The initial surgical goal for high-energy midfoot trauma is to maintain the length of medial and/or lateral columns while stabilizing the keystone central column. This can be accomplished with a primary ORIF if the soft tissue envelope permits or with a temporary spanning external fixation to allow for delayed reconstructive procedures if feasible. Pulverized midfoot fractures that result in loss of arch height and/or length of the medial or lateral columns may need to be anatomically reduced while maintaining the functional axis related to the ankle and lower extremity. Articular surface restoration becomes a secondary goal in these pulverized fracture




patterns. Often, these fracture patterns are associated with a compromised soft tissue envelope that requires immediate attention. Stabilizing the foot in its anatomic shape with an external fixator relieves the strain to the surrounding soft tissues and allows for future staged reconstructive procedures to improve further stability and function to the foot (Clinical Case IV).

External fixation may also be utilized as a joint distractor to facilitate ORIF for severe midfoot crush injuries. In these case scenarios, the external fixation is beneficial in achieving fracture reduction and alignment to the columns of the foot. For example, a lateral column spanning external fixator can be utilized as a joint distractor to restore the length in the lateral column of the foot when it is associated with a crushed cuboid.
Alignment of the foot in this manner also facilitates an ORIF of the medial and/or central columns.

Partial or total enucleations of the talus commonly present with a transverse to oblique lateral wound associated with a medial talus dislocation. In rare circumstances, the talus can be extruded medially or plantarly through the body of the calcaneus. Lateral talar dislocations are often closed injuries and are not easily amenable to closed reductions as are medial talar dislocations. Often, the talar head lies medial and can be entrapped between the posterior tibial and flexor digitorum longus tendons preventing a closed reduction.

Open wounds associated with a talus dislocation require surgical debridement and irrigation to remove any retained debris that can cause infection. The talus is carefully inspected to determine if any soft tissue attachments remain. For certain case scenarios in which no soft tissue attachments are present within the talus, a decision has to be made in regards to reimplantation and stabilization of the talus to its peritalar joints with external fixation or to perform a talectomy with the insertion of antibiotic-impregnated beads and/or spacer to manage the dead space along with a spanning external fixator. Most commonly reimplantation of the talus is highly preferable unless the open wound is heavily contaminated or the patient is immunocompromised. Close postoperative observation of the reimplanted and fixated talus is paramount in order to reduce any risks of postoperative complications.

External fixation for the management of calcaneal fractures can be quite challenging secondary to the degree of difficulty for joint reduction that can be achieved with the limited placement of half-pins and smooth wires around the fracture pattern. Typically, a half-pin or threaded transcalcaneal pin can be inserted in either the superior or the inferior aspect of the posterior tuberosity to reduce the primary fracture line, medial wall, and/or achieve alignment of the calcaneal tuberosity through traction and manipulation (Clinical Cases V and VI). Another option is to place traction on a half circular ring attached to one or two opposing smooth or olive wires that are placed across the posterior calcaneal tuberosity followed by a circular external fixator to maintain joint reduction (Figure 11.2).

In general, the overall alignment, height, and length of the calcaneal body can be improved with external fixation. In addition, frontal plane alignment of the calcaneal tuberosity can be also reduced with external fixation. In contrast, reduction of the lateral calcaneal wall and/or articular surface of the posterior facet is often only feasible through a limited open reduction for comminuted calcaneal fractures. Tongue-type and two-part fractures involving the posterior facet of the subtalar joint may be reduced with a limited open exposure technique and combined with external fixation (Clinical Case VII).

Other calcaneal fracture patterns often require ORIF to achieve near-anatomic alignment. The technique of external fixation for calcaneal fracture management is not to achieve an anatomic reduction of the articular surface but to reestablish the shape of the calcaneus and to realign the calcaneus to the talus and lower extremity. This technique is utilized to improve the positioning of the calcaneus and allow for osseous consolidation. Improved overall alignment of the calcaneus facilitates future reconstructive surgical options to relieve pain and improve function if deemed necessary.

An important concept for midfoot stabilization is to have fixation at both proximal and distal regions to the injured site(s). In most cases, midfoot trauma stabilization with external fixation begins with insertion of a transcalcaneal or half-pin in the



calcaneus. A 5 mm threaded transcalcaneal pin is typically utilized if stabilization of both the medial and lateral columns of the foot is needed. The transcalcaneal pin is driven from medial to lateral direction and within the junction of the superior and inferior portion of the posterior calcaneal tuberosity. An alternative 5 mm threaded half-pin can be driven into the posterior portion of the calcaneal tuberosity in a medial or lateral orientation and according to which column of the foot requires stabilization. For the lateral column of the foot, spanning external fixation may include a second half-pin that can be inserted into the proximal region of the anterior process of the calcaneus if not fractured. Typically, a 4 mm threaded half-pin is utilized and a small 0.5 to 1 cm incision is made and carried down to the level of bone below or between the peroneal tendons. Please note that it is important to place a soft tissue sleeve directly down to the level of calcaneus and thus prevent any injury to the sural nerve and/or peroneal tendons. After appropriate fixation is achieved in the calcaneus, half-pin placement is then carried out at the level of the metatarsals. To further stabilize and span the lateral column of the foot, a 4 mm threaded half-pin is then inserted into the base of the fifth and fourth metatarsals. The insertion of the half-pin begins at the proximal region of the metaphyseal/diaphyseal region of the fifth metatarsal and is aimed approximately 15 degrees superiorly to obtain good purchase at the base of the fourth metatarsal. Utilization of a self-drilling half-pin is advantageous as positioning of the appropriate insertion of the half-pin can be confirmed under C-arm fluoroscopy and then driven into the metatarsal bases. Additional stabilization of the lateral column of the foot can be achieved with the insertion of a 3 or 4 mm threaded half-pin into the diaphysis of the fifth metatarsal shaft. Alternative fixation of the lateral column of the foot is the insertion of a 4 mm threaded half-pin into the cuboid if not fractured and for management of a crush injury involving the anterior process of the calcaneus.