Essentials of Orthopedic Surgery, third edition / 02-Skeletal Trauma

80 J.N. Delahay and S.T. Sauer

Fractures of the Talar Neck

Similar to the scaphoid bone of the wrist, the talus in the ankle is unusual among bones in that it has a retrograde blood flow. As such, fractures through the neck of the talus are frequently complicated by avascular necrosis of the dome of the proximal segment. Historically, this injury was called aviator’s astragalus. In an effort to minimize complications, open reduction and internal fixation with delayed weight-bearing are usually recommended, especially for displaced fractures.

Ankle Sprains

Ankle sprains are common. The distal anterior tibiofibular ligament, the lateral ligament complex, and the medial deltoid ligament are the three important ligament complexes. The biggest mistake in the treatment of ankle sprains is often found in the attitude of the first physician who sees such a patient and utters something to the effect that “This is only a sprain—you will be all right in a few days.” Such a statement is, unfortunately, unrealistic and causes a great deal of patient dissatisfaction. Elevation and rest for a few days is generally helpful, but early motion and rehabilitation may also be recommended during this time. It appears that open suturing of torn ligaments at the ankle is very rarely necessary, but the use of a walking cast or fracture boot with the foot in slight dorsiflexion often allows patients to assume their normal activities much faster than otherwise might be the case. The cost of casting, however, is muscular atrophy of the calf and delayed rehabilitation. Various braces are commonly used, and these may then be continued for athletic activities in the subacute period. Pain, swelling, and/or disability lasting more than 2 months after a significant ankle sprain is rare, and other pathologic processes should be investigated.

Achilles Tendon Rupture

Occurring in a sports-related injury in the middle-aged athlete, this tendon rupture may well be overlooked, but it should always been suspected, even though the patient may think that an ankle sprain has occurred. The Thompson test, which consists of squeezing the calf and noting the foot to plantar flex, is most useful. These injuries may be treated by conservative means using a cast in plantar flexion or surgically by direct tendon repair. Occasionally, a sudden pain in the calf may be interpreted as a torn Achilles tendon, but more often only a few fibers of the gastrocnemius tear, similar to the so-called ruptured plantaris. Rest, elevation, and/or walking at first with an elevated heel amazingly relieve discomfort. Nonsteroidal antiinflammatory drugs for prevention of deep venous thrombosis may be added to the treatment regimen. (See Chapter 13 for further details.)

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Lisfranc Dislocation of the Foot

The Lisfranc joint, which is the joint between the tarsal bones and the metatarsals, may be injured in sport and other accidents. It is, unfortunately, frequently missed, and X-rays of the ankle are ordered that do not show this area. If the examiner is unsure and the pain and tenderness are in the midfoot rather than over the malleoli, a comparison foot X-ray may be useful. These injuries usually consist of lateral dislocation of one or more of the metatarsal bones, and if not treated (thus restoring perfect anatomical congruity of the joint), long-term disability will result.

Distal Foot Fractures

Most fractures of the metatarsals and toes are treated conservatively; although metatarsal fractures may be immobilized in a walking cast, this is often unnecessary. Fractured toes generally are treated by taping the toe gently to its neighbor for support. The fracture of the base of the fifth metatarsal, which may be caused by avulsion by the peroneus brevis tendon, is quite common and can be benign. This fracture is generally misinterpreted to be an ankle sprain by the patient. Walking cast, stiff-soled shoes, and/or elastic stockings are all acceptable options. Excellent healing is the norm, with pain reduction occurring in about 3 weeks.

Summary and Conclusions

Orthopedic trauma can range from isolated soft tissue or bony injury to a multiply-injured patient with a combination of life-threatening injuries to many organ systems. Knowledge of anatomy and of the common orthopedic injuries mentioned in this chapter is important for diagnostic and treatment purposes. More importantly, however, is a systematic approach to examining every orthopedic trauma patient. It is essential to evaluate and stabilize a patient’s airway, breathing, and circulation before any orthopedic evaluation. Advanced Trauma Life Support (ATLS) training is important for all medical personnel who have initial contact with the trauma patient to maximize the efficacy of treatment and provide the best chance of survival.

Suggested Reading

Beaty JH, Kasser JR (eds) Rockwood and Wilkins’ Fractures in Children, 5th ed. Philadelphia: Lippincott, 2002.

Bucholz RW, Heckman JD (eds) Rockwood and Green’s Fractures in Adults, 5th ed. Philadelphia: Lippincott, 2002.

82 J.N. Delahay and S.T. Sauer

Questions

Note: Answers are provided at the end of the book before the index.

2-1. In fracture mode of loading, torsional loading produces:

a.Transverse fractures

b.Compression fractures

c.Avulsion fractures

d.Oblique fractures

e.Spiral fractures

2-2. Neural injury that involves an anatomic disruption of an axon with an intact sheath:

a.Neuropraxia

b.Axonotmesis

c.Neurotmesis

2-3. Phase of fracture healing at about 4 to 6 weeks, when the soft callus is reworked into hard callus:

a.Vascular phase

b.Metabolic phase

c.Mechanical phase

2-4. Complications of fractures include:

a.Malunion

b.Nonunion

c.Stiffness

d.Infection

e.Myositis ossificans

f.Avascular necrosis

g.Reflex sympathetic dystrophy

h.All of the above

2-5. Fracture of the upper extremity that is often treated with operative fixation in adults:

a.Clavicle

b.Humeral shaft

c.Midshaft radius and ulna

d.Surgical neck of humerus

e.Radial head

2-6. Portion of the thoracolumbar spine that contains the posterior longitudinal ligament:

a.Anterior column

b.Middle column

c.Posterior column

d.Transverse process

2-7. Open fractures of the pelvis are associated with a mortality rate of:

a.10%

b.25%

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c.50%

d.75%

e.100%

2-8. Femur fractures that are most often associated with a pathologic process:

a.Femoral neck fractures

b.Intertrochanteric fractures

c.Subtrochanteric fractures

d.Shaft fractures

e.Supracondylar fractures

2-9. Injury about the knee that most often results in a vascular injury:

a.Supracondylar femur fracture

b.Patellar fracture

c.Dislocation of the knee

d.Tibial plateau fracture

e.Tibial spine fracture

2-10. Treatment of a displaced bimalleolar ankle fracture should not include:

a.Open reduction internal fixation

b.External fixation

c.Percutaneous fixation

d.Immediate casting