Hindfoot injury

The important structures of the foot can be divided into several categories. These include:                        

• bones and joints  

• ligaments and tendons

• muscles

• nerves

• blood vessels

Anatomy of foot

bones and joints   

• Hind foot -talus

-calcaneus

• Mid foot (b.t chopart’s&lisfran’s joints)

-coneiforms -cuboid -navicular

• For foot -metatarsal -phalanges

foot consists of 28 bones. These are• 7 tarsal bones

– calcaneus– talus– medial cuneiform– intermediate cuneiform– lateral cuneiform– cuboid– navicular

• 5 metacarpal bones (1st, 2nd, 3rd, 4th, 5th from great toe to little toe respectively)

• 5 proximal phalanges (1st, 2nd, 3rd, 4th, 5th from great toe to little toe respectively)

• 4 middle phalanges (2nd, 3rd, 4th, 5th from second toe to little toe respectively)

• 5 distal phalanges (1st, 2nd, 3rd, 4th, 5th from great toe to little toe respectively)

• 2 sesamoid bones below the 1st metatarsal head

Joint

The joint between the metatarsals and the first phalanx is called the metatarsal phalangeal joint (MTP) movement in these joints is very important for a normal walking pattern.

• Not much motion occurs at the joints between the bones of the toes. The big toe, or hallux, is the most important toe for walking, and the first MTP joint is a common area for problems in the foot.

Ligaments and tendons

Nerves

• The main nerve to the foot, the posterior tibial nerve, enters the sole of the foot by running behind the inside bump on the ankle (medial malleolus). This nerve supplies sensation to the toes and sole of the foot and controls the muscles of the sole of the foot. Several other nerves run into the foot on the outside of the foot and down the top of the foot. These nerves primarily provide sensation to different areas on the top and outside edge of the foot.

Vessels• The main blood supply to the foot, the posterior tibial artery, runs

right beside the nerve of the same name. • The posterior tibial artery passes behind the ankle then winds

down to the inner side. Here its pulse can be felt behind the medial malleoli. Moving towards the sole of the foot it divides into two branches called the lateral and medial plantar arteries that supply the sole.

• Anterior tibial artery its pulse can be palpated in front of the ankle joint. In the foot it continues as the

• dorsalis pedis artery. Pulse of this artery can be felt just proximal to the first web space. Dorsalis pedis artery gives off a arcuate artery that along with its branches supplies the outer four toes. The dorsalis pedis artery continues down to supply the great toe.

• The peroneal artery descends down and divides into branches that supply the posterior and outer aspect of the heel

Talus injury

Mechanism of injury

Direct injury : usually high-impact trauma as road traffic accidents, gun shot injury.

Indirect injury : usually low-impact trauma as falling , increase in training

Fracture of the talus

Anatomy• Composed of body,

head, neck, posterior and lateral processes

• 60% covered with articular cartilage

• No musclulotendinous attachments

Features of talus injury

•Pain , swelling , deformity and tenting

•Tenting may cause sloughing of skin and infection

Dislocation around the talus

• Subtalar dislocation– Inversion & eversion injuries to the foot

– Common S&S of dislocation

– Compromised neurovascular function

– SLC 4 wk

• Talar dislocation– Most are open injuries

– Reduction with soft tissue management

– SLC (may be with pins) 6 wk

X-ray

•Not always easy to see

•CT may be helpful

•

Treatment of talus fracture

No displacement : split plaster ,when swelling subsides complete plaster for 6-8

weeks

Displaced : closed reduction

Open reduction

Stabilization with 1 or 2 screws

Below knee plaster for6-8 weeks

complications

Avascular necrosisdue to poor blood supply posterior half of body may

collapse and ankle may need arthrodesis

Calcaneal injury

•Fall from a ladder

Usually associated with hip and spine injury

•Extra articular injury affects processes and post. Part of bone

•Easy to manage , good prognosis

Intra articular :

Cleavage of bone obliquely

Severe comminution

•Pain , swelling , bruising , wide heel , thick tissue , loss of concavity below lateral

malleolus

•

•Subtalar joint is stiff but ankle joint is still movable

•Check for compatment syndrome of foot

• ’‘severe pain, intensive bruising and decreased sensibility’‘

TREATMENT

elevation and icepacks till swelling subsides

Undisplaced: closed treatment ,exercise , when swelling subsides , firm bandage, non wt bearing on

crutches for4-6 weeks

Displaced : reduction and fixation with screws , immobilization in slight equinus to relieve tension on

achillis tendon , wt bearing is permitted after 4-6 weeks

treatment

•Displaced , intra articular : open reduction and internal fixation with plates and screws . Bone grafts to fill defects ,

drainage of blood

•It is a difficult surgery that requires complete familiarity with local anatomy

•

Post operatively. . .

•Light splint + elevation as

pain subsides , exercise should begin

•2-3 weeks later , let the pt out 8 weeks….partial weight bearing , 4 more

weeks for complete wt bearing

•

complications

•Problems in shoe fitting talocalcaneal stiffness and osteoarthritis

… ARTHRODESIS .……

•X-ray

•Extraarticular: obvious

•Intraarticular: obvious,CT is best Displaced: lateral view shows flattened

Bohler’s angle

Thanks

Done by :

Lamees Abdulrahman