Open Reduction and Internal Fixation of Fracture-dislocations of the Tarsometatarsal Joint

Patient Selection

Injuries to tarsometatarsal (TMT) joint less than 1% of all fractures
Most common mechanism is axial load to hyper plantarflexed foot
TMT injuries easily missed; up to 20% missed or misdiagnosed; poor results if treated inappropriately: chronic joint instability, persistent pain, deformity, midfoot arthritis
Indication for open reduction and internal fixation (ORIF) is TMT injuries with displacement and instability
Contraindications include active infection, vascular insufficiency
Consider delaying ORIF for massive midfoot edema; can reduce, provisionally fix with percutaneous pinning or external fixator to prevent skin necrosis, allow soft-tissue recovery (Figure 1)
Plantar ecchymosis can be pathognomonic of high-grade midfoot injury

Weight-bearing AP, lateral, oblique views; non–weight-bearing radiographs have 50% misdiagnosis rate (Figure 2)
On AP, assess first, second TMT joints for fracture and diastasis
On oblique, assess for lateral column alignment
Fleck sign (small bone avulsion) can indicate unstable injury (Figure 3)
If plain radiographs not diagnostic, consider stress radiographs, CT, MRI
Stress radiographs performed under anesthesia; can define diastasis at TMT joints
CT helps identify associated fractures, extent of joint injury
MRI can identify Lisfranc ligament tear
Current classification systems focus on mechanisms, patterns of displacement (Figure 4)

May 13, 2023 | Posted by admin in Uncategorized | Comments Off