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On-line CEUs
TARSOMETATARSAL JOINT 1-5 FRACTURE DISLOCATION - December 2004/January 2005
Katherine Bagnato, OTC, ATC/L
Available credit for this article: 1 CEU
A fifty-one year-old male was carrying furniture down the stairs when he tripped down the flight of stairs injuring his left foot. He was in severe pain and unable to ambulate on the left lower extremity (LLE). He was taken to the emergency room for evaluation and treatment. X-rays determined the patient sustained a left foot fracture dislocation of the entire tarsometatarsal articulation, including disruption of the Lisfranc ligament. The Lisfranc ligament is an important anatomical structure due to the attachments on the medial cuneiform to the second metatarsal. It is a major stabilizer of the midfoot. The injury was described in detail to the patient and treatment options were given. The options of continuing with conservative treatment of closed reduction and casting versus surgical intervention consisting of open reduction and internal fixation of the left foot were given. Due to the severity of injury, especially of the Lisfranc ligament, it was recommended that the patient undergo surgical intervention in order to regain full use of his left lower extremity and foot. Consent was given for this procedure.
The patient was taken to the operating room for an open reduction internal fixation (ORIF) of the tarsometatarsal joints 1-5. 4.0 Zimmer cannulated screws were placed across the first metatarsal joint and Lisfranc joint. After this fixation three 4.0 DePuy cannulated screws were placed across the fifth, fourth, and third tarsometatarsal joints. This allowed for fixation at all injured articulations. The wounds were dressed and a short leg splint was applied to the left lower extremity. The procedure was well tolerated. The patient was educated in proper splint/cast care, elevation of the extremity, and post-operative swelling. He was released from the hospital three days after the procedure with a non-weight bearing status and instructed to return in 10 days for follow up evaluation. At two-weeks post-operative, the patient returned to the office for evaluation and treatment of his left tarsometatarsal joint (TMT) 1- 5 fracture dislocation with ORIF. The short leg splint and ace wraps were removed. The sutures on the dorsum of the foot were removed. The incisions were examined and found to be clean, dry, and intact.
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Left Foot Fracture Dislocation 1-5 S/P ORIF
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Left Foot Fracture Dislocation 1-5 S/P HW removal
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There were no signs of infection, drainage, or erythema at the foot. There was swelling present in the dorsum of the foot and tenderness over the fracture/dislocations. The left lower extremity was neurovascularly intact. There was decreased sensation over the incisions found on the dorsum of the foot 1-5. X-rays were taken and showed good alignment and position of the hardware and tarsometatarsal joints with no widening at the Lisfranc ligament. The risks and complications of bracing were explained to the patient. Instructions on proper brace application were given. The patient consented to application of a long ankle-foot orthosis to the left leg. He was instructed to continue with his non-weight bearing status for 10 more weeks. This would be a total of 12 weeks of NWB, which allows for adequate fracture healing and restoration of joint and ligamentous structures. The importance of compliance with the weight bearing restrictions was stressed to the patient. He was instructed to return to the office in four weeks for further evaluation and treatment.
At seven-weeks post-operative, the patient returned to the office for evaluation and treatment of his left tarsometatarsal joint 1-5 fracture dislocation with ORIF. The patient presented in the office without crutches and ambulating full weight bearing on the left lower extremity with a limp. The incisions on the dorsum of the foot were well healed. There was swelling on the dorsum of the foot and tenderness over the tarsometatarsal joints 1-5. X-rays were taken and showed adequate position of dislocations 1-5 and hardware. There was possibly a 1-2 mm increase in space between the medial cuneiform and base of the second metatarsal. An in-depth discussion with the patient concerning compliance of medical treatment was given. Several diagrams and anatomy were given to educate the patient in the severity of his injury and the importance of avoidance of weight on the left foot to allow ample healing to the foot structures. The patient agreed to attempt to be more compliant with this treatment plan. The ankle-foot orthosis was reapplied to the left leg. He was instructed to continue with nonweight bearing for 5 more weeks. In four weeks, he was scheduled to return to the office for further evaluation by x-ray and discuss possible treatment consisting of hardware removal of the left foot.
At ten-weeks post-operative, the patient returned to the offi ce for evaluation and treatment of his left tarsometatarsal joint 1-5 fracture dislocation with ORIF. The patient was non-weight bearing on the left lower extremity. The incisions on the dorsum of the foot were well-healed. There was no swelling over the dorsum of the left foot. There was minimal tenderness over the Lisfranc ligament and minimal tenderness over the 5th metatarsal hardware. The left lower extremity was neurovascularly intact. Xrays were taken and showed adequate position of dislocations 1-5 and hardware. There was no change from previous x-rays. At this point, the patient was advised of the need for hardware removal of the left foot. The risks, benefits, and procedure were given. The patient consented to this procedure and was scheduled for hardware removal at the local hospital. He was instructed to continue with the nonweight bearing (NWB) status for two more weeks. At 12 weeks post-operative, he was instructed to begin weight bearing with crutches and progress to weight bearing as tolerated (WBAT) in the anklefoot-orthosis.
At twelve weeks post-operative, the patient underwent a second operation consisting of hardware removal of the tarsometatarsal joints. The hardware was located by use of C-arm x-ray. Small incisions were made over the hardware and blunt dissection made to locate the heads of the screws. The screws were backed out starting with the 1st metatarsal and Lisfranc with progression to the 5th, 4th and 3rd metatarsals. The small wounds were irrigated and closed. Xeroform, dry gauze and ace wraps were applied. The patient was placed in a post-operative shoe. The procedure was well tolerated. He was released with a weight bearing as tolerated status and instructed to return to the office for evaluation and treatment in one week.
At thirteen weeks post-operative ORIF/one week post-operative hardware removal, the patient returned to the office for evaluation and treatment. The incisions from the hardware removal were clean, dry and intact. The sutures were removed. There was swelling over the forefoot of the left foot and tenderness over the incisions. The left lower extremity was intact. The ankle and foot had good range of motion. X-rays were taken and standing views of the foot showed good alignment of the tarsometatarsal joints 1-5 with no gross widening of the Lisfranc ligament. Standing films in full-weight bearing (FWB) are important to check for instability of the Lisfranc ligament. The patient was instructed to continue with progression to full weight bearing (FWB) to the left lower extremity. He was instructed to continue with the post-operative shoe until he felt comfortable. At that time, he was allowed to wear normal, good supporting shoes. He was allowed to increase his activities of daily living (ADLs) as tolerated and to return to the office in four weeks for further evaluation.
At 17 weeks post-operative ORIF/5 weeks’ postoperative hardware removal, the patient returned to the office for evaluation and treatment. Upon evaluation, there was scar tissue palpated over the great toe. There was mid-foot swelling and tenderness over the interspaces of the metatarsals 1-5. There was no tenderness over the Lisfranc ligament. With compression of the metatarsals, pain was elicited. Range of motion was limited in flexion and extension of the great toe. There was good ankle and subtalar motion. The left lower extremity was neurovascularly intact. Standing x-rays taken showed healed fractures, good alignment, and no widening of the Lisfranc ligament. The patient was shown stretching exercises for the foot and ankle with emphasis on the great toe. He was given a prescription for a foot orthosis with metatarsal support and instructed to attempt to wear widewidth shoes for better comfort. The patient was instructed to return to the office as needed basis.
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(period to obtain CEUs on-line for this article expired January 6, 2006). |
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