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The FOot

6/12/2018

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By: DR. AUSTIN COSTA

When to order foot X-rays?:
  • Ottawa midfoot rules
    • Pain with palpation of base of 5thmetatarsal
    • Pain with palpation of navicular
    • Inability to bear weight both at time of injury and in ED
  • Suspected injury with high energy mechanism 
Picture
Anatomy (From proximal to distal):
  • Hindfoot 
    • Calcaneus and talus
  • Chopart joint 
  • Midfoot 
    • Navicular, medial cuneiform, middle cuneiform, lateral cuneiform, and cuboid
  • Lizfranc joint
    • Lizfranc ligament connects medial cuneiform and 2ndMT on plantar aspect of foot
  • Forefoot 
    • Metatarsals, phalanges
Picture
​Standard Views:
  • AP
    • Forefoot 
    • Midfoot
    • Lizfranc injury
      • Alignment of 1stMT and medial cunneaform
      • Alignment of 2ndMT and middle cunneaform
Picture
Oblique
  • Forefoot
  • Midfoot
  • Calcaneus 
  • Alignment for 3rdMT with lateral cuneiform
  • Alignment of 4thMT with cuboid
Picture
  • Lateral
    • Hindfoot 
      • Boehler’s angle
        • upper edge of the calcaneal body posteriorly to the upper edge of the posterior articular facet of the calcaneus (red)
        • upper edge of the posterior articular facet of the calcaneus to the upper edge of the anterior process of the calcaneus (blue)
        • Normal is 25-40 degress ​
Picture
  • Dorsal foot arch
    • Weight bearing films (if able to tolerate)
    • Allows spreading of metatarsals
Picture
  • 1. ​Approach to foot X-rays:
    • Assess cortical disruption for fractures in area of tenderness
      • Forefoot
        • AP, oblique
      • Midfoot
        • AP, oblique
      • Hindfoot
        • Oblique, lateral
        • Boehler’s angle < 25 degress = calcaneal depression fracture
  •  2. Lizfranc Injury
    • Plantar ecchymosis
    • Stress tarso-MT joint
    • Get weight bearing films!
    • Instability ED Ortho consult
Picture
  • 3. Base of 5thMetatarsal 
    • Pseudo-Jone(Zones)
      • Ankle inversion
      • Peroneus brevis insertion
    • Jones (Zone II) 
      • Metaphyseal-diaphyseal junction
      • At level of 4th-5thmetatarsal joint
      • High risk of non-union
    • Diaphyseal Stress Fracture (Zone III)
      • Repetitive microtrauma
Picture
Management:
  • Hindfoot: Splint (Bulky Jones), NWB
    • Boehler’s angle
    • Look for spinal injuries
  • Midfoot: Splint (sugar tong w/ posterior slab), NWB
    • Lizfranc. -> Weight bearing films
  • Forefoot: 
    • Metatarsals: CAM boot, NWB -> WBAT. Except 1stand base of 5th zones 2&3
    • Phylanges: Buddy tape, post op shoe, unless significantly displaced/rotated
References
  1. Londner M, Hammer D, Kelen GD. Foot injuries. In: Tintinalli JE, Kelen GD, Stapczynski JS, Ma, OJ, Cline DM, editors. Tintinalli’s Emergency Medicine. 8 th ed. New York: McGraw-Hill; 2004; (cited 2017, Sep 08)
  2. Smith, M. S., Hatch, R., & Eiff, M. (2012). Calcaneous and Other Tarsal Fractures; Metatarsal Fractures; Toe Fractures; . In Fracture Management for Primary Care (3rd ed., pp. 276-326). Philadelphia, PA: Saunders.
  3. Weatherford, B. (n.d.). 5th Metatarsal Base Fracture. Retrieved September 08, 2017, from http://www.orthobullets.com/foot-and-ankle/7031/5th-metatarsal-base-fracture
  4. Hatch, R. L., & Hacking, S. (2003, December 15). Evaluation and Management of Toe Fractures. Retrieved September 08, 2017, from http://www.aafp.org/afp/2003/1215/p2413.html
  5. Foot Fracture Treatment & Management. (2017, August 03). Retrieved September 08, 2017, from http://emedicine.medscape.com/article/825060-treatment#d10
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  • RESIDENCY
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    • Explore Charlotte
    • Official Site
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    • EMS
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      • Tox Faculty
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    • Medical Students at CMC
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  • #FOAMed
    • EM GuideWire
    • CMC Imaging Mastery
    • Pediatric EM Morsels
    • Blogs, etc. >
      • CMC ECG Masters
      • Core Concepts
      • Cardiology Blog
      • Dr. Patel's Coding Blog
      • Global Health Blog
      • Ortho Blog
      • Pediatric Emergency Medicine
      • Tox Blog
  • Chiefs Corner
    • Top 20
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    • Schedules >
      • Conference/Flashpoint
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    • Resources >
      • Fox Reference Library
      • FlashPoint
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      • Student Resources
      • PGY - 1
      • PGY - 2
      • PGY - 3
      • Simulation Reading
      • Resident Wellness
      • Resident Research
      • Resume Builder
    • Individualized Interactive Instruction