Injury factors may determine treatment of foot, ankle fractures
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KOLOA, Hawaii — Injury factors may help determine the treatment pathway for Lisfranc, talar and calcaneal fractures, according to a presenter at Orthopedics Today Hawaii.
In his presentation, J. Tracy Watson, MD, noted Lisfranc or tarsometatarsal fractures are traditionally fixed with two longitudinal incisions and open reduction of the medial column followed by one of two dorsal approaches. The first approach is a medial incision between the first and second rays and the intercuneiform joint, but, if needed, a lateral incision can be performed between the fourth and fifth metatarsals.
Previously published research has also shown patients with ligamentous Lisfranc injuries have better outcomes with primary fusion, according to Watson.
“The key is not to dismiss this as an ‘ankle sprain’ or a ‘foot sprain’ because, often, these are overlooked and they do not get the necessary evaluation and you miss these chronic ligamentous injuries,” Watson said.
Patients with talar fractures can be treated with closed reduction either in the emergency department or the OR, according to Watson. However, he said the key to good outcomes is making sure the patient’s skin will allow for definitive fixation.
Although the vascularity of the talas does not make talar neck fractures emergencies, Watson said surgeons should consider soft tissue injuries and neurovascular concerns.
“Closed manipulation or percutaneous stabilization, placing an [external fixator] or percutaneous wires to get these reduced and decrease the amount of skin damage or skin tenting is primarily what you need to do, especially if you are not going to be the person fixing it in the long run,” Watson said.
Finally, with calcaneal fractures, Watson noted surgeons can reduce the fracture by reducing the sustentacular fragment with a plate or screw. Additional wires can also be added to maintain overall stability, he said.
Once the joint is largely restored, Watson noted surgeons can either leave the injury alone to heal, allow the soft tissues to heal before performing a formal extensile lateral approach to restore lateral wall and narrow heel or evaluate the soft tissues medially and perform a sinus tarsi approach to restore the lateral wall and reduce subfibular impingement. – by Casey Tingle
Reference:
Watson JT. The treatment of upper and lower extremity fractures: An interactive lecture series. Presented at: Orthopedics Today Hawaii; Jan. 12-16, 2020; Koloa, Hawaii.
Disclosure: Watson reports he is on the editorial panel for the Journal of Bone and Joint Surgery, the Journal of Orthopaedic Trauma, Clinical Orthopaedics and Related Research, the Journal of Trauma, Current Orthopaedic Practice and Orthopedics Today; is a consultant and designer for Smith & Nephew, NuVasive, Bioventus, AOS and Zimmer Biomet; and is a chair for the American Academy of Orthopaedic Surgeons Biological Implants and Regenerative Medicine Committee.