Fractures of the Foot

9 Fractures of the Foot


Fei Zhang, Ye Tian, Zongyou Yang, and Tao Liu


Overview of Foot Fractures


image Anatomic Features


The foot is made up of a total of 26 bones of different shapes, which are supported by a network of approximately 32 muscles and tendons, 109 ligaments, and 45 articulations. The foot is divided into three sections: the forefoot, midfoot, and hindfoot. The forefoot is composed of 5 metatarsal bones and 14 phalanges which make up the toes. The midfoot consists of five out of a total number of seven tarsal bones, including three cuneiforms, one tarsal navicular, and one cuboid bone. The hindfoot includes the calcaneus and talus bone. There are five metatarsal bones (labeled 1–5 starting at the big toe), each consisting of a shaft or body, and a base and head. The base is wedge-shaped, expanding posteriorly. The head presents a convex articular surface, articulating distally with the phalangeal bones. There are 14 phalangeal bones in the foot, 3 in each toe except the big toe which has 2, and each bone consists of a base, a body, and a head ( Fig. 9.1).



image OTA Classification and Coding System for Foot Fractures


According to the Orthopaedic Trauma Association (OTA) classification, a foot fracture is coded as number “8” for its anatomic location; the talus, calcaneus, tarsal navicular, cuboid, cuneiforms, metatarsals, and phalanges are coded as numbers “81,” “82,” “83,” “84,” “85,” “87,” and “88,” respectively. In addition, multiple fractures of the foot are coded as number “89.” The classification varies with individual bones of the foot due to complex anatomic features of each bone ( Fig. 9.2).


image Epidemiologic Features of Foot Fractures in the China National Fracture Study


A total of 201 patients with 202 foot fractures were investigated in the China National Fracture Study (CNFS). The fractures accounted for 11.40% of all patients with fractures and 11.02% of all types of fractures. The population-weighted incidence rate of foot fractures was 38 per 100,000 population.


The epidemiologic features of foot fractures in the CNFS are as follows:


More males than females


More right-side injuries than left-side injuries


The highest risk age group is 15–64 years


Injuries occurred most commonly via falls and crushing injury



image Foot Fractures by Sex

See Table 9.1 and Fig. 9.3.


Table 9.1 Sex distribution of 201 patients with foot fractures in CNFS

























Sex


Number of patients


Percentage


Male


132


65.67


Female


69


34.33


Total


201


100.00



image Foot Fractures by Injury Side in CNFS

See Table 9.2 and Fig. 9.4.


Table 9.2 Injury side distribution of 201 patients with foot fractures in CNFS





























Injured side


Number of patients


Percentage


Left


98


48.76


Right


102


50.75


Bilateral


1


0.5


Total


201


100.00



image Age and Sex Distribution of 201 Patients with Foot Fractures in CNFS

See Table 9.3 and Fig. 9.5.



image


image Foot Fractures by Location in CNFS

See Table 9.4 and Fig. 9.6.


Table 9.4 Segment distribution of 201 patients with foot fractures in CNFS based on AO classification

































Segment


Number of fractures


Percentage


81–85


65


32.18


87


51


25.25


88


40


19.8


89


46


22.77


Total


202


100.00



image Foot Fractures by Causal Mechanisms in CNFS

See Table 9.5 and Fig. 9.7.



image


image Clinical Epidemiologic Features of Foot Fractures


A total of 39,867 patients with 41,136 foot fractures were treated in 83 hospitals of China over a 2-year period from 2010 to 2011. All cases were reviewed and statistically studied; the fractures accounted for 9.61% of all patients with fractures and 9.53% of all types of fractures. Among these 39,867 patients, there were 2,466 pediatric patients (2,502 foot fractures) and 37,401 adults patients (38,634 foot fractures).


Epidemiologic features of foot fractures are as follows:


More males than females


Slightly more left-side than the right-side fractures


The high-risk age group is 36–40 years, the same age group for males, whereas the high-risk age group for females is 46–50 years


The most common foot fractures among adults are calcaneus fractures, in contrast to children, where the most common fractures are metatarsal


image Fractures of Foot by Sex

See Table 9.6 and Fig. 9.8.


Table 9.6 Sex distribution of 39,867 patients with foot fractures

























Sex


Number of patients


Percentage


Male


28,385


71.20


Female


11,482


28.80


Total


39,867


100.00



image Fractures of the Foot by Fracture Side

See Table 9.7 and Fig. 9.9.


Table 9.7 Fracture side distribution of 39,867 patients with foot fractures





























Fracture side


Number of patients


Percentage


Left


19,331


48.49


Right


19,628


49.23


Bilateral


908


2.28


Total


39,867


100.00



image Fractures of the Foot by Age Group

See Table 9.8 and Fig. 9.10.



image


image Foot Fractures in Children and Adults by Individual Foot Bone

See Table 9.9 and Fig. 9.11.



image


Talar Fractures (Segment 81)


image Anatomic Features


Examining its anatomic region, the talus bone can be subdivided into three parts: head, neck, and body. Between 60 and 70% of the talar surface is articular, forming seven articulations with adjacent bones. The head is semicircular in form, carrying the articulate surface of the navicular bone. The neck, the constricted area between the body and head, is roughened for the attachment of the joint capsule. The irregular body is cuboid in shape, wide in the front and narrow in the back, which gives stability when the ankle is dorsiflexed. While its superior, medial, and lateral articulate surfaces join together to make up the trochlea of the talus, the posterior surface (facies articularis calcanea posterior) is separated by a furrow, the sulcustali, which, together with the sulcus calcanei, forms a cavity, the sinus tarsi. Behind the trochlea is a posterior process with medial and lateral tubercles separated by a groove for the flexor halluces longus tendon. The medial and lateral tubercles provide attachment for the medial talocalcaneal ligament and the posterior talofibular ligament, respectively. The medial articulate surface of the body, which is semilunar in shape, is only half the area of the lateral triangle surface of the body. The lateral surface projects laterally as a broad-based, wedge-shaped prominence, referred to as the lateral talar process, from which the lateral talocalcaneal ligament originates and passes immediately beneath its fibular facet to the lateral surface of the calcaneus.


The subtalar joint consists of three articulating surfaces: the anterior, middle, and posterior facets, with the posterior facet representing the major weight-bearing surface. The anterior and the middle facets usually conjoin as one anterior articulation facet ( Fig. 9.12).


image OTA Classification of Talar Fractures


Based on the OTA classification, the talus is coded as number “81” for its anatomic location. According to fracture location, talar fractures can be divided into three types: 81-A, avulsion, process, or head fractures; 81-B, neck fractures; and 81-C, body fractures ( Fig. 9.13).


image Clinical Epidemiologic Features of Talar Fractures


A total of 1,140 adult patients with 1,143 talar fractures were treated in 83 hospitals of China over a 2-year period from 2010 to 2011. All cases were reviewed and statistically studied, including 561 patients with left-side fractures, 576 with right-side fractures, and 3 with bilateral fractures. There were 803 males and 337 females, with a male to female ratio of 2.38:1.


Epidemiologic features of talar fractures are as follows:


More males than females


The high-risk age group is 26–30 years, the same age group for males, whereas the high-risk age group for females is 36–40 years


The most common fracture type is type 81-A, the same type for both males and females


The most common fracture group is group 81-A2, the same group for males, while the common fracture group for females is group 81-A1




image Talar Fractures (Segment 81) by Sex

See Table 9.10 and Fig. 9.14.


Table 9.10 Sex distribution of 1,140 patients with talar fractures

























Sex


Number of patients


Percentage


Male


803


70.44


Female


337


29.56


Total


1,140


100.00



image Talar Fractures (Segment 81) by Age Group

See Table 9.11 and Fig. 9.15.



image


image Talar Fractures (Segment 81) by Fracture Type

See Table 9.12, Table 9.13, Fig. 9.16, and Fig. 9.17.



image
































































81-A Talus, avulsion, process, or head fractures


81-A1 Avulsion


209 fractures


M: 117 (55.98%)


F: 92 (44.02%)


0.06% of total adult fractures


0.54% of adult foot fractures


18.29% of talar fractures


39.36% of type 81-A


81-A1.1 Anterior


image


81-A1.2 Other


image


81-A2 Process


278 fractures


M: 190 (68.35%)


F: 88 (31.65%)


0.07% of total adult fractures


0.72% of adult foot fractures


24.32% of talar fractures


52.35% of type 81-A


81-A2.1 Lateral


image


81-A2.2 Posterior


image


81-A3 Head fracture (without neck fracture)


44 fractures


M: 29 (65.91%)


F: 15 (34.09%)


0.01% of total adult fractures


0.11% of adult foot fractures


3.85% of talar fractures


8.29% of type 81-A


81-A3.1 Noncomminuted


image


81-A3.2 Comminuted


image


81-B Talus, neck fractures


81-B1 Nondisplaced


107 fractures


M: 69 (64.49%)


F: 38 (35.51%)


0.03% of total adult fractures


0.28% of adult foot fractures


9.36% of talar fractures


29.48% of type 81-B


81-B1 Nondisplaced


image


81-B2 Displaced with subluxation of subtalar joint


146 fractures


M: 122 (83.56%)


F: 24 (16.44%)


0.04% of total adult fractures


0.38% of adult foot fractures


12.77% of talar fractures


40.22% of type 81-B


81-B2.1 Noncomminuted


image


81-B2.2 Comminuted


image


81-B2.3 Involves talar head


image


81-B Talus, neck fractures


81-B3 Displaced with subluxation of subtalar and ankle joints


110 fractures


M: 85 (77.27%)


F: 25 (22.73%)


0.03% of total adult fractures


0.28% of adult foot fractures


9.62% of talar fractures


30.30% of type 81-B


81-B3.1 Noncomminuted


image


81-B3.2 Comminuted


image


81-B3.3 Involves talar head


image


81-C Talus, body fractures


81-C1 Ankle joint involvement, dome fractures


62 fractures


M: 44 (70.97%)


F: 18 (29.03%)


0.02% of total adult fractures


0.16% of adult foot fractures


5.42% of talar fractures


24.90% of type 81-C


81-C1.1 Noncomminuted


image


81-C1.2 Comminuted


image


81-C2 Subtalar joint involvement


75 fractures


M: 56 (74.67%)


F: 19 (25.33%)


0.02% of total adult fractures


0.19% of adult foot fractures


6.56% of talar fractures


30.12% of type 81-C


81-C2.1 Noncomminuted


image


81-C2.2 Comminuted


image


81-C3 Ankle and subtalar joint involvement


112 fractures


M: 94 (83.93%)


F: 18 (16.07%)


0.03% of total adult fractures


0.29% of adult foot fractures


9.80% of talar fractures


44.98% of type 81-C


81-C3.1 Noncomminuted


image


81-C3.2 Comminuted


image


image Injury Mechanism


Neck fractures are the most common talar fractures. The usual mechanism is associated with hyperdorsiflexion of the ankle as the talar neck impacts the anterior margin of the tibia, as may occur in an automobile accident or a fall from a height. The body of the talus locks in the ankle mortise following a talar neck fracture, and the remaining portion of the foot, including the head and calcaneus, is displaced medially. The continuous axial load may rupture the interosseous talocalcaneal ligament, the posterior talofibular ligament, and the posterior talocalcaneal ligament, causing the body of the talus to move out of the ankle mortise posteromedially. The resultant fracture line will run obliquely upward and laterally.


Body fractures of the talus occur most commonly as a result of axial compression load, as seen in a fall from a significant height. Ankle joint fractures may also accompany this injury. Fractures of the posterior and lateral processes are often results of violent contraction of nearby attached muscles as the injury occurs.


Talar head fractures are relatively uncommon, usually resulting from force transmitted along the metatarsal rays to the talar head.


image Diagnosis


Most talar fractures are marked by acute pain, considerable swelling and tenderness, and limited or partially limited motion. If fractures are displaced markedly or the injury results in dislocation, then deformity may be present. The anteroposterior (AP) view of the ankle joint can reveal most talar fractures, while the oblique view provides better visualization of the head and neck of the talus, even with small fragments. It is important to note the extension and direction of fracture displacement and the presence of fractures of adjacent articulations. Particular attention should be given to the ankle mortise, the distal tibia, and the remaining tarsal, to rule out possible fractures. Computed tomography (CT) scan and magnetic resonance imaging (MRI) can better reveal the nature of the fractures and provide accurate assessment of the articular involvement, as well as the degree of fracture displacement.


image Treatment


Stable nondisplaced talar body fractures and avulsion fractures can be treated with immobilization by casting. Nondisplaced, unstable fractures and displaced talar body fractures can be managed by fixation of compression screws with minimally invasive techniques. Comminuted fractures can be treated with secondary arthrodesis if there is persistent pain or swelling. Stable, nondisplaced talar neck fractures can be treated nonsurgically, in contrast to displaced talar neck fractures, which require surgical intervention. A displaced talar neck fracture with associated dislocation may be treated first with closed reduction. Emergency open reduction and internal fixation may be indicated if closed reduction fails.


image Other Common Classifications of Talar Fractures


image Hawkins Classification of Talar Neck Fractures

The Hawkins classification of talar neck fractures is as follows:


Type I: Nondisplaced


Type II: Associated subtalar subluxation or dislocation


Type III: Associated subtalar and ankle dislocation


Type IV: Canale and Kelley


Type IV: With associated talonavicular subluxation of dislocation ( Fig. 9.18)


image Clinical Epidemiologic Features of Talar Fractures According to Fracture Location

A total of 1,143 adult talar fractures were treated in 83 hospitals of China over a 2-year period from 2010 to 2011. All cases were reviewed and statistically studied. Their epidemiologic features are as follows:


Talar process fractures are the most common talar fractures


Type II fractures are the most common type of talar neck fractures


Talar head fractures are rare, only accounting for 3.85% of talar fractures



Talar Fractures by Fracture Location

See Table 9.14 and Fig. 9.19.



image



































Talar fractures


Fractures of the talar process


487 fractures


M: 307 fractures (63.04%)


F: 180 fractures (36.96%)


0.13% of total adult fracture


1.26% of adult foot fracture


42.61% of talar fractures


Talar process fracture


image


Fractures of the talar neck


363 fractures


M: 276 (76.03%)


F: 87 (23.97%)


0.10% of total adult fracture


0.94% of adult foot fracture


31.76% of talar fractures


Talar neck fracture


image


Fractures of the talar head


44 fractures


M: 29 (65.91%)


F: 15 (34.09%)


0.01% of total adult fracture


0.11% of adult foot fracture


3.85% of talar fractures


Talar head fracture


image


Fractures of the talar body


249 fractures


M: 194 (77.91%)


F: 55 (22.09%)


0.07% of total adult fracture


0.64% of adult foot fracture


21.78% of talar fractures


Talar body fracture


image


Talar neck fractures (Hawkins classification)


Type I Nondisplaced


107 fractures


0.03% of total


0.28% of foot


9.36% of talus


29.48% of talar neck


Hawkins Type I


image


Type II Displaced, with subluxation and dislocation of the subtalar


joint


146 fractures


0.04% of total


0.38% of foot


12.77% of talus


40.22% of talar neck


Hawkins Type II


image


Type III Displaced, with subluxation and dislocation of the subtalar


and talotibial joints


87 fractures


0.02% of total


0.23% of foot


7.61% of talus


23.97% of talar neck


Hawkins Type III


image


Type IV Displaced, with subluxation and dislocation of the talotibial, subtalar, and talonavicular joints


23 fractures


0.01% of total


0.06% of foot


2.01% of talus


6.34% of talar neck


Hawkins Type IV


image


Calcaneal Fractures (Segment 82)


image Anatomic Features


The calcaneus is the largest of the tarsal bones; rectangular in shape, it lies inferior to the talus. The calcaneus has six surfaces: superior, inferior, anterior, posterior, medial and lateral. It has three talocalcaneal facets on its upper surface, and one calcaneocuboid facet on its front.


Superior: On its upper surface are three smooth facets, posterior, middle, and anterior, which articulate with the lower surface of the talus to form the subtalar joint. The middle one-third of the surface is the posterior facet, which is large and oval or oblong. It is anteriorly tilted, at an angle of 45 degrees from the midsagittal plane. The middle and anterior facets are located on the medial side of the upper calcaneal surface and are usually continuous with each other. On the medial side of the bone, below the middle talocalcaneal facet, is a shelf-like projection, the sustentaculum tali, which supports the talar neck and also serves for the attachment of several ligaments. The posterior one-third surface of the upper calcaneal surface is roughened and is in between the posterior aspect of the ankle joint and the Achilles tendon.


Inferior: The inferior roughened area of the calcaneus gives attachment for the long plantar ligament and the quadratusplantae. The plantar-surface forepart of the calcaneus is a small rounded projection known as the small calcaneal tubercle, which gives attachment to the plantar calcaneocuboid ligament. The back part of the planter surface is an eminence called the calcaneal tubercle.


Medial: The medial wall of the calcaneus is depressed. Under the surface of the sustentaculum tali of the calcaneus, there is a groove running obliquely downward from posterior to anterior, which contains the flexor hallucis longus tendon.


Lateral: The lateral wall of the calcaneus is flat and smooth, except for a small ridge called the peroneal tubercle. Passing below the peroneal tubercle of the calcaneus is the groove for peroneus longus tendon.


Anterior: The anterior surface of the calcaneus, which is square in shape, has the smallest surface of all and has a saddle-shaped articulation, forming the calcaneocuboid joint with the cuboid bone.


Posterior: The posterior half of the calcaneus is an oval-shaped projection, which can be subdivided into three parts: upper, middle, and lower. The upper part of the posterior surface of the calcaneus is separated from the Achilles tendon by the subtendinous bursa and fat tissue; the middle part of the posterior surface, broad and rough, is the insertion point of the Achilles tendon; while the lower part is at a forward decline and continues with the calcaneal tuberosity. On the lower edge of the calcaneal tuberosity, on either side, are its lateral and medial processes serving as the origins of the abductor hallucis and abductor digit minimi ( Fig. 9.20).



image OTA Classification of Calcaneal Fractures


Based on OTA classification, the calcaneus is coded as number “82” for its anatomic location. According to fracture location, calcaneal fractures are classified into three types: 82-A, avulsion, process, or tuberosity; 82-B, extra-articular body fractures; and 82-C, articular fractures involving the posterior facet ( Fig. 9.21).


image Clinical Epidemiologic Features of Calcaneal Fractures (Segment 82)


A total of 11,008 adult patients with 11,720 calcaneal fractures were treated in 83 hospitals of China over a 2-year period from 2010 to 2011. All cases were reviewed and statistically studied, including 5,092 patients with fractures on the left side, 5,204 on the right side, and 712 bilateral. There were 9,228 males and 1,780 females, with a male to female ratio of 5.18:1.


Epidemiologic features of calcaneal fractures are as follows:


More males than females


The high-risk age group is 36–40 years, the same age group for males, whereas the high-risk age groups for female are 36–40 and 46–50 years


The most common fracture type is type 82-C



image Calcaneal Fractures by Sex

See Table 9.15 and Fig. 9.22.


Table 9.15 Sex distribution of 11,008 patients with calcaneal fractures

























Sex


Number of patients


Percentage


Male


9,228


83.83


Female


1,780


16.17


Total


11,008


100.00



image Calcaneal Fractures by Age Group

See Table 9.16 and Fig. 9.23.



image


image Calcaneal Fractures by Fracture Type

See Table 9.17, Table 9.18, Fig. 9.24, and Fig. 9.25.



image


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Mar 12, 2022 | Posted by in ORTHOPEDIC | Comments Off on Fractures of the Foot

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