

o Type II: Intra-articular coalition

§ A – no secondary arthritis

§ B – secondary arthritis

· Adult (Osseous Maturity)

o Type I: Extra-articular coalition

§ A – no secondary arthritis

§ B – secondary arthritis

o Type II: Intra-articular coalition

§ A – no secondary arthritis

§ B – secondary arthritis

Step 3: Most common possible surgical procedures based on Articular Classification System

· Juvenile IA

o Resection with interposition of extensor digitorum brevis muscle

· Juvenile IB

o Triple arthrodesis

· Juvenile IIA

o Resection with interposition of arthroeresis

o Isolated/single arthrodesis

o Triple arthrodesis

· Juvenile IIB

o Triple arthrodesis

· Adult IA

o Resection with interposition of extensor digitorum brevis muscle

o Triple arthrodesis

· Adult IB

o Resection with isolated/single arthrodesis

o Triple arthrodesis

· Adult IIA

o Isolated/single arthrodesis

o Triple arthrodesis

· Adult IIB

o Triple arthrodesis

Tibialis Posterior Tendon Dysfunction: Johnson & Strom; Conti; Funk

Johnson & Strom – clinical/radiographic classification

· Stage I – tendon length normal; peritendonitis and/or tendon degeneration

o Signs and symptoms

§ Foot appears normal, minimal changes on x-ray

§ Gradual onset of pain along tendon course, palpable/focal pain just proximal to medial malleolus, pain increases with activity

§ Fullness inferior to medial malleolus (appreciate from posterior view)

§ Mobile/normal hindfoot alignment, normal FF to RF relationship

§ Mild weakness on single heel-raise test (patient senses abnormality)

o Pathology

§ Synovial proliferation with possible degeneration

§ Split tears in tendon, enlarged 2x width

o Treatment

§ Conservative: break cycle of inflammation, NSAIDs, orthoses (deep heel cup, 4-6 mm Kirby skive, medial phalange, inverted device, Richie brace), NOTE: monitor patient, should not progress to stage II or III with conservative care

§ Surgical: synovectomy, tendon debridement, rest (BK cast 3 weeks)

· Stage II – tendon elongated, hindfoot mobile

o Signs and symptoms

§ Increase severity and distribution of pain, continues post-activity

§ Pain along tendon for moderate length

§ Fullness and tenderness inferior to medial malleolus (appreciate posteriorly)

§ Mobile/valgus RF; FF aBduction (positive too-many-toes sign)

§ Marked weakness on single heel-rise test

§ X-ray

· AP foot: FF aBduction, navicular subluxed off talar head, increased T-C angle

· LAT foot: T-N fault, increased talar declination angle

§ MRI: discontinuity and “balling up” of tendon

o Pathology

§ 2-3 cm tendon degeneration, longitudinal tears, secondary adhesions to sheath

§ Yellowish white-brown appearance, firm consistency, off-white “fish-flesh” proximally

§ Possible single transverse tear (rounded-off ends), “white-sign” proximal to rupture site

o Treatment

§ FDL transfer, under tension, undersurface of navicular via drill hole; BK cast 6 weeks + PT

§ Proximal attachment of TP muscle to FDL debated

§ Kidner, Young, STJ arthroereisis, Evans, Dwyer, Koutsougianis, isolated arthrodesis

· Stage III – tendon elongated, hindfoot deformed and stiff

o Signs and symptoms

§ Fixed flatfoot

§ Medial pain, more suggestive of DJD (because of activity-related sharp pain on rest), may transfer to lateral RF and over sinus tarsi because of lateral talar process impingment; NOTE: tendon itself is instrinscally less painful

§ Fixed/valgus RF with significant eversion and “too-many-toes” sign

§ Marked weakness on single heel-raise test (may be impossible)

§ X-ray

· Similar, but more marked than Stage II

· 2° degenerative changes at STJ, TN, CC

o Pathology

§ Similar but more advanced than Stage II

o Treatment

§ Realignment with STJ arthrodesis

§ Isolated arthrodesis, Evans, Dwyer, Koutsougianis

· *Stage IV – rigid hindfoot and valgus angulation of talus; early ankle joint degeneration

o *Myerson MS: Adult acquired flatfoot

Conti – MRI Classification

MRI grading of tendon pathology was shown to have prognostic value and serve as a better predictor for clinical outcome after surgical treatment, superior to intraoperative tendon evaluation, which was found to have a limited role in determining tendon reconstruction.

· Type IA

o 1-2 fine longitudinal tendon splits without degeneration, often on tendon undersurface

o Clinical correlate: symptoms < 6 months, minimal swelling or tenderness, no RF valgus

· Type IB

o Multiple longitudinal tendon splits with mild fibrosis and increase width; no degeneration

o Clinical correlate: similar to Type IA but present for 6-12 months

· Type II

o Narrowed tendon with long longitudinal splits and degeneration, often bulbous appearance distal to attenuated portion

o Clinical correlate: symptoms 1-1.5 years with onset of increased RF valgus

· Type IIIA

o Diffuse tendon swelling, prominent uniform degeneration, and few intact tendon strands

o Clinical correlate: symptoms > 2 years with minimal inversion strength, marked RF valgus

· Type IIIB

o Complete tendon rupture with replacement by scar tissue

o Clinical correlate: symptoms > 2.5 years with classic signs of rupture

Funk – surgical classification

· Group I

o Avulsion of tendon from its navicular insertion

o Sx treatment: reattach distal tendon to navicular via non-absorbable suture through drill holes

· Group II

o Complete mid-substance tendon rupture just distal to medial malleolus

o Sx treatment: transfer/interposition of FDL tendon

· Group III

o Longituindal tear without complete tendon rupture

o Sx treatment: tendon debridement and synovectomy

· Group IV

o Synovitis without visible tear or disruption of tendon

o Sx treatment: synovectomy and decompression (sheath release)

Peroneal Tendon Dislocation: Eckert & Davis

· Grade I

o Superior peroneal retinaculum is ruptured from collagenous lip and lateral malleolus. The fibular periosteum is lifted/avulsed. The peroneal tendons can be anteriorly displaced over the lateral malleolus and after reduction, are unstable only with applied tension.

o Tx: suture incised fascia to posterior margin of intact collagenous lip (remaining retinaculum)

· Grade II

o Distal 1-2 cm of the dense fibrous lip on the posterior edge of the lateral malleolus is elevated along with the retinaculum, which is completely torn. Tendons are usually found over lateral malleolus and very unstable when reduced.

o Tx: same as Grade I

· Grade III

o A thin fragment of cortical bone with the collangeous lip is avulsed from the deep surface of the peroneal retinaculum. Tendons are always found over lateral malleolus and very unstable when reduced. X-rays are diagnostic (avulsion fracture observed)

o Tx: 2 K-wires inserted from posterolateral to anteromedial through the fracture fragment and fibula. Soft tissue repair is similar to Grades I and II.

· Grade IV

o Avulsion of superficial peroneal retinaculum from posterior insertion on calcaneus with anterior dislocation of tendons over the retinaculum. This is in contrast to Grades I-III, where the superior peroneal retinaculum is separated from its fibular attachment. The tendons dissect through, with the retinaculum lying deep to dislocating peroneal tendons.

o Tx: Primary repair of the retinaculum

· Treatment Guidelines

o Surgical correction is required for all four grades due to the ineffectiveness of closed treatment. Post-operative management is immobilization in a short leg NWB cast x 3 weeks followed by 2-3 weeks in a walking cast.

o Acute Grade I and III injuries can potentially be treated with 6 weeks short leg cast immobilization, however there is a high dislocation rate associated with this treatment option.

Tendo-Achilles Rupture: Kuwada

· Type I: Partial tear of tendon – Tx: 8 weeks cast immobilization if tear constitutes < 50% of tendon

· Type II: Complete rupture, defect < 3 cm – Repair: typically end-to-end anastomosis

· Type III: Complete rupture, defect 3-6 cm – Repair: end-to-end anastomosis with autogenous tendon graft flap, possible augmentation with synthetic graft

· Type IV: Complete rupture, defect > 6 cm – Repair: gastrocnemius recession, followed by end-to-end anastomosis with a free and/or synthetic tendon graft