Download as PDF, PPTX
Uploaded byLibin Thomas
Acute isolated medial midtarsal dislocation
The document describes two case reports of acute isolated midtarsal dislocations. Case 1 involved a 23-year-old male who sustained a medial talonavicular dislocation playing volleyball, which was treated with closed manipulation and casting. Case 2 involved a 35-year-old woman who fell from a height onto a plantarflexed foot, causing dorsal dislocation of the talonavicular and calcaneocuboid joints, requiring open reduction and K-wire fixation. The discussion covers classification of midtarsal injuries, mechanisms of various dislocation patterns, and the rarity of isolated dorsal midtarsal dislocations. Early anatomical reduction and stable fixation were concluded to improve outcomes for these midfoot dislocation injuries.
More Related Content
Similar to Acute isolated medial midtarsal dislocation
Acute isolated medial midtarsal dislocation
- 1. ACUTE ISOLATED MIDTARSAL (CHOPART’S)DISLOCATION- CASE REPORTS An Ortho Club presentation by Dr. Libin Thomas Manathara Junior resident, Department of Orthopaedics, Amala Institute of Medical Sciences Special thanks to Prof. C. Jayaprakash, Dr. Sudheer U, Dr. Kishore P, Dr. Ajith Jose
- 2.
- 3. CASE REPORT #1 •A 23 year old male sustained an injury to the left foot while playing volleyball • He reported landing on a plantar flexed foot and associated varus (medial) stress following a serve • He was evaluated clinically and no neurovascular deficits were noted • Xrays were obtained which revealed the manner of injury producing the deformity- an isolated midtarsal medial displacement
- 5. CASE REPORT #1 •After adequate analgesia and sedation, closed manipulative reduction was attempted by keeping the knee flexed to eliminate the pull of the tendoachilles and providing counter traction • Traction was applied to the fore and mid foot keeping it plantar flexed with the dominant hand and the talus with ankle joint was stabilized with the non dominant hand • The distal component was laterally displaced and a definitive “pop” was both heard and felt to denote successful reduction
- 6. CASE REPORT #1 •Post reduction vascularity was confirmed to be normal, Xrays were obtained to confirm the stability of reduction and the left ankle and foot was immobilized in a below knee plaster of Paris splint • The splint was converted to a short leg cast 1 week later • The foot and ankle were immobilized for a total of 6 weeks following which the patient was mobilized and follow up continued
- 8.
- 9. CASE REPORT #2 •A 35-year-old woman fell 6 feet from a wall and landed on her feet, with the left forefoot plantarflexed on the hindfoot, resulting in immediate pain • She was initially treated with below-the-knee plaster splint immobilization at a local hospital • There was no reduction in pain so she was referred for expert management • The patient had no other injuries and radiographs of the left foot, after removing the plaster splint, showed isolated dorsal dislocation of the talonavicular joint with subluxation of the calcaneocuboid joint
- 12. CASE REPORT #2 •Based on the degree of disruption of ligamentous structure, and the amount of displacement, it was decided that the best treatment option for this patient was surgical relocation and stabilization of the left foot • Open reduction of the midtarsal joint was thereafter performed
- 13. CASE REPORT #2 •An anterolateral approach was used to expose the disrupted ligaments and the midtarsal joints
- 14. Operative photograph showing theplane of surgery between the extensor digitorum longus and the peroneal tendons of the left foot through an anterolateral skin incision
- 15. CASE REPORT #2 •The talonavicular joint was reduced by means of plantarflexing and inverting the forefoot, followed by relocation of the talar head into anatomical position
- 16. Operative photograph showing dorsaldislocation of the navicular over the talus
- 17. CASE REPORT #2 •This maneuver resulted in complete anatomical realignment of the talonavicular joint, after which a single transfixation Kirschner-wire (K- wire) was used to stabilize the correction, and the distal end of the K- wire was kept external on the lateral aspect of the foot
- 18. CASE REPORT #2 •Intraoperative image intensification fluoroscopy then revealed the calcaneocuboid joint to persist to be dislocated, and this portion of the mid tarsal joint was then reduced with manipulation that entailed distraction and dorsiflexion of the forefoot on the hindfoot and the plantar calcaneonavicular (spring) ligament; the dorsal calcaneocuboid ligament, as well as the capsular tissues, were repaired using 1-0 polyglycolic acid sutures • Postoperative radiographs, taken with the plaster cast in place, showed complete reduction of the mid tarsal joint • Following the operation, the right foot was immobilized in a short-leg cast for 6 weeks, and the K-wire was removed at the 12-week follow-up visit
- 19. Postoperative radiograph showing anatomical reductionof the talonavicular and the calcaneocuboid joints A single 2-mm Kirschner- wire is holding the talonavicular joint reduction
- 20. Postoperative clinical photograph showinga single Kirschner-wire with the distal end kept outside the left foot and the anterolateral skin incision
- 21.
- 23. DISCUSSION • Midtarsal joints,including the talonavicular and calcaneocuboid joints, are functionally closely related to the subtalar and Lisfranc joints • Isolated midtarsal injury is uncommon
- 25. DISCUSSION • Main andJowett classified a series of 71 midtarsal joint injuries into 5 groups according to the direction of the deforming force and the resulting displacement: • medial forces • longitudinal forces • lateral forces • plantar forces • crush injury
- 26. DISCUSSION • Medial- Medialforces caused • fracture-sprains • fracture subluxation or dislocation • swivel dislocation
- 27. DISCUSSION • Fracture-sprains-These arecaused by inversion strains of the foot. Radiographs show flake fractures of the dorsal margins of the talus or navicular and of the lateral margins of the calcaneus or cuboid • Fracture-subluxations and dislocations- The forefoot is displaced medially, leaving the hindfoot in normal alignment with the tibia
- 28. DISCUSSION • Swivel dislocations-High falls accounted for most of these as well as for the fracture-subluxations and dislocations • A medial force applied to the forefoot disrupts the talo-navicular joint but leaves the calcaneo-cuboid joint intact • The foot rotates medially but does not invert or evert, the axis of rotation appearing to be the interosseous talo-calcaneal ligament, which remains intact • This contrasts with the more common occurrence in which this ligament ruptures, allowing subtalar dislocation
- 31. Medial swivel dislocation Theantero-posterior view shows dislocation of the talo-navicular component: the calcaneus has swivelled beneath the talus, taking with it the cuboid
- 32. Medial swivel dislocation Anoblique view shows the calcaneo-cuboid component intact
- 33. Medial swivel dislocation Alateral view shows the talus and the ankle in oblique profile in a vertical plane, but the calcaneus and the rest of foot are in true lateral profile, indicating that the calcaneus has swivelled beneath the talus
- 34.
- 37. DISCUSSION •Dorsal forces disruptedthe plantar ligamentous structure, resulting in dorsal midtarsal dislocation •The Hong Kong paper was the first report of an isolated dorsal midfoot dislocation •It is rare because of the strong ligamentous structures around the midtarsal joint: the strongest ligamentous structures of the midtarsal joint are on the plantar side which is protected by • the long and short plantar ligament • bifurcate ligament • the plantar calcaneonavicular (spring) ligament which are important as supports for the arch of the foot
- 40. DISCUSSION • Therefore, dorsalmidtarsal dislocation resulting from disruption of these plantar ligaments is less common than other types of midtarsal dislocation • The mechanism of injury in the Hong Kong paper was a dorsally directed force that disrupted the plantar ligamentous structures of the MTJ, resulting in dorsal displacement of the forefoot on the hindfoot following a fall from a height • Whereas in case report #2, the patient had also fallen from a height of 6 feet and landed on both feet, with the left forefoot plantarflexed on the hindfoot
- 41. DISCUSSION • Perhaps theresultant plantarflexory force sustained at the MTJ, without concomitant plantarflexion of the ankle, may have disrupted the dorsal and plantar ligamentous structures of the MTJ, injuries that were identified intraoperatively, thereby causing isolated dorsal MTJ dislocation • This mechanism of injury is unusual and that the patient described, case report #2, represents the first such case described in the literature
- 42. CONCLUSION • Early anatomicalreduction and stable fixation has been shown to improve the clinical results in these types of midfoot dislocation • In our first case the nature of injury was an isolated midtarsal joint dislocation- talonavicular alone (medial), which was stable with closed reduction and plaster immobilisation • The patient is still under follow up and functional outcome monitored • In the second case dislocation of both talonavicular and calcaneocuboid joints warranted additional fixation with K- wire given the unique nature of the dislocation, namely dorsal
- 43.