Chapter 25: Trauma

Medical Management and Assessment of the

Polytrauma Patient
Assessment of Lower Extremity Injury
General Evaluation and Treatment of Fractures
Calcaneal Fractures
Talar Fractures
Osteochondral Fractures
Navicular Fractures
Cuboid Fractures
Cuneiform Fractures
Fifth Metatarsal Base Fractures
Metatarsal Fractures (1st, 2nd, 3rd & 4th)
Tarsometatarsal Joint Dislocations/Fractures
Subtalar Joint Dislocations
Ankle Fractures
Ankle Inversion Sprain
Deltoid Ligament Ruptures
Compartment Syndrome
Open Fracture Classification System and Treatment
Soft Tissue Injuries
Crush, Gunshot, and Lawnmower Injuries
Puncture Wounds
Epiphyseal Plate Injuries (also see chapter 19,
Pediatrics)
Digital Fractures and Dislocations
1st MPTJ Trauma
Nail Bed Trauma
Toe Tip Injuries With Tissue Loss
Dog and Cat Bites
 TRAUMA
Medical Management and General Assessment of
the Trauma Patient
1. First Priorities:
a. Evaluate and establish an appropriate airway and ventilate with 100%
oxygen (intubate if ventilation is inadequate, but stabilize cervical spine with
Philadelphia collar)
b. Control external hemorrhage
c. Inspect patient for skin color, alertness, chest wall motion, and extremity
motion
d. Auscultate the chest for breath sounds and establish adequate ventilation
(if suspect pneumothorax with respiratory distress, insert chest tube without
waiting for x-ray confirmation)
e. Obtain vital signs

NOTE* Carotid pulse is palpable at systolic BP of 60 mm Hg, femoral pulse

at 70 mm Hg, and radial pulse at 50 mm Hg

f. If pulselessness/hypotensive from blunt trauma to chest or a penetrating

wound of precordium with distended neck veins not relieved by thoracostomy
tube, open chest for effective CPR
g. Establish IV lines and begin infusion (if patient is hypotensive use femoral
lines via cutdown in conjunction with upper extremity infusion). Use
crystalloid, colloid and/or blood as indicated (lactated Ringer's is preferred
because it prevents metabolic acidosis)

NOTE* In general, blood transfusions should be instituted when crystalloid

infusion exceeds 50 ml/kg

NOTE* If systolic BP is less than 100 mm Hg, place IV in both antecubital

spaces, and if inaccessible do greater saphenous cutdown

h. If patient still hypotensive insert arterial line to monitor BP and blood gases
i. Initiate EKG monitoring
j. Assess neurologic status by Glasgow coma scale
i. Check pupillary response, extremity posturing, and response to commands
ii. Evaluate motor function of all extremities and trunk
iii. If sensory and/or motor deficit, establish spinal cord level of functional
changes
k. Obtain admission blood work (CBC and coagulation profile, arterial blood
gases, urinalysis, and venous blood chemistries)

2. Second priorities:
a. Obtain a H&P if possible
b. Secondary examination of the head, chest, abdomen, pelvis, and
extremities with attention paid to life threatening injuries
c. Obtain appropriate x-rays (cervical, chest, etc.)
d. Place a Foley catheter and check for occult blood in the urine
e. Place a NG tube and check for occult blood in the GI tract
f. Splint extremity fractures
g. Complete neurologic examination
h. Tetanus prophylaxis
i. Culture and sensitivity of open wounds
j. No antibiosis unless specific indication is apparent
k. Perform emergency surgery if required

3. Third priorities:
a. Systematic evaluation of the body
b. Specialty radiology (CT, angiograms)
c. Specialty consultations
d. Invasive monitoring (Swan-Ganz)
e. Urgent Surgery

Assessment of Lower Extremity Injury

1. Examination:
a. Rapid neurovascular assessment

NOTE* Lower extremity injuries are of low initial priority unless there is frank
bleeding. With an arterial injury, there is a pulsatile flow or spurt of bright
red blood. if present exert manual pressure initially, surgical repair later

b. Quantity and quality of pulses

c. Observe motor function
d. Inspect for lacerations, swelling, deformities e. Joints palpated

NOTE* Signs of ischemia are pain, pallor, paresthesias, paralysis,

pulselessness. You have 6 hours to reverse before permanent 2.
pathological changes occur
Traumatic limb or digital amputation salvage:
a. The avulsed part should be placed in sterile saline soaked gauze, sealed in
a plastic bag, and immersed in ice water
b. The avulsed part that has been properly cooled may last up to 24 hours c.
The avulsed part that is not cooled within about the first 8 hours has a poor
chance of being replanted

General Evaluation and Treatment of Fractures

1. Determine type of fracture:
a. Classification of fractures:
i. Transverse
ii. Oblique
iii. Spiral
iv. Comminuted
b. Stable or unstable:
i. How much bone to bone contact is there?
ii. Are the fragments well aligned?
iii. Is the area subject to movement?
iv. How extensive is the soft tissue involvement?
v. How is the blood supply to the fractured segment?
vi. What kind of bone is involved in the fracture?
c. Open or closed
d. Intraarticular or extraarticular
d. Cortical or cancellous bone involvement

NOTE* Characteristics of cortical and cancellous bone

Cortical Cancellous
Osteogenic properties poor good
Fractures surfaces small large
Soft tissue support poor (few) good
Vascularization poor good
Inherent stability poor good

e. Description of a fracture based upon the 4 basic relationships (described

by the mnemonic LARD):
i. Length and location
ii. Angulation
iii. Rotation
iv. Displacement

2. Treatment of fractures: After determining the location and evaluating

the patient's physiological status, a treatment regimen is tailored to the
patient's needs:
a. Rest, Ice, Immobilization, Compression, Elevation
b. Closed reduction (with or without internal fixation). The mechanisms of
closed reduction are:
i. Step 1- Increase the deformity
ii. Step 2- Distract the fragments
iii. Step 3- Reverse the mechanism of injury
c. Open reduction (with or without internal fixation)
d. Excision of fracture fragments
e. Amputation

Calcaneal Fractures
A disabling injury of the foot. There are a number of associated injuries when
dealing with a calcaneal fracture including: compression fracture of the
lumbar vertebrae, laceration of the kidney-renal damage, fractures of the
lower extremity, and compartment syndrome
1. Anatomical considerations:
a. The largest tarsal bone that has a thin cortical shell enclosing cancellous
bone that contains traction trabeculae radiating from the inferior cortex and
pressure lamellae converging to support the posterior and anterior facets.
b. The calcaneus articulates with the talus through 3 facets, the largest being
the posterior
c. The middle and anterior facet have a common joint cavity with the TN joint
and are separated from the larger posterior facet by the sulcus calcaneus.
d. The lateral end of the tarsal canal gives attachment to the bifurcate
ligament, the EDB, and the inferior extensor retinaculum.
e. Boehler's tuber joint angle overlies the posterior articular facet and is a
measurement of the sagittal plane between the anterior and posterior aspect
of the calcaneus (normal 20-400)
f. Gissane's critical angle is the position that abuts with the lateral process of
the talus and which under compression force acts as a wedge creating the
primary fracture line in the calcaneus

2. Radiological Examination
a. Plain film x-rays

i. A-P NOTE* Evaluating integrity of the bone plus Boehler's angle and the Critical
view angle of Gissane is essential in the diagnosis
ii.
Lateral view
iii. Anthensen's view (demonstrates medial and posterior facets of the STJ)
iv. Isherwood views:
 Oblique lateral (anterior process and calcaneocuboid)
 Medial oblique axial (medial and posterior facet)
 Lateral oblique axial (posterior facet) v. Broden's projections
 Broden 1 (shows the posterior facet from anterior)
 Broden 2 (shows the sinus tarsi to posterior)
b. Tomography
c. CT scanning (The Gold Standard)

3. Classification: Due to the fact that two types of fractures exist (intra-
articular and extra-articular) the classification that is best used is a
combination of the Rowe (inclusive for extra-articular) and Essex-Lopresti
(inclusive for intra-articular, replacing Rowe 4 8 5)
a. Rowe:
i. Type 1a: Fracture of the tuberosity
ii. Type 1b: Fracture of the sustentaculum tali
iii. Type 1c: Fracture of the anterior process (most common; female
patients predominate, mostly related to wearing high heeled shoes)
iv. Type 2a: Beak fracture
v. Type 2b: Avulsion fracture involving the tendo Achilles insertion
vi. Type 3: Oblique body fracture not involving the STJ
vii. Type 4: Body fracture involving the STJ
viii. Type 5: Joint depression fracture with comminution
b. Essex-Lopresti:
i. Fractures not involving the STJ: Tuberosity fractures
 Beak type
 Avulsion medial border -Vertical
 Horizontal
ii. Fractures involving the calcaneal-cuboid joint:
 Parrot-nose type
 Various
iii. Fractures involving the STJ:
 Without displacement
 Tongue-type with displacement
 Centro-lateral depression of the joint
 Sustentaculum tali fracture alone
 Comminuted

NOTE* The primary fracture line is vertical from the vertex of the critical angle of
Gissane to the plantar aspect. The secondary fracture line is determined by the
direction of the force

c. Sanders: A new classification that utilizes CT scanning rather than plain

radiographs for its identification. This is the first system to have a prognostic
value
i. Type 1: nondisplaced
ii. Type 2: two part posterior facet fracture
(a) Fracture through the lateral column
(b) Fracture through the central column
(c) Fracture through the medial column
iii. Type 3: three part posterior facet fracture with central depression
(ab) Fracture through lateral and central columns
(the bone between FX a and b is depressed)
(ac) Fracture through lateral and medial columns
(the bone between FX a and c is depressed
(bc) Fracture through the central and medial columns
(the bone between FX b and c is depressed)
iv. Type 4: Four part posterior facet fracture

4. Mechanism of injuries:
a. Torque injuries (extra-articular fractures)
i. Anterior process fx
ii. Avulsion fx
iii. Sustentacular fx

b. Direct impaction (extra-articular fractures)

i. Tuberosity fx
ii. Beak fx
c. Falls from a height (intra-articular fractures)
d. Concussive force from below (intra-articular fractures)

5. Clinical Diagnosis of Calcaneal Fractures:

a. Anterior process fractures:
i. Swelling- well defined 3-4 cm. anterior to the lateral malleolus
ii. Inversion and adduction increase pain

NOTE* Must R/O 5th metatarsal base fractures

b. Beak and avulsion fractures:

i. "Pop" sound heard/felt on the heel with sudden pain
ii. Pes planus antalgic gait
iii. Weakness of plantarflexion
iv. Edema, ecchymosis, bullous lesions (Mondor's sign)
c. Fractures of the medial and lateral process:
i. Heel thickens, edema, and ecchymosis
ii. ROM of ankle, STJ, and MTJ within normal limits
d. Fracture of the body no STJ involvement
i. Inability to bear weight
ii. Edema/ecchymosis
iii. Generalized pain around the heel
iv. Pain with ROM of ankle and STJ
e. Fracture of sustentaculum tali
i. Pain and edema on the medial aspect of the foot 1 inch below the medial
malleolus
ii. Pain inferior to medial malleolus on dorsiflexion (FHL)
iii. STJ ROM decreased and painful
iv. Ankle joint ROM WNL
f. Tongue depression fractures
i. Rapid edema and severe pain and inability to bear weight
ii. Severe bleeding under fascia
iii. Discoloration of the heel extending to the calf
iv. Blister formation
v. Flattened arch
vi. Decreased plantarflexion (Hoffa's sign)
vii. Widened heel
viii. R/O compression fracture of lumbar vertebrae and ankle (10%
occurrence)

6. Treatment:
a. Anterior process fractures:
i. Small fragment fractures
 Soft cast NWB for 2-4 weeks (early mobilization important)
ii. Large displacement fragment
 RIF or excision (it is recommended to wait 1 year before excision)

b. Beak or avulsion fractures:

i. Beak fractures
 BK cast 4-6 weeks (weight bearing if fragment not displaced)
 If fragment displaced closed reduction followed by BK NWB cast for 6
weeks in plantarflexion with gradual weightbearing
 RIF (screw) if closed reduction unsuccessful followed by BK NWB cast
ii. Avulsion fractures
 ORIF followed by screw fixation followed by BK NWB cast in plantarflexion
for 4 weeks followed by a neutral position BK cast for 2 weeks
c. Fractures of the medial and lateral process:
i. For nondisplaced treat with compression dressing/ice/elevation NWB. After
edema subsides, follow with well molded BK cast for 4 weeks
iii. For displaced fragment closed reduction followed by BK NWB cast for 6
weeks

d. Fracture of the body not involving the STJ:

i. For non displaced use compression dressing/ice/elevation with ROM
exercises immediately (NWB 4-6 weeks)
ii. If displaced, closed reduction with BK NWB cast 6-8 weeks (Steinmann pin
can be used with proximal displacement)

e. Fracture of the sustentaculum tali:

i. Compression dressing/ice/elevation
ii. ROM excercises immediately for FHL
iii. BK cast with progressive weightbearing
iv. Firm shoe with orthoses
v. If displaced closed reduction followed by BK cast 4 weeks NWB followed by
weight-bearing 2 weeks

NOTE* Treatment for significant calcaneal fractures has traditionally been

conservative (either closed reduction or posterior percutaneous pin
fixation). However, calcaneal fractures treated by these methods resulted
in a marked disability that gradually resolved to a tolerable level but with
many sequelae (widening of the heel, significant malalignment in varus or
valgus, and lateral impingement syndromes). If the talus was left impacted
into the posterior facet region, anterior ankle arthritis developed. Because
of this, new techniques have been advocated.
Open Reduction Technique:
The lateral approach is used most for the primary incision. The medial
approach is used when needed for more accurate reduction and rigid
stabilization, or when CT scan demonstrates that most of the pathology lies
medial in the fracture. A wide lateral flap is made incorporating the
peroneal tendons and sural nerve, down to the subperiosteal layer.
Timing is important to give a satisfactory result. Some advocate waiting 4-7
days to allow the swelling to resolve, but immediate fixation can also be
done if the fracture is open or is associated with a compartment syndrome
Several technical options are available with regard to hardware: a. Either
3.5 mm. cortical or 4.0 mm. cancellous screws can be used to fix the
reduced posterior facet to the sustentacular fragment b. Neutralize the
entire calcaneus with 3.5 mm. reconstruction plates, flattened 1/3 tubular
plates (possible in combination), or cervical plates (plates are
recommended for neutralizing the interfragmental screw repair and for
holding the lateral wall
f. Tongue and joint depression fractures:
i. Closed reduction
ii. Open reduction (extensive)

c. A transverse K-wire is inserted through the calcaneus to attach a Kirschner

traction device for manipulation (traction reduces the medial wall) d. A bone
graft would not be necessary if adequate lateral to medial wall reduction is
performed. However, some feel that a bone graft is necessary under the
posterior facet after it has been elevated from the body of the calcaneus

b. A plate stabilizing the lateral wall (the plate is the key in preventing the
posterior heel from drifting into varus)
c. A transverse K-wire or Schanz screw is inserted into the posterior body and
helps reduce the Medial wall indirectly to pull the heel out of varus, and lock
in the medial cortices before the lateral-to-medial lag screws are inserted

7. Further considerations of treatment of intra-articular fractures:

a. Displaced intra-articular calcaneal fractures require open reduction in
order to restore joint congruency
b. The Essex-Lopresti maneuver can be used in elderly patients with intra-
articular tongue-type fractures who cannot tolerate surgery

NOTE* The Essex-Lopresti maneuver is a technique of reduction. The patient

is taken to the OR and using fluroscopic control, a Steinmann pin is driven
c. into the posterior tuberosity from the posterior aspect of the heel. The pin is
then used as a lever to elevate the impacted and depressed joint surface
and tongue portion. This is accomplished by pushing the protruding portion
of the pin downward toward the plantar aspect of the heel. If the articular
surface and posterior tuberosity are noted to fall into proper alignment the
pin is advanced into the anterior calcaneus to fixate the fracture. A second
pin may be driven parallel to the first for added fixation. A BK cast is applied
Summary of correction: If there is visual congruency of the subtalar joint,
visual alignment of the fracture through Gissane's angle, and radiographic
absence of an intra-articular step off at the posterior facet with reduction of
the medial wall on the axial view, then reduction must be considered
anatomic
 NOTE* The 4 areas to consider when evaluating the intra-articular fracture of
the calcaneus are posterior facet disruption, medial wall (determines
height), lateral wall blow out (determines width) and calcanel cuboid joint
a. Posterior facet: Indication for ORIF is with more than a 3 mm step off
involving the posterior facet or if there is an angulation of the tuberosity
fragment greater than 10 0
b. Medial wall pathology: 1 cm or more displacement of the medial wall is
indicative of increased shortening and increased width, and should be
treated with ORIF
c. Lateral wall pathology: Lateral wall disruption can cause sural nerve
irritation and peroneal tendon dysfunction, therefore should be reduced
d. Calcaneal cuboid joint: Involvement can be treated with closed reduction
8. Surgical incisions:
a. Medial approach: The main advantage of this approach is in the direct
visualization of the reduction of the posteriolateral fragment and the
superiomedial fragment and sparing the peroneals and sural nerve
i. McRenolds horizontal incision
ii. Stephenson vertical incision
iii. Zwipp medial "L" incision
b. Lateral approach: Gives expansile exposure to the lateral wall of the
calcaneus, the calcaneocuboid joint and most importantly the posterior facet
(site of major pathology)
i. Modified -Kocher incision
ii. Oilier incision
iii. Right angle incision (consists of a vertical and horizontal arm; an excellent
expansile incision which exposes the entire lateral rearfoot complex via a
subperiosteal flap, and can be extended proximally if a concomitant ankle

NOTE* The most advantageous approach includes the use of a primary

lateral incision with an ancillary medial incision if there is difficulty
reducing the posteriolateral and superiomedial fragments
fracture is present)

9. Complications of Calcaneal Fractures:

a. Heel pain
b. Peroneal tendonitis
c. Osteoarthritis of the STJ, MTJ, and ankle joint
d. Heel pad damage
e. Bony prominence
f. Flexor tenosynovitis
g. Sural or posterior nerve entrapment
h. Calcaneus gait (weak plantarflexion)
i. Rigid pes planus
j. Reflex sympathetic dystrophy
k. Infection

NOTE* In cases of severe comminution, the question of primary subtalar

fusion or triple arthrodesis is still debated
Talar Fractures
1. Anatomy:
a. 2nd largest tarsal bone with more than 1 /2 the surface being cartilage b.
No muscular or tendinous attachments
c. The 3 main parts are the head, body and neck. The neck deviates medially
15-200 and is its most vulnerable part
d. The FHL lies within a groove on the posterior talar tubercle held by a
retinacular ligament
e. Inferiorly 3 facets are present; between the posterior and middle is a
transverse groove which (with the calcaneus) forms the tarsal canal that
exits laterally into the sinus tarsi

2. Blood supply:
a. Extraosseous blood supply comes from:
i. Posterior tibial (#1)
ii. Anterior tibial (#2)
iii. Perforating peroneal (#3)
b. The talar neck is supplied by an anastamosis of 2 vessels:
i. Artery of the tarsal sinus
ii. Artery of the tarsal canal

3. Classification:
a. Chips and avulsions
b. Compression fractures
c. Fractures of the body:
i. Non displaced
ii. Displaced
iii. Comminuted
d. Fractures of the neck (Hawkins' classification): All caused by some fall
or
accident resulting in a severe dorsiflexory force to the foot
i. Group 1: Vertical fracture of the neck that is undisplaced
 One of the three sources of the blood supply is disrupted (a 13% chance
of avascular necrosis has been reported)
ii. Group 2: Vertical fracture of the neck that is displaced, the STJ is
subluxed or dislocated, and the ankle joint is WNL
 Two main sources of blood supply are interrupted (a 42% chance of
avascular necrosis has been reported)
 Prognosis is related to the development of avascular necrosis
iii. Group 3: A vertical fracture of the neck that must be displaced and the
body of the talus must be dislocated from both the ankle and subtalar joints
 All three sources of blood supply are disrupted (91 % chance of avascular
necrosis)
iv. Group 4: The fracture of the talar neck is associated with dislocation of the
body from the ankle and the subtalar joints with an additional dislocation or
subluxation of the head of the talus from the T-N joint
 Avascular necrosis reported in 100% of cases

NOTE* Hawkins' sign is an area of translucency of subarticular or

subchondral bone seen on x-ray, following injury, which
indicates healing is occurring
 NOTE* Early anatomical reduction in displaced fractures yields the most
favorable long term results
e. Fractures of the talar dome (Berndt and Harty): see section
Osteochondral fractures
f. Dislocations:
i. Anterior dislocations
ii. Posterior dislocations
iii. Lateral dislocations
iv. Medial dislocations
v. Total dislocation

4. Treatment:
a. Talar neck:
i. Group 1:
 BK/NWB cast for 6-12 weeks, followed by NWB with no cast for an
additional 2-5 months with ROM ankle excercises (prognosis is excellent)
 ii. Group 2:
 Closed reduction with BK/NWB cast until evidence of union
 Early ORIF when and if closed reduction fails or the original reduction is
unstable (prognosis related to the development of avascular necrosis)
iii. Group 3:
 ORIF with accurate anatomical reduction must be achieved followed by
BK/NWB cast for 3-4 months (prognosis is poor)
 iv. Group 4:
 As per Group 3

NOTE* If the talus must be removed, a Blair procedure is recommended

NOTE* Arthrodesis procedures have been stated to give better results as a

secondary procedure than a talectomy alone

NOTE* Hawkins grades 3 and 4 fractures were thought to be unsalvagable

but with modem ORIF techniques there are improved chances of restoring
normal function after injury.
a. The operative incision to the talus must not inflict any additional harm to
the arteries bringing blood to the body and the neck the most critical blood
supply coming from the posterior tibial in the deltoid: ligament attachment.
An additional blood supply courses into the undersurface through the
talocalcaneal ligament
b. The talus must be reduced as quickly as possible to protect any remaining
blood supply by untwisting and reducing tension in the deltoid ligament, and
to encourage revascularization
c. An atraumatic operative approach is needed that allows adequate
visualization for anatomic reduction (Oilier lateral incision, transverse
Cincinnati incision or a posterolateral vertical incision work well)
b. Lateral process:
i. Undisplaced:
 BK cast partial weight bearing 4 weeks
i. Displaced:
 Excision of bone fragment if symptomatic

c. Total talar dislocations (out of the ankle mortise and STJ, anterior to the
fibula, head directed medially, talus rotated on the longitudinal axis so its
inferior aspect points posteriorly):
i. Manipulation:
 Usually not successful but should be attempted
ii. Skeletal traction:
 Steinmann pin through calcaneus attached to traction apparatus to
achieve an open space between the tibia and calcaneus. The assistant
inverts and plantarflexes the foot, as the surgeon presses both thumbs on
the posterior aspect of the talus by inward and backward movement to
rotate the talus. Afterward, the pin is removed and the foot is immobilized
in an anterior and posterior splint for 7 days with the knee bent to 300 and
ankle at 90°. This is followed by a BK cast for 6-8 weeks. Avascular
necrosis is inevitable.
 If there is an open wound treat appropriately.

Osteochondral Fractures
1. Classification (Berndt and Harty):
a. Stage 1: A small area of compression of subchondral bone
b. Stage 2: A partially detached osteochondral fragment
c. Stage 3: A completely detached osteochondral fragment remaining in the
defect.
d. Stage 4: A displaced osteochondral fragment

2. NOTE* It has been found that 44% are lateral and anterior, and 56% are
Mechanism medial and posterior. Lateral lesions are shallow wafer shaped and
of injury: medial lesions are deep cup shaped
a. Lateral
lesions: Inversion and dorsiflexion
b. Medial lesions: Inversion, plantarflexion and lateral rotation of the tibia on
the talus

3. Diagnosis:
a. Stage 1:
i. Usually no symptoms, and has been diagnosed as an ankle sprain
ii. ROM of the ankle is WNL and painless
b. Stage 2:
i. Painful with associated collateral ligament damage
 Lateral dome lesions have pain over the lateral collateral ligaments
 Medial dome lesions have pain over the deltoid
ii. Ankle ROM may be limited due to traumatic synovitis
c. Stage 3 8 4:
i. Pain is more severe
ii. Decreased ROM of the ankle, joint locking or crepitus, and/or instability of
the collateral ligaments

Note* The diagnosis can be made on x-ray (the A-P view shows the medial
talar dome clearly, the lateral dome is obscured but can be visualized in
the medial oblique), but the use of tomograms or CT are best

4. Treatment:
a. Conservative: For stage 1, 2, 3 medial lesions via NWB BK cast for 6 weeks
followed by a patellar-bearing brace until the fracture heals
b. Surgical: For stage 3 lateral and 4, surgery to remove fragment, or
stabilize fragment using K -wire or Herbert screw

NOTE* Review of the literature reveals that surgically treated patients have
better results in preventing post-traumatic arthritis. However, conservative
vs. surgical treatment depends upon the size/location/stage of the fracture
fragment

Staging System for Osteochondral Lesions

Radiographs T2W-MRI Arthroscopy
Stage 1 Normal Marrow edema Normal or
(diffuse high signal irregularity and
intensity softening of
cartilage
Stage 2 Semicircular Low signal line Articular cartilage
fragments surrounds fragment breached, definable
but nondisplaced
fragment
Stage 2A Subcortical lucency High-signal fluid
within fragment
Stage 3 Semicircular High signal line Displacable
fragment surrounds fragment fragment
Stage 4 Loose body Defect talar dome Loose body
Navicular Fractures

Fractures of the navicular are easily missed,, and are important to diagnosis
quickly as a delay in treatment could lead to traumatic arthrosis of
Lisfranc's joint as well as the T-N joint. Isolated fractures are uncommon,
and usually occur in conjunction with Lisfranc's dislocations and fractures of
the rearfoot. Stress fractures of the navicular have been seen in runners
but more frequently in basketball players, and this problem is often
misdiagnosed as anterior tibial tendonitis

1. Anatomy:
a. Cancellous bone which is convex distally where it articulates with the three
cuneiforms and is concave proximally to accomodate the talar head
b. The dorsal navicular surface is roughened and serves as an attachment for
the dorsal talonavicular ligament, cuneonavicular ligaments and the
cubonavicular ligament
c. The plantar surface is so roughened and is invested by the plantar
calcaneonavicular ligament (spring ligament)
d. The lateral surface serves the attachment for the navicular portion of the
bifurcate ligament
e. The navicular tuberosity provides the major attachment site for the
posterior tibial tendon
f. The blood supply is from the dorsalis pedis and the medial plantar artery
which form an arcade of 6-8 randomly arranged vessels that penetrate the
navicular surface (the central 1 /3 is relatively avascular)

2. Navicular Fracture Classification by Watson-Jones

a. Type I- Fracture of the tuberosity
i. Relatively common as compared to other types
ii. The mechanism of this fracture is acute eversion of the foot causing an
avulsion-type fracture, caused by increased tension placed on the tibialis
posterior tendon
iii. These fractures are generally non-displaced because of the multiple soft
tissue attachments to the tuberosity
iv. Best demonstrated radiographically on the AP and oblique x-ray with the
foot in moderate equinus
v. It is important to differentiate this fracture from a type II accessory
navicular
vi. If the type I fracture is severely displaced you should suspect
calcaneocuboid involvement
vii. The combination of a severely displaced fracture and compression
fracture of the cuboid and/or calcaneus is referred to as the NUTCRACKER
SYNDROME
vii. Treatment is with an Unna-type boot of BK partial weight-bearing cast x 4
weeks.
viii. If a symptomatic non-union occurs it is recommended that the fragment
be
removed and reattachment of the tibialis posterior performed

b. Type II- Fracture of the dorsal lip

i. Most frequent fracture of the navicular and is intraarticular

ii. The mechanism of injury is plantarflexion of the foot followed by
either forced inversion or eversion
iii. Best seen on the lateral x-ray

iv. Can be confused with 2 accessory ossicles in the same area, the os
supratalare and os supranaviculare
v. Treatment is with a BK partially weight-bearing cast for 4-6 weeks
vi. If late problems such as a painful dorsal prominence occurs, excision of
the fragment is recommended

c. Type IIIA - Fracture of the body without displacement

d. Type IIIB - Fracture of the body with displacement

i. A severe injury that causes disruption of the talonavicular and

cuneonaviclar joints
ii. Can be either displaced (type A) or nondisplaced (type B)
iii. The mechanism of injury can result from either direct crush or blow,
or indirect from a fall from a height with the foot in a marked
plantarflexion position at the moment of impact
iv. These fractures are usually intraarticular
v. DP, lateral, and oblique x-rays will demonstrate the fracture
vi. A differential diagnosis for a type Ill navicular fracture include a bipartite
tarsal navicular and lithiasis of the navicular
vii. Treatment of nondisplaced fractures is with a BK walking cast for 6-8
weeks
viii. Treatment of displaced fractures is with ORIF and a BK non-weight-
bearing cast for 6-8 weeks

e. Type IV- Stress fracture of the navicular

i. Usually an athletic injury, most commonly track and field
ii. Symptoms are increased pain with activity, and decreasing pain
following the activity
iii. Usually intraarticular
iv. Usually found with either a bone scan, CT scan, or MRI
v. Early diagnosis is important to prevent a complete fracture and an
eventual nonunion
v. Treatment is a BK non-weight-bearing cast for 4-6 weeks if nondisplaced,
and if displaced ORIF with a BK non-weight-bearing cast for 6-8 weeks

NOTE* Watson-Jones navicular fracture classification described 3 types:

Type 1 (tuberosity fx), Type 2 (dorsal lip fx), and Type 3 (transverse body fx)
Cuboid Fractures
The cuboid is a key bone in the rigid lateral column of the foot. Its position is
stabilized by several structures to ensure its structural and functional
integrity
1. Anatomy:
a. The cuboid is locked in articulation with 5 bones of the foot (4th and 5th
metatarsals, calcaneus, lateral cuneiform, and a fibrous articulation with the
navicular)
b. Primarily cancellous
c. Dorsally, the bifurcate ligament attaches the calcaneus to the cuboid, the
dorsal cuneocuboid ligaments tether the cuboid to the lesser tarsus
d. Dorsolaterally, the dorsal tarsometatarsal ligaments attach the cuboid to
the metatarsal bases
e. Plantarly, the long and short plantar ligaments attach to and cross the
cuboid while adding to the maintenance of the longitudinal arch
f. The sural nerve and lesser saphenous vein cross over the cuboid area
g. The peroneus longus courses plantarly under the peroneal groove in the
cuboid
h. The arterial supply is made up of an arterial rete system supplied by the
lateral malleolar artery, the lateral tarsal artery and the arcuate artery

2. Classification system:
a. Type 1: Stress fracture
b. Type 2: Avulsion fractures
(a) Bifurcate ligament area
(b) Tarsometatarsal ligament area
c. Type 3: Body fracture, nondisplaced
d. Type 4: Indirect crush fracture or nutcracker fracture
e. Type 5: Plantar dislocation
f. Type 6: Direct crush

3. Avulsion Fractures:
a. Most common on the lateral aspect at the calcaneocuboid joint and the 5th
met-cuboid articulation.
b. Avulsion fracture of the tuberosity due to tension on inferior
calcaneocuboid ligament.
c. Adduction of the cuboid on the calcaneus will result in avulsion due to
tension on lateral calcaneocuboid ligament.

NOTE* Avulsion fractures of the cuboid must be differentiated from os cuboid

secondarium, os peroneum and/or os vesalianum

d. Treatment is closed reduction with casting

4. Fractures of the body of the cuboid:

a. Due to axial rotary forces while the foot contacts the ground in a
plantarflexed position- usually associated with fracture of the base of the 5th
metatarsal and calcaneus
b. Crush fracture as above mechanism but with more force (a nutcracker
effect)
c. Treatment is closed reduction with BK cast 6-8 weeks or arthrodesis in
case of crush fracture

5. Stress fractures:
a. Should be suspected if concerned about peroneus longus tendonitis,
calcaneocuboid arthritis, dropped cuboid, and capsulo-ligamentous strain in
the cavus foot type.
b. Treatment: BK cast 6-8 weeks (first 2 weeks NWB)
 NOTE* In general, treatment for type 1, 2, and 3 injuries is usually NWB BK
cast for 6-8 weeks. Avulsion fractures are sometimes opened if the
dislodged fragment is felt to be intraarticular or will cause impingement
on the peroneal tendons. Type 5 dislocations must be reduced, with
closed reduction under general anesthesia attempted first with an
inversion-adduction force on the forefoot while pushing the cuboid up
from the arch. If this fails, open reduction is advised. Type 4 fractures
usually require autogenous bone grafting for anatomic alignment of the
calcaneocuboid and tarsometatarsal joints

Cuneiform Fractures
1. Avulsion fractures:
a. Usually located on the medial aspect of the internal cuneiform as an
avulsion due to pull of the tibialis anterior

2. Fractures of the body:

a. Mechanism: Either by direct trauma or rotational force

3. Stress fractures:
a. Diagnosed by bone scans, CT, or tomography b. Treated with BK WB cast

4. Treatment: Requires traction to reduce the dislocation and allow

anatomical reduction of the cuneiforms to prevent chronic pain and arthritis

NOTE*
a. Cuneiform fractures are usually associated with Lisfranc dislocations
b. The mechanism of the dislocation and fractures of the cuneiforms involves
the forefoot and rearfoot acting as levers, with the lesser metatarsals
displaced laterally and dorsally
c. Fracture of the 2nd metatarsal base is an important factor in causing
dislocation or fracture of the middle cuneiform
d. Lisfranc's ligament interruption has an effect on a middle cuneiform
fracture/dislocation

Fifth Metatarsal Base Fractures

Fractures of the 5th metatarsal are commonly associated with inversion
sprains of the ankle, therefore, with any ankle inversion injury, the 5th
metatarsal base should always be evaluated. This is the Stewart
Classification
1. Type 1: A true Jone's fracture which occurs between the epiphysis and
diaphysis (metaphyseal level).
a. Usually oblique or transverse in nature
b. Situated at the distal end of the articular capsule above the
intermetatarsal ligaments
c. The mechanism of injury is internal rotation of the forefoot while the base
of the 5th metatarsal remains fixed, The capsule is only stretched and the
peroneus brevis takes practically no part on the injury
d. Upon physical examination, extreme mobility of the shaft of the 5th
metatarsal is found
e. This is an unstable fracture with a very poor blood supply and because of
this, this fracture has a very high propensity for non-union
f. Treatment is with a non-weight-bearing cast BK cast for 4-6 weeks, or If
displaced, then ORIF

2. Type 2: Intraarticular fracture of the 5th metatarsal base with one or two
fracture lines
a. A result of shearing force caused by the internal twisting of the forefoot
while the peroneus brevis is contracted
b. Displacement of the fragments depends upon the extent of the damage to
the capsule and ligaments
c. Treatment is with an Unna-type boot or BK non-weightbearing cast for 4-6
weeks, or if nonreducible, then ORIF

3. Type 3: This is an avulsion fracture of the base of the 5th metatarsal

a. This is oftentimes mistaken in the literature for a Jones fracture. It is the
most proximal injury, where a small fragment is torn away, the fracture is
extraarticular, and the fracture line is usually at right ankles to the long axis
of the metatarsal base
a. The mechanism of injury is primarily a sudden sharp contraction of the
peroneus brevis when the ankle is in plantarflexion
b. The treatment is with an Unna-type boot of BK non-weightbearing cast for
4-6 weeks, or if nonreducible then ORIF with tension bend wiring or screw
fixation. If the fragment is too small for fixation, then excision of the
fragment and reattachment of the peroneus brevis tendon is recommended

4. Type 4: This is a comminuted intraarticular fracture of the 5th metatarsal

base
a. The mechanism of injury is similar to Type 2, but in this case the 5th
metatarsal base gets crushed between the cuboid and the ground causing
fragmentation
b. There is a high rate of non-union
c. Treatment is an Unna-type boot or a BK non-weight-bearing cast for 46
weeks, or if fracture fragments are severely displaced, bone grafting and
ORIF may be required

5. Type 5: A fracture that occurs in children, where there is a partial

avulsion of the epiphysis with or without a fracture line or hairline crack as
seen in Type 2. This fracture can also be classified as a Salter-Harris I.
a. The treatment is a BK non-weight-bearing cast for 4-6 weeks

Metatarsal Fractures (1st and 2nd-3rd-4th)

1. Classification:
a. Site:
i. Epiphyseal
ii. Diaphyseal
iii. Metaphyseal
b. Type:
i. Incomplete separation of the bony fragments
ii. Complete separation
iii. Greenstick fracture
iv. Buckle type fracture
c. Configuration:
i. Transverse
ii. Spiral
iii. Oblique
iv. Comminuted
v. Stress fracture

d. Relationship of the fragments:

i. nondisplaced
ii. Displaced:
 Shifted sideways
 Rotated
 Distracted
 Overriding
 Angulated
 Impacted
e. Relationship to outside environment:
i. Simple
ii. Compound

NOTE* If, wound is open treat accordingly :(check blood loss, shock etc)
tetanus prophylaxis,
NOTE*antibiotic
Salter devised
therapy,
a classification
skin coveragesystem
as necessary,
describing fractures of long
rigid reductionbones
of fracture, and fluid replacement as necessary
1. Location of the fracture: diaphysis, metaphysis, physis, epiphysis,
intraarticular
2. Extent of the fracture: complete or incomplete
2. 3. Arrangement of the fracture: transverse, spiral, oblique, compression,
Treatment: comminuted
a. Closed
reduction with BK NWB cast 4-6 weeks
b. Open reduction:
i. Monofilament wire
ii. K-wires
iii. AO technique

NOTE* Complications include pseudoarthrosis, avascular necrosis, and

malposition NOTE* Radiographic diagnosis of this fracture should not be confused with
the normal apophysis present in children (closed b age 15 in boys and 12
in girls). and Iselin's disease (osteochondrosis) Also differentiation should
be made between an avulsion fracture and an os vesalianum and os
NOTE* Radiographic
perineum evidence of chronicity is manifested by a wide
radiolucent fracture line, periosteal reaction, thickening of the
lateral margin of the cortex adjacent to the fracture with or
without callus, and intramedullary sclerosis
3.
First metatarsal fractures:
a. Anatomy:
i. Articulates laterally with the 2nd metatarsal, proximally with the medial
cuneiform, and distally with the base of the proximal phalanx of the hallux
ii. 2.7 cm proximal to the head of the 1 st metatarsal (on the lateral aspect) is
the foramen for the nutrient artery
iii. Plantar surface is concave, causing this side to be under tension during
weight bearing
iv. Holds the sesamoids, the tibial being larger separated by the crista or
central ridge (if more than 2 sesamoids, bipartite indicating multiple
ossification centers)
v. Muscles around the 1st metatarsal:
 Peroneus longus: involved in 1st metatarsal base avulsion fractures
 Tibialis anterior
 EHL
 EHB
 Adductor hallucis
 Abductor hallucis
 FDB
 Tibialis posterior
vi. Arterial supply is the dorsalis pedis and 1 st plantar metatarsal

b. Classification:
a. Salter classification is based on 6 categories
i. Site: anatomical location
ii. Configuration: transverse, oblique, spiral, etc.
iii. Open or closed
iv. Location
v. Extent: complete or incomplete
vi. Relationship of the fracture fragments to each other: displaced, angulated,
rotated, etc.

c. Treatment:
i. Simple fractures with no displacement are treated NWB BK cast for 6-8
weeks
ii. Displaced fractures should be anatomically reduced (usually open
reduction ORIF)
iii. Open fractures: treated as per open fracture classification
4. External fixator device for metatarsal fractures: A miniature
external fixation device can be utilized in the treatment of metatarsals.
Maintains the normal metatarsal parabola pattern
a. Indications: When a metatarsal fracture is severely comminuted or when a
significant loss of bone stock is present (gunshot)
b. This supplies rigid fixation giving stability to the fracture and can be
combined with other forms of fixation
c. It is capable of both compression and lengthening the metatarsal
fragments and can be combined with bone grafting as needed
d. Should be reserved for patients for whom reduction by any other means
cannot be obtained

5. Internal metatarsal fractures (metatarsals 2-3-4): Treated like the

other metatarsal fractures
A: Is a diaphyseal fracture with straight plate fixation without lag screw
B: is a diaphyseal/metaphyseal neck fracture with application of L plate with
lag screw fixation
C: Is a metaphyseal base fracture with application of T-plate with lag screw
fixation
 Ankle Fractures
1. Classifications:
a. Lauge-Hansen: A two-word description indicating the position of the.
foot at the time of injury, and the direction of the talus. Five types of
injuries listed:
i. Supination-Adduction
ii. Pronation-Abduction
iii. Supination-External Rotation
iv. Pronation-External Rotation
v. Pronation-Dorsiflexion

NOTE* The major advantage of the classification is to enable the examiner

to assess
In supination
the stability
injuries,
of the
the ankle
sequence
fromstarts
the x-rays
with the
by predicting
anterior syndesmosis,
b. ligamentous
and in pronation
injuries injuries, with the deltoid-medial malleolus complex.
Danis- In external rotation injuries, the progression of lesions simply follows the
Weber: anatomic sequence around the ankle joint: deltoid-medial malleolus
Based complex, anterior syndesmosis, fibula, and posterior syndesmosis.
on the
location of the fracture of the fibula and is useful for determining the
appropriate form of treatment for ankle fractures.
i. Type A: Below the joint level
ii. Type B: At the level of the joint
iii. Type C: Above the level of the joint

2. Lauge-Hansen:
a.
NOTE* The hallmark of this injury is an avulsion fibular fracture at the level of
the ankle or below.
Supination-Adduction:
i. Stage 1: Transverse fracture of the lateral malleolus usually below or at the
level of the ankle mortise or lateral collateral ligamentous rupture (pulloff)
ii. Stage 11: Stage I plus an oblique fracture of the medial malleolus (pushoff)

NOTE* Variants of Stage If S -A injuries are: rupture of the deltoid ligament

rather than fractures of the lateral malleolus, concomitant damage to the
tibiofibular syndesmosis with fracture of the medial and lateral malleolus,
avulsion fracture of the lateral malleolus proximal to the A.T.F. with
damage to the lateral collateral ligament, S-A fracture of the medial
malleolus without injury to the lateral side,

NOTE* Healing is more favorable with supination injuries (less overall

damage)
 b. Pronation Abduction:
1. Stage I: Fracture of the medial malleolus or tear of the deltoid ligament
ii. Stage II: Stage I plus rupture of the anterioinferior tibiofibular and
posterioinferior tibiofibular ligaments and transverse tibiofibular ligament,
with fracture of the posterior lip of the tibia
iii. Stage III: Stage II plus an oblique supramalleolar fracture of the fibula (the antero-
posterior tibiofibular ligaments tear but the interosseous ligament does
not)

c. Supination-External Rotation:

NOTE* This is the most common fracture of the ankle, and its hallmark is a
spiral
fracture of the fibula i. Stage
I: Rupture of the anteroinferior tibiofibular ligament, sometimes with
avulsion of the bony fragment between the tibia and fibula. (tibia:
Chaput, fibula: Wagstaff)
ii. Stage II: Stage I plus a spiral oblique fracture of the lateral malleolus.
iii. Stage III: Stage 11 plus a fracture of the posterior lip of the tibia
(Volkmann's fracture)
iv. Stage IV: Stage III plus a fracture of the medial malleolus

d. Pronation-External Rotation:

NOTE* 'The hallmark is a high fibular fracture.

i. Stage I: Fracture of the medial malleolus or a tear of the deltoid ligament.

ii. Stage II: Stage I plus a tear of the anteroinferior tibiofibular ligament and
interosseous ligament.
iii. Stage III: Stage II plus an interosseous membrane tear and a spiral
fracture of the fibula 7-8 cm. proximal to the tip of the lateral malleolus
iv. Stage IV: Stage III plus a fracture of the posterior lip of the tibia.
e. Pronation-Dorsiflexion:
i. Stage I: Fracture of the medial malleolus
ii. Stage II: Fracture of the anterior inferior aspect of the tibia
iii. Stage Ill: Supramalleolar fracture of the fibula (transverse)
iv. Stage IV: Fracture of the posterior aspect of the tibia (Pilon fracture) Reudi
and Allgower divided these into:
 Grade I: Cleavage fracture of the distal tibia with no disruption of the
internal surface
 Grade II: Internal surface disruption with no comminution
 Grade III: Impaction and comminution

NOTE* In a fall from a height, where there is pronation-dorsiflexion injury,

axial compression is present, which will result in the following fractures of
the tibial plafond:
a. if the talus is dorsiflexed upon impact, anterior portion of tibial plafond is
fractured
b. if the talus is plantarflexed upon impact, posterior portion of the tibial
plafond fractures
c. if the talus is in neutral position upon impact, central shattering of the
articular surface of the tibial plafond takes place
3. Danis-Weber fractures:
a. Type A (Supination-adduction Lauge-Hansen): The fibular fracture occurs
below the level of the tibial plafond and therefore below the level of the
syndesmotic ligaments. It is associated with a vertical fracture of the medial
malleolus.
b. Type B (Supination-external rotation or Pronation-abduction Lauge-
Hansen): An avulsion fracture of the medial malleolus and fracture of the
fibula that begins at the level of the tibial plafond. The posterior rim of the
tibia might also be fractured
c. Type C (Pronation-external rotation Lauge-Hansen): Characterized by
rupture of the syndesmosis and a fibular fracture that is located above the
tibial plafond. Associated injuries are an avulsion fracture of the medial
malleolus or deltoid ligament rupture and a large or small posterior malleolar
fracture.

4. Other fractures:
a. Tillaux fracture: Fracture of the anterior tubercle of the tibia due to
tension of the IATF ligament. Also a type 3 epiphyseal injury of the
anterolateral distal tibia.
b. Wagstaff-Lefort fracture: Vertical fracture of the anterior margin of the
lateral malleolus due to an avulsion of either the anteroinferior tibiofibular or
anterior talofibular ligaments.
c. Maisonneuve fracture: Fracture of the proximal fibula , associated with
tibiofibular diastasis.
d. Pankovich classification of Wagstaff fractures:
i. Type l: Avulsion fracture and fibular fragments remaining attached to the
anterior talofibular ligament and IATF ligament
ii. Type Il: Oblique fracture with fragment remaining attached to the IATF
ligament
iii. Type III: Oblique fracture of the fibula in addition to a fracture of the
anterior tibial tubercle
e. Bosworth fracture: Fibular oblique fracture caused by external rotation
but the fracture occurs after posterior dislocation of the fibula. This causes
closed reduction to be impossible.
f. Frost. fracture: A triplane fracture which is a combination of Tillaux and
Salter-Harris Type 2 occurring at the distal tibia
g. Pott's Fracture: A fracture of the distal fibula and disruption of the
deltoid ligament (or medial malleolar fracture)
h. Cooperman's fracture: This is a Salter-Harris triplane type 4 epiphyseal
ankle fracture which consists of 2 fragments: the first is composed of the
tibial shaft, medial malleolus, and the anteromedial portion of the epiphysis;
the second consists of the remainder of the metaphysis, epiphysis, and
attached fibula.
i. Chaput's tubercle: The anterolateral tubercle of the distal tibia
j. Shepherd's fracture: Fracture of the posterolateral tubercle of the talus.
k. Volkmann's fracture: A fracture of the posterolateral corner of the distal
tibia (Volkmann's triangle), medial malleolus, fibular shaft, and tibiofibular
diastasis.
l. Ashurst's sign: The overlap of the anterior tibial tubercle and the medial
2/3 of the distal fibula normally is found on the A-P x-ray of the ankle.
Ashurst's sign is present with a lessening of this overlap due to widening of
the ankle mortise due to disruption of the anterior tibiofibular ligament
m. Thurston-Holland sign: The spike of metaphyseal bone attached to the
fractured epiphysis seen with Salter-Harris 2 fractures.

4. Treatment of ankle fractures:

a. General considerations: A decision to perform surgery takes in account all
aspects of the patient's condition. In general, the best long term results in
terms of restoration of function and avoidance of posttraumatic arthritis are
directly related to treatment that restores anatomy and allows for early
range of motion and early weight-bearing. Early ORIF should be done
provided that the initial evaluation of the patient reveals a satisfactory
.neurovascular status and skin condition of the foot. Early ORIF reduces
swelling by stabilizing the fracture and also reduces bleeding. If the fracture
is open, the wound should be cultured and broad spectrum IV antibiotics
started, followed by wound debridement, irrigation, and ORIF as indicated.
The wound is left open and delayed primary closure is performed at least 5
days later. Closed reduction of displaced ankle fractures rarely accomplishes
restoration of normal anatomy without repeated forced manipulations, and
does not allow for early ambulation and range of motion.

NOTE* ORIF is indicated for all ankle fractures with a greater than 2 mm.
lateral or posterior displacement of the lateral or medial malleolus
b. Absolute criteria:
i. Fractures and dislocations must be reduced immediately
ii. All joint surfaces of the ankle must be anatomically reduced iii. Reduction
must be maintained while the fractures are healing iv. Motion of the joints
should be started as soon as possible

c. Other criteria:
i. ORIF of the fibula should precede fixation of the medial malleolus because
it provides a buttress to the talus, which tends to displace laterally and pull
along the medial malleolus. Shortening of the fibula must be prevented (see
chapter 29: Ankle Conditions, Nonunion of Malleoli)
ii. Repair of the deltoid is difficult and rarely necessary, and should be
reserved for more severe injuries in which soft tissues around the ankle are
damaged.
iii. Large displaced fragments of the anterior and posterior processes of the
tibia, which are present in some indirect ankle fractures, should be
anatomically reduced (if at least 1 /4th the weight-bearing surface) in order
to restore congruity of the articular surface (reduction of these fragments
prevents subluxation of the talus)
iv. Fracture of Chaput tubercle and Wagstaff fractures should always be
reduced and fixed
v. A displaced yet essentially intact fibula requires syndesmotic screws for
proper reduction
 NOTE* Stability of the syndesmosis is tested by pulling the fibula laterally
with a bone hook.
NOTE*When
Observe
thereforistendon
more than
dislocations,
2-3 mm of i.e.
lateral
posterior tibial tendon into the
displacementankle
of thejoint
fibula, instability is present and the use of a
syndesmotic screw(s) is indicated. It is desirable to insert this screw 2-3
cm above the tibial plafond. When there is a plate attached to the fibula,
one cortical screw can be removed and replaced with a syndesmotic
screw. When drilling for a syndesmotic screw, the direction must be
anteromedial to avoid inserting the screw posterior to the tibia
d. Fixation of the fibula: Should be fixed prior to the medial malleolus
i. AO Technique:
Interfragmentary screws are inserted most often from the anterior edge in a
posteroinferior direction
 Overdrilling is unnecessary and may cause comminution of the fragment
 3.5 mm cortical screws are most often used
ii. Cerclage Wiring:
 It is useful in comminuted fractures while a plate is being applied to the
lateral side of the fibula
 Can be used as an adjunctive device for an oblique fracture of the fibula
while an intramedullary nail is being used
iii. Inyo Nails:
 Excellent for transverse fractures of the distal fibula
 Useful in osteoporotic bone but requiring cerclage wiring of an oblique
fracture of the fibula prior to insertion
 When inserting the nail, it is critical to reduce the fracture anatomically in
order to avoid penetration outside the bone

e. Fixation of the medial malleolus: Requires fixation with a device that

provides compression between the fracture fragments I. AO technique:
 Essentially only 4.0 mm cancellous screws should be used for fixation of
the medial malleolus (self-tapping 4.5 mm malleolar screws are not
practical because the head of the screw is too large and prominent after
insertion)
 A screw usually 40-45 mm in length is usually used
 In osteoporotic bone a washer would be used to prevent penetration of the
head of the screw head
 A second screw is used when the malleolar fragment is large (a K -wire
can be used first to prevent rotation of the fragment and retained for
additional stability)

f. Closed reduction:
i. The main advantage of closed reduction is lack of postoperative wound
complications
ii. Closed reduction is contraindicated in unstable ankle fractures in which
both malleoli are fractured
iii. Closed reduction is acceptable in fractures when open reduction is
contraindicated (vascular compromise, neglected open fractures, pyoderma,
skin necrosis or contusion)
iv. Gravity is utilized by positioning the leg horizontally and in external
rotation while holding the foot in one hand with the heel resting in the palm.
This effectively produces internal rotation and adduction of the talus and in
that way reduces the fibula and brings in position the medial malleolus
 A short leg cast is first applied while the fracture is being reduced, then is
extended to a long leg cast with the knee in 30° of flexion. A minimum of
6 weeks of immobilization is required
5. Factors that result in irreducible fractures:
a. Interpositon of the deltoid ligament
b. Trapping of the tibialis posterior tendon
c. Trapping of the medial tendon(s)
d. Dislocation and fracture-dislocation of the fibula behind the tibia
6. Soft tissue complications of fractures and dislocations of the ankle:
a. Skin: Blistering, decubitus breakdown, slow wound healing
b. Massive Edema: Treat with compression immediately, cold application,
elevation, rigid internal fixation and early ROM
c. Fracture blisters: Direct result of edema. ORIF must be delayed for 3-7
days
d. DVT's: Due to plaster immobilization, venous insufficiency, sickle-cell.
Treat casted patients with sub-Q heparin 2500-5000 units Q 8-12 hours if
they are at risk
e. Chondrolysis of the ankle (cartilage necrosis): Leads to posttraumatic
arthritis
f. Avascular necrosis of the talus
g. Infection following open fractures (5-30%)
h. Nerve injuries
i. Nerve disruptions (complete and incomplete)
ii. Reflex sympathetic dystrophy syndrome
i. Arterial injuries
j. Tendon injuries
k. Ligament injuries
i. Medial deltoid
ii. Lateral ligament (chronic thickening, local tenderness, inversion
instability, anterior subluxation)

7. Bony complications of fractures and dislocations of the ankle:

a. Fractures of the lateral malleolus:
i. Non-union and malunion (external rotation) with chronic swelling and
widening of the ankle
b. Fractures of the medial malleolus:
i. Non-union: More common than the lateral malleolus due to soft tissue
interposition between the fragments
 Chronic diastasis
 Loose bodies
 Arthritic changes
c. Fractures of the posterior tibial margin: Greater than 25% margin renders
the ankle unstable leading to posterior subluxation
i. Posterior subluxation
 Medial and lateral malleoli and syndesmosis torn
ii. Malunion with posterior subluxation
 Most common complication
d. Fractures involving the distal tibiofibular syndesmosis:
i. 2nd only to plafond injuries, leads to arthrodesis of the ankle
ii. Mortise widening
e. Vertical or Pilon fractures of the distal tibia:
i. Varus or valgus deformity
ii. Traumatic arthritis
iii. Articular incongruity
f. Epiphyseal injuries:
i. Articular incongruity is the main concern
ii. Vascular embarassment
iii. Posttraumatic arthritis
iv. Varus or valgus deformity of the ankle
v. Angular deformity
vi. Leg length discrepancy vii. Bone and joint sepsis

Midtarsal Joint Dislocations

The talonavicular and the calcaneocuboid joints function as a single unit in
movements (functions with STJ in inversion and eversion) so are considered
together as the MTJ. Injuries are rare
1. Classification (Main and Jowett): Midtarsal joint injuries are defined
according to the direction of the force producing the dislocation. a. Medial
force results in three grades of injuries:
i. Fracture sprain of calcaneus, talus, navicular, or cuboid
ii. Fracture/subluxation or dislocation with medial subluxation or dislocation
of forefoot while the talocalcaneal relationship remains normal
iii. Swivel dislocation with only the T-N joint dislocating
b. Longitudinal force injuries:
i. Fracture of the navicular takes place
c. Lateral force injuries:
i. Fracture sprain of the navicular tuberosity, dorsal chip of the talus or
navicular, and lateral fracture of the cuboid
ii. Fracture/subluxation will result in T-N lateral subluxation and nutcracker
fracture of the cuboid
iii. Swivel dislocation with the talus dislocating laterally relative to the
navicular
d. Plantar force injuries:
i. Result in dorsally dislocated talus and calcaneus relative to the navicular,
and cuboid chip fractures also present dorsally, as well as anteroinferior
calcaneal fractures
e. Crush injuries: Have variable patterns. Usually associated with open
wounds

2. Treatment:
a. Medial force injuries: reduced by traction and reversal of the mechanism of
injury with casting (WB or NWB)
b. Lateral force injuries: closed reduction first. C-C fusion is recommended for
persistent symptoms. Triple arthrodesis has been the traditionally
recommended treatment if conservative care has failed

Tarsometataral Joint Dislocations/Fractures (Lisfranc

dislocation)
 This type of injury occurs in conjunction with high energy trauma (equestrian
injuries) as well as minor twisting injuries, which are also associated with
injuries to the cuneiforms, cuboid, and the navicular. The key to
understanding this injury is the structural integrity provided by the slotting
in the base of the second metatarsal, which is surrounded by 5 adjacent
bones that create a tight mortise. There is no ligament between the base of
the 2nd and 1st metatarsals, but a ligament extends from the medial base
of the 2nd metatarsal obliquely to insert into the medial cuneiform.
Soft tissue loss and vascular impairment can be a major problem in this
setting
The 2nd metatarsal is the key to stability of Lisfranc's joint.
The dorsal tarsometatarsal ligaments are weaker than the plantar
tarsometatarsal ligaments.
1. Mechanism of injury:
a. Abduction and plantarflexion: 2nd metatarsal is fractured, the remaining
ligaments give way and the forefoot is subluxed laterally
b. With continued abduction, there may be a nutcracker-like fracture of the
cuboid.

2. Classifications:
a. Hardcastle et. al.
i. Type A: Total incongruity (the metatarsals displace in a unit in one plane
ii. Type B; Partial incongruity ( at least one of the tarso-metatarsal joints is
not displaced)
iii. Type C: Divergent (the 1 st metatarsal is displaced medially and the other
metatarsals are displaced laterally)
b. Quenu and Kuss
c. Myerson: Further subdivided Hardcastle's classification
i. Type A: Total incongruity
ii. Type 131: Partial incongruity, medial metatarsals
iii. Type B2: Partial incongruity, lateral metatarsals
iv. Type C: Divergent patterns
v. Type Cl: Partial displacement
vi. Type C2: Total displacement

3. Diagnosis: Via x-ray (A-P & lat)/tomography (A-P)/CT scan

a. Widening between the base of the 1 st and second metatarsals or the
middle and medial cuneiforms is often present. This widening can also be
between the base of the second and third metatarsals or middle and lateral
cuneiforms.
b. An avulsion fragment referred to as the "FLECK SIGN" is often present
between the base of the 1st and 2nd metatarsals or middle and medial
cuneiforms.
c. Projected lines from the base of the metatarsals should not intersect the
corresponding cuneiforms or cuboid.
d. Angulation of the metatarsals can occur without apparent fracture at the
base.
e. Widening between the base of the 5th metatarsal and the cuboid can
occur.

NOTE* Due to the spontaneous relocation that this fracture dislocation can
produce, x-rays do not usually show the true magnitude of the severity of
this injury

4. Treatment: Includes splinting, casting, closed reduction and casting,

closed reduction and percutaneous pinning, or open reduction and
percutaneous pinning (according to type)
a. If instability is present but alignment is anatomic with release of the force,
immobilizing the extremity in a BK NWB cast is appropriate.
b. If instability is present and alignment is not anatomic with release of force,
then pinning (open or closed) is mandatory followed by casting.
c. If severely unstable, then open anatomic reduction with heavy gauge K -
wires or screw fixation is the procedure of choice.
d. With severe joint comminution, primary arthrodesis may be considered
NOTE* Pin placement according to Myerson classification type: a. Type A: 2 K-
wires (medial and lateral)
b. Type B 1: 2 medial K-wires
c. Type B2: 1 wire laterally
d. Type C: 3 or more wires
The medial pin should go across the 1st metatarsal-cuneiform joint, the 2nd
pin should go across the 3rd and 4th tarsometatarsal joints, and a 3rd pin
across the 2nd ray articulation. The pins should remain in place for a
minimum of 6 weeks

NOTE* Always pin the 2nd metatarsal base

 NOTE* Most feel that stability and anatomic reduction depends upon the 2nd
metatarsal, so that if the 2nd metatarsal relocates, all the other metatarsals
will follow if there is no damage to the intermetatarsal ligaments

5. Complications:
a. Amputation
b. Sepsis
c. Thrombophlebitis
d. Compartment syndrome
e. Neuroma formation (either traumatic or postsurgical “amputation” type)
f. Post-traumatic arthritis

Ankle Inversion Sprain

Also see Chapter 29, Ankle Conditions: Chronic Lateral Ankle Instability

Definition: A sprain is a disruption of fibers, a strain is plastic deformation

with elongation
Inversion sprains by definition involve lateral ligament disruption. The
anterior talofibular ligament resists internal rotation, plantarflexion, and
anterior subluxation of the talus. The posterior talofibular ligament functions
to reinforce the ankle joint and the calcaneofibular ligament functions to
resist adduction forces.
1. Anatomy:
a. Lateral ligaments:
i. Anterior talofibular (ATFL) (intracapsular): The primary stabilizing structure
preventing anterior displacement of the talus (fan shaped).
ii. Calcaneofibular (CFL) (extracapsular)
iii. Posterior talofibular (PTFL) (intracapsular/extrasynovial): The thickest and
strongest and the least likely to be injured
iv. Lateral talocalcaneal ligament

NOTE* PTFL is 20-45° posteroinferior to the fibular bisection so allows STJ

range of motion.
NOTE* Inversion of the ankle is resisted primarily by the ATFL when the ankle
is plantarflexed and by the CFL when the ankle is dorsiflexed.

NOTE* Angular relationships between the ATFL and the CFL is 100° in the
frontal plane and 105° in the sagittal plane. This sagittal plane angle
decreases with STJ supination and increases with STJ pronation. The
angular relationship between these two lateral ligaments is very d cult to
attain during reconstructive ankle stabilization repair tending to cause a
decrease in allowable STJ supination at the expense of attaining stability
against inversion stress.
2. Ligament composition:
a. 67% water
b. Remaining 33%: 90% collagen type 1, elastin, and glycosaminoglycans
3. Causative Factors:
a. Tibial varum
b. Calcaneal varum
c. Plantarflexed -1st ray
d. Rigid forefoot valgus
e. STJ varum
f. Uncompensated equinus
g: Muscle imbalance (peroneal insufficiency)
h. Previous sprains (elongated ligaments no longer restrain inversion)
i. Torsional abnormalities
j. Short leg syndrome
k. Ankle varus

4. Mechanism of injury:
a. Internal rotation, plantarflexion, and adduction of the talus beyond normal
physiologic limits

5. Classifications of inversion ligamentous injuries (mechanism of

injuries):
a. Leach (1983)
i. 1 st degree (ATFL rupture)
ii. 2nd degree (ATFL, CFL, and capsule rupture)
iii. 3rd degree (all three ligaments and capsule)
b. Diaz (1st word describes the position of the foot and ankle and the second
word the direction of the force applied: similar to Lauge Hansen
classification)
i. Supination-inversion (with a plantarflexed ankle or a neutral ankle)
ii. Supination internal rotation
iii. Supination plantarflexion

NOTE* Additionally, ankle sprains can be classified into:

Type I: stretching of the ligaments or tearing of the ATFL
Type II: a partial rupture or tearing of the ATFL and CFL
Type III: a total rupture of the ATFL, CFL, PTFL, and capsule or tearing of the
ligaments

6. Diagnosis:
a. Scout films
b. Stress views (local anesthesia: peroneal block + local ankle infiltration):
Can use a Telos® apparatus for better quality control
i. Inversion stress: A 5-6° difference between the injured and uninjured ankle
signifies ligamentous rupture
 NOTE* Always take bilateral inversion stress films when examining a patient
radiographically with potential grade III ruptures

NOTE* Degree of talar tilt is not a true indication of which ligament is ii.
ruptured
Push-pull stress (anterior draw sign): The ability to pull the ankle out of the
mortise more than 4 mm. usually indicates a rupture of the anterior
talofibular ligament

NOTE* There are certain situations where the stress test may be invalid:
genetic ligamentous
NOTE* Thelaxity,
main history
indication
of chronic
for ankle
ankle
arthrography
instability,ininability
a soft tissue injury is to
to achieve evaluate
adequateaanesthesia,
possible ankle
or inability
diastasis
toand
properly
to confirm
maneuver
ligamentthe tears
uninjured ankle. In these cases, ankle arthrography would be indicated

c. Ankle arthrography: In performing this test you must consider the following
i. The patient must have no allergy to iodine
ii. The injection should be administered at the anterior-medial aspect of
the ankle (to prevent confusion from the actual injury)
iii. The test must be performed within the first 5-7 days following the
injury
iv. Dye that is found within the normal anatomical confines of adjacent
tendon sheaths and not within the surrounding soft tissue should be
considered a normal anatomical variant
d. Peroneal tenography: A diagnostic technique for evaluation of the
calcaneo-fibular ligament. If dye is injected into the peroneal tendon sheath
and is found to enter the ankle joint but no dye is seen in the soft tissue
surrounding the ankle, a negative test.

NOTE* For some patients there is a normal communication between the

peroneal tendon sheath and the ankle joint capsule: gives a false
positive
7. Differential diagnosis and associated findings:
a. 5th metatarsal base fractures (avulsion and Jones)
b. Stieda's process fracture (talar posterior process)
c. Calcaneal avulsion of the EDB
d. Calcaneal anterior process fracture
e. Talar dome fractures (medial or lateral)
f. Sinus tarsi syndrome
g. Peroneal stenosing synovitis
h. Peroneal tendon dislocations
i. Peroneal neuropathy
NOTE* A Jones fracture is a transverse fracture secondary to a triplane load
with pull of the peroneus brevis
8. Treatment:
a. Symptomatic therapy: Used for patients with negative stress x-rays,
patients with a significant medical history which would contraindicate more
definitive therapy,. geriatrics with a sedentary lifestyle, and patients who
present to treatment 3-4 weeks following injury.
i. Elastic compression
ii. Ice
iii. Analgesics
iv. Weight-bearing to tolerance
v. Physical therapy (proprioceptive excercises and strengthening)

NOTE* TEMPER is an acronym for ankle sprain rehabilitation:

T: Timely diagnosis/temporary immobilization
E: Edema reduction
M: Muscle strengthening
P: Proprioceptive excercises
E: External stabilizing devices
R: Return to activity

b. Definitive therapy: Either immobilization (preferred) or surgery

i. Immobilization:
 48 hours following the injury a BK weightbearing cast is applied for 3-6
weeks
 This is followed by an Aircast® for an additional 3 weeks (for athletes this
is continued for 6-9 weeks)
 Stress x-rays should be repeated in 6 months to evaluate the treatment

ii. Surgical treatment 2-3 days following injury (must be young and athletic
who need complete stability):
  Single ligament rupture:
Watson-Jones*: This uses the peroneus brevis, which passes through the
fibula from posterior to anterior, through the neck of the talus from dorsal to
plantar, back through the fibula, from anterior to posterior, and sutured
back onto itself.
Lee Procedure (modified Watson-Jones)*: This uses the peroneus brevis
tendon, which is then passed through the fibula, from posterior to anterior,
and then sutured back onto itself.
Evans*: This utilizes the peroneus brevis through an oblique hole through
the fibula sutured back onto the belly of the peroneus brevis.
Storren
Nilsonne
Pouzet
Haig
Castaing and Meunier
Dockery and Suppan

 Double ligament rupture:

Elmslie*: Originally described as using the fascia lata and passed through a
drill hole in the lower aspect of the fibula, through the calcaneus, back
through the same drill hole, and tied onto itself, after passing through the
neck of the talus.
Chrisman and Snook*: This uses the split peroneus brevis, which is passed
through the fibula from anterior to posterior through a flap in the calcaneus,
and is then sutured back to the peroneus brevis tendon. Stroren
Hambly
Winfield
Gschwend-Francillon

 Triple ligament rupture:

Spotoff
Rosendahl and Jansen

8. Inversion injuries can result in the following:

a. Sprains of the STJ ligaments
b. Medial STJ subluxation
c. Dislocation of the talus
d. Osteochondral fractures of the talar dome
e. Shear fractures of the head of the talus medially
f. Shear fractures of the navicular laterally
g. Avulsion fractures of the posterior aspect of the talus
h. Avulsion fracture of the base of the 5th metatarsal
i. Fracture of the cuboid
j. Avulsion fracture of the lateral malleolus
9. Complications:
a. Inappropriate diagnosis and lack of treatment
b. Early complications
i. Painful hemarthrosis
ii. Hematoma
iii. Rarely, gangrene of the skin of the lateral ankle in cases of rupture of the
perforating peroneal artery
c. Neuropraxia in grades II and III with damage to the intermediate dorsal
cutaneous nerve

NOTE* With greater than 20% of stretching, fascicular interruption may

occur, causing permanent neurotmesis of the intermediate dorsal d.
cutaneous nerve and producing a profound lateral foot and ankle
sensory loss
The most common surgical complication of primary ankle repair, involves the
intermediate dorsal cutaneous nerve
i. Entrapment neuropathy
ii. Laceration
e. Late complications of surgical repair result from overzealous tightening of
the lateral ankle structure (grade III ankle sprains should be fixed in neutral
not in eversion
f. Painful sinus tarsi can occur later from an everted ankle position
 LIGAMENTOUS INJURIES

Lateral Medial

Common Rare
Adduction (inversion) Rarely alone
Type I (Anterior Talofibular Ligament) palpable tenderness Abduction or External Rotation
Talus Stable - Anterior drawer sign Edema
- Inversion stress (occhymosis in deltoid area)
- X-Ray (Bilateral)
Deltoid ligament ruptured to variable
degree
Treatment 1 strap assesment made as per
2 physical therapy Close (1956)
1. Mortise view
Type II Anterior Talofibular Ligament Palpable tenderness 2. If lateral displacement of
Calcaneal Fibular Ligament diffuse ankle pain talus
If plantar flexion • possible anterior deltoid ligament 2mm + Type I
rupture 3mm + Type II
Talar stability 4mm + Type III
+ Anterior drawer Treatment 1. Type I strap
- Inversion stress 2. Type II
- X-Ray 3. Type III -cast B, K., W. B.
Treatment 1. strap (occ. B. K.. W.B. cast)
2. physical therapy
3. youth - possible ligament

Type III AnteriorTaloflbular ligament

Calcaneofibular ligament
Post Deltoid if plantar flexion
1. Talar stability
+ Anterior drawer
+ Inversion stress
- X-Ray
Syndesmotic
Treatment (usually occurs in young athlete) Rare
1. ligament repair with cast Rarely alone
2. physical therapy Abduction external rotation
Edema
ecchymosis -in syndesmotic area

Anterior + Post Tibiofibular ligament

interosseous ligament
usually with Maisonneuve fracture
Treatment 1. Dap. on other assoc injury
2. Mild -cast B.K., W.B.
3. Severe, A.O. Fixation
Deltoid Ligament Ruptures
1. Anatomy: The deltoid takes origin off the medial malleolus, which ends
structurally in two colliculi (one anterior and one posterior), divided by an
intercollicular groove. There is a superficial and a deep deltoid: a. Superficial
deltoid
i. Naviculotibial
ii. Calcaneotibial (strongest)
iii. Superficial talotibial
b. Deep deltoid
i. Deep anterior talotibial
ii. Deep posterior talotibial

2. Mechanism of Injury: Solitary injury to the deltoid is rare, it is usually

accompanied by other ligament injuries or fractures.

NOTE* Most common are fractures of the fibula and ruptures of the
tibiofibular ligaments a.
Types
of injuries:
i. Supination-external rotation
ii. Pronation-external rotation
iii. Pronation-abduction

3. Signs and symptoms:

a. Pain and swelling on the medial and anterior aspects of the ankle
b. Since there are usually associated injuries, the usual presentation is a
completely edematous and ecchymotic ankle that is being splinted

4. Diagnosis:
a. Scout films (with pronation injuries a high fibular x-ray)
b. Stress x-ray (local anesthesia): Can be done by hand or using a Telos®
apparatus
i. Mortise view of the ankle where the foot is abducted and everted in relation
to the leg
ii. Lateral view where the foot is anteriorly displaced in relation to the leg

NOTE* Stress views are done bilaterally and the clear space is what is
compared Note* A clear space of 1 cm. or greater is diagnostic of a complete rupture,
and a displacement of 3mm. or more means tearing of part of the deltoid

5. Treatment:
a. Usually closed reduction and with BK NWB cast with the foot in inversion is
sufficient for 3-6 weeks, followed by a BK weight-bearing cast for another 3-6
weeks.
b. Surgical repair is indicated if closed reduction does not replace the talus to
its proper position.
 NOTE* This can occur if the deltoid gets rolled up or inverted, or if the
posterior tibial tendon gets trapped.
Compartment Syndrome
Usually diagnosed in the arm and leg, also occurs in the foot, and can follow
several types of injuries, most commonly multiple fractures or crushing
injuries. This entity should be considered in the differential diagnosis in
patients presenting with a painful swollen foot post trauma
1. Definition: Increased compartmental pressure resulting in decreased
perfusion and ultimate ischemic changes to the tissues on the compartment.
This can eventually result in contractures and poorly functioning limbs,
a. Physiology: At rest the intramuscular pressure is approximately 5 mm Hg.
During a muscular contracture the pressure can increase up to 150 mm Hg or
more. At relaxation, the compartment pressure rapidly drops, and within 5-10
minutes, has returned to baseline. With a compartment syndrome, there is
no drop of pressure

2. Types of compartment syndrome:

a. Acute: Occurs when the resting pressure in the compartment exceeds the
available perfusion pressure. This is usually the result of trauma with
hemorrhage or gross muscular edema causing the increased compartmental
pressure. If untreated tissue necrosis is inevitable
b. Chronic: Occurs when the resting pressure is higher than the normal
resting pressure but not so high as to cause hyperprofusion. Following
excercise, the time for pressure to return to baseline is protracted. This
results in a relative prolongation of the ischemic time resulting in symptoms
during or following excercise. Actual muscle necrosis is unusual

3. Diagnosis: Measurement of an increased intramuscular pressure in the

compartment via a wicks catheter (usually greater than 30 mm Hg)

Two criteria must be fulfilled for this diagnosis to be made: a space that is limited by
fascia, skin, or bone must be present; second increased compartment pressure
caused by a decrease in compartment size or an increase in the size of the contents
within that compartment must be present
Any injury with a pressure greater than 30 mm Hg should undergo an
immediate fasciotomy

Note* The patient might still present with a pulse because the vascular
collapse occurs first at the arteriolar level 4.
Compartments of the foot:
a. Medial compartment: Its borders are the medial and lateral intermuscular
septum, the medial portion of the plantar aponeurosis, the tarsus
(proximally) and shaft of the first metatarsal (distally). It contains the
abductor hallucis flexor hallucis brevis, and the FDL tendon
b. Central compartment: Its borders are the medial and lateral intermuscular
septum, the central portion of. the plantar aponeurosis, the tarsus
(proximally) and interosseous fascia (distally). It contains the flexor digitorum
brevis, FDL tendon with lumbricals, quadratus plantae, adductor hallucis, PT
and peroneal tendons
c. Lateral compartment: Its borders are the lateral intermuscular septum,
lateral portion of the plantar aponeurosis, and the associated osseous
components. It contains the abductor digiti minimi, flexor digiti minimi, and
opponens digiti
d. Interosseous compartment: Its borders are the metatarsals and the
interossei fascia. It contains the interossei

5. Clinical Findings:
a. Pain out of proportion to the clinical findings b. Paresthesias
c. Pulselessness
d. Or none of the above

6. Treatment:
a. Fasciotomy
i. Double dorsal technique:
 Midfoot and forefoot: 2 dorsal longitudinal incisions, one over the 2nd
metatarsal and the other over the 4th (deepened down to the metatarsal
shaft) where a hemostat is passed into each adjacent interosseous space.
The wound is closed secondarily in 5 days.
ii. Extensile medial incision
iii. Combined approach

7. Associated complications:
a. Comminuted fractures
b. Severe soft tissue injuries
c. Post-ischemia swelling
d. Intramuscular hematomas associated with bleeding diasthesis
e. Crush injuries

Open Fracture Classification System and

Treatment
1. Gustillo and Anderson described an open fracture classification
system:
This depends upon the mechanism of injury, degree of soft tissue damage,
the configuration of the fracture, and the level of contamination
a. Type 1:
i. Wound less than 1 cm long and clean
ii. Minor soft tissue damage is present
ii. Fracture is simple, transverse, or short oblique with minimal
comminution
b. Type 2:
i. Wound more than 1 cm. long without extensive tissue damage, flaps
or avulsions
ii. There is a slight crushing injury, moderate comminution of the fracture ill.
Moderate contamination
c. Type 3: Extensive soft tissue damage, including muscles, skin, and
neurovascular structures, with a high degree of contamination (high velocity
injuries, farm injuries)
i. Type 3A: Open fractures with adequate soft tissue coverage of bone despite
extensive soft tissue laceration
ii. Type 3B: Open fractures having extensive soft tissue loss with periosteal
stripping and bone exposure. Severe contamination and severe comminution.
Usually a local or free flap is needed for bony coverage
iii. Type 3C: Open fractures are associated with arterial injury requiring
microvascular repair, regardless of the soft tissue coverage

2. General principles of treatment:

a. Tetanus history and therapy administered
b. Thorough H & P conducted (blood loss measured-CBC,HCT, Hb) with
neurological, musculoskeletal, and vascular assessment of the lower
extremities
c. Complete x-rays
d. Appropriate antibiosis should be administered in the E.R. (cultures and
gram stains should be taken)

NOTE* The primary bacteria encountered in open fractures is Staph. aureus.

However, the choice of antibiotic is determined by the extent of the soft
tissue injury. Gustillo and Anderson recommend cefazolin for type 1 and 2
open fractures (2 gm initially followed by 1 gm Q 6 hr for 3 days). For type 3
injuries a cephalosporin plus an aminoglycoside (1.5 gm/kg body weight
then 3 to 5 gm/kg body weight in divided doses) is used. Penicillin is added
for farm injuries to cover Clostridium sp.

e. Immediate debridement and irrigation, with repeat debridement and

irrigation in 24-48 hours

NOTE* The irrigant can contain either 1 gm cefazolin in 1 liter of sterile

saline, or 50,000 units of bacitracin and 1 million units of polymyxin B f.
in 1 liter of sterile saline. All
foreign debris should be excised
g. All marginal, macerated skin, and soft tissue should be debrided
h. Fluorescein (non-toxic dye) may be used to assess the viability of the soft
tissue structures
i. The wound should be kept moist and re-evaluated in 48-72 hours, with
repeated debridements, especially if soft tissue coverage is necessary
 NOTE* 10-15 mg/kg of fluorescein is injected IV and observed under UV light
after 10-20 minutes. Vascularized tissue will fluoresce yellow-green and
nonvascularized tissue will appear dark blue

j. For type 1, 2, and 3A open fractures delayed primary closure, using skin
grafts within 5-7 days
k. For type 3B and 3C open fractures, the soft tissue loss is so great that the
use of skin flaps is necessary and a delay in using them becomes apparent
because of the repeated debridements
l. External fixation should be used for all type 3 and unstable type 2 fractures

The advantages of external fixators include the ease of application without

additional trauma, allows for daily wound inspections and care, allows for
grafting procedures, accomplishes compression/reduction of the
angulation/ stabilization of the fracture without much surgical trauma

m. Internal fixation (screws, plates, pins, etc.) should be used for articular
and metaphyseal open fractures. This is done preferably within 8 hours of the

NOTE* An open fracture untreated in the initial 7-8 hours (golden period) is
generally considered to convert from a contaminated wound to an infected
wound
injury

3. Absolute indications for open reduction:

a. Irreducible fractures where function and alignment can not be obtained
otherwise
b. Displaced intra-articular fractures where incongruity will lead to
degeneration of the joint
c. Displaced epiphyseal fractures with a large potential for growth
disturbance
d. Major avulsion fractures with muscle ligament attachments
e. Nonunions that do not have the capacity to unite (pseudoarthrosis and
avascular nonunions

4. Antibiotic considerations:
a. Limiting the duration of the initial antibiotic therapy is important to
minimize the emergence of resistant nosocomial bacteria
b. Type 1 fractures are treated with Cefazolin 2 gm STAT followed by 2 gm Q
8 h for 48 to 72 hours
c. Type 2 and 3 are treated with combined therapy, using cefazolin as above,
plus an aminoglycoside (Gentamycin or Tobramycin) dosed at 1.51.7 mg per
kg on admission, followed by 3.0 to 5.0 mg per kg per day in divided doses.
The duration of therapy is 3 days unless overt infection develops
d. Administer 10 million units of Pen G if the injury was sustained on a farm,
to cover for Clostridium sp.
Soft Tissue Injuries
1. Classification:
a. Tidy wound: Surgical incision, laceration
b. Untidy wound: Crush, avulsion, abrasion
c. Wound with tissue loss: Excision, burn, ulcer, avulsion
d. Infected wound: Established (cellulitis, lymphangitis, abscess, bum, or
vasculitis) or Incipient (bum, contaminated wound, abrasion)

2. Treatment (general):
a. Tetanus prophylaxis
b. Antibiotic prophylaxis
c. H 8 P, including vascular, neurological, musculoskeletal and integumentary
status
d. Inspection of the wound under local or regional anesthesia
e. Initial gentle cleansing of the wound with a mild soap (no strong
antiseptics that can cause tissue damage)
f. X-rays, CBC, and urinalysis as necessary
g. Primary wound care: remove all foreign and devitalized material
copious flushing, atraumatic tissue handling, avoid tourniquet
h. Skin closure when appropriate

3. Treatment (specific):
a. Tidy wound: Once debrided, can be closed after appropriate skin cleansing
(skin edges may be freshened)
b. Untidy wound: Deep damage must be repaired and skin closure should be
delayed until wound demarcation has progressed to the point where viability
is reasonably assured. Secondary or delayed primary closure may be
indicated. Swelling within closed compartments may indicate the need for the
release of damaged fascia or skin
c. Wound with tissue loss: Must prevent the wound from drying out and must
cover exposed vital structures using biological dressings, porcine xenografts,
or appropriate autograft
f. Infected wound: Prior to closure the wound must be debrided and
converted to a contaminated wound, and then a clean wound (check with
C&S and colony counts: less than 105 bacteria per millimeter means
contamination)

Crush Gunshot and Lawnmower Injuries

1. General protocols:
a. Priority is given to prevention of infection especially Clostridia sp.
b. Therefore tetanus prophylaxis is given (see chapter Infectious Disease)
c. Antibiotic therapy is started after cultures are taken
d. Debridement and copious lavage under local/regional, or general
anesthesia
e. Depth and extent of the wounds carefully explored and inspection with
removal of all foreign bodies and all non-viable tissue and packed open
f. The wound is reexamined under regional/general anesthesia in 24-48
hours, and after further debridement the wound is packed open
g. The wound should not be closed before 5-7 days (check cultures and use
clinical judgement)

NOTE* The most important criterion is the clinical appearance of the wound
in the decision to close a wound. The number 105 bacteria present in the
wound is mentioned as a criteria of active infection, as it has been seen on
the board exams (this is unreliable)

h. Use xenograft as necessary to prevent further contamination

i. Use split thickness skin flap immediately on the dorsum of the foot if the
tendons are exposed without the paratenons (this is the only time immediate
coverage is utilized)
j. Rigid stabilization of fractures

Puncture Wounds

These wounds deserve special attention because they characteristically have

a benign presentation that can rapidly progress to OM if not treated
appropriately. Complications run as high as 10%. Pseudomonas is the most
common pathogen isolated

1. General protocols:
a. Tetanus prophylaxis
b. Remove all foreign material, leave wound open, do C&S
c. Start broad spectrum antibiotics
d. If no improvement in 3 days suspect a gram (-) infection
e. If bone or joint is penetrated or if wound is deep, surgical exploration
and debridement are necessary
f. If pain persists after 4 days of treatment use bone/gallium scans, sed rate,
WBC to follow patient progress

Epiphyseal Plate Injuries: Also see section: Pediatrics

(Pediatric Fractures)
1. Anatomic differences: Since the growth plate is radiolucent, acute injury
can only be inferred from widening of the growth plate or from displacement
of the adjacent bones on plain x-ray. The periosteum is stronger, thicker, and
produces callus more quickly than in adults

2. Biomechanical differences: Pediatric bone is less dense, more porous

with a smaller lamellar content than adult bone. It also will fail not only in
tension, as adult bone, but in compression as well. Hence there are certain
pediatric fracture patterns: buckle fractures, plastic deformation of bone, and
greenstick fractures

3. Physiological differences: Growth provides the basis for a greater

degree of remodeling than is possible with the adult (a bump of a malunion is
corrected by periosteal resorption; a concavity is filled out by periosteal new
bone). This is an example of Wolff's Law. Also, a fracture through the shaft of
long bone stimulates longitudinal growth (increased nutrition of the growth
cartilage), which can result in a longer bone as a result of a fracture. Because
of this, pediatric fractures can be treated more conservatively than with an
adult

4. Growth plate injuries: Problems after injury are rare, but when growth is
disturbed, the reason is from avascular necrosis of the plate, crushing or
infection of the plate, formation of a bone callus bridge between the bony
epiphysis and metaphysis, and hyperemia producing local overgrowth. There
are 2 types of growth plates, epiphyseal (those that form under pressure)
and apophyseal (those that form under traction)

5. Anatomy: The growth plate is a cartilagenous disc situated between the

epiphysis and the metaphysis. The germinal cells are attached to the
epiphysis and their blood supply is from the epiphyseal vessels. As the
germinal cells multiply, the cell population of the plate increases. The plane"
of separation in the physis is most frequently at the junction of the calcified
and uncalcified cartilage, known as the zone of transformation. With an
epiphyseal separation, most of the important germinal part of the plate
usually remains with the epiphysis. If much of the germinal layer is disturbed,
growth may be affected

6. Classification: Salter-Harris
a. Type 1: A complete separation of the growth plate at the zone of
transformation, no disruption of growth, treated with closed reduction and
immobilization for 3 weeks
b. Type 2: Separation of the growth plate with extention of the fracture line
into the metaphysis. This extension creates the 'Thurston Holland Sign'.
There is usually no growth disturbance and it is treated the same way as type
1
c. Type 3: Separation of the growth plate with extension of the fracture line
into the epiphysis so that it is intraarticular. Potential for growth disturbance
as the fracture line crosses the entire growth plate, and must not be left
displaced by ORIF
d. Type 4: A fracture from the metaphysis through the growth plate and into
the epiphysis, and can result in growth disturbance. This fracture is unstable
and requires ORIF
e. Type 5: A crush type injury usually with subsequent growth disturbance.
Treated with closed reduction (if displaced) and immobilization 3-6 weeks
NWB
f. Type 6: A scooping out of a portion of the growth plate, via some type of
projectile causing osseous and soft tissue damage. Any large fragments
of bone are reduced. Bony bridging causing growth disturbances can be a
complication here. Treat the bony bridge with resection and interposition of
fat or silicone rubber
g. Type 7: An intraarticular fracture that does not involve the physis. Very
difficult to diagnosis in the very young. Treat with immobilization if
nondisplaced and ORIF if the fragment is large and displaced (or excision of
the fragment if too small to reduce)

7. Apophyseal Injuries: Either an inflammatory process secondary to

traction vs. a Salter-Harris fracture type 1
a. Calcaneal apophysitis: Involves reduction of stress to the apophysis, (heel
lifts, orthoses, and local anti-inflammatory measures) with severe cases
requiring BK casting. Later calf muscle stretching is helpful
b. Tuberosity of 5th metatarsal: Injury from direct impact or forced inversion
of the foot. If the tuberosity is displaced, closed reduction with immobilization
for 3 weeks

8. Treatment: Always advise of the long term sequelae of the fracture

9. Internal fixation devices: Smooth K-wires should be employed and

should be buried to avoid infection of the plate which can cause an autolysis
of the plate. Never use threaded pins or screws across a growth plate

10. Specific ankle fractures:

a. Tillaux fracture: A Salter-Harris type 3 of the tibia involving the lateral
aspect of the tibia. This fracture is unique to the age group of 12-13 year
olds. Treatment is ORIF if displaced or unstable, and closed reduction with
immobilization for 6 weeks if stable and in anatomic alignment
b. Triplane: A Salter-Harris type 4 fracture of the tibia. Diagnosis is made by
visualizing the fracture on at least 2 views. An unstable fracture, requiring
ORIF

Digital Fractures and Dislocations

1. Fractures of the hallux:
a. Communited fracture of the distal phalangeal tuft i. Mechanism: Direct
trauma
ii. Treatment:
 Local anesthesia and prep
 Avulse the nail atraumatically
If closed fracture reduce any gross prominences, replace
nail plate as part of compression dressing, patient
instructed to check vascular status frequently, Reece© shoe,
ice packs
If open fracture, tetanus prophylaxis, IV antibiotics, debride
necrotic tissue and loose exposed bone leaving no
prominences, irrigate copiously, open drainage, Reece©
shoe, and follow appropriately

b. Intra-articular dorsal avulsion fracture of the distal phalangeal base:

i. Mechanism: Forced plantarflexion of the hallux IPJ (stubbing) resulting in
avulsion of the EHL insertion
ii. Treatment of displaced fracture (most common): ORIF followed by
Reece© shoe
iii. Treatment of nondisplaced (uncommon): Closed reduction with slipper
cast, or BK cast (with or without percutaneous pinning)

c. Hallux IPJ intra-articular fractures of the distal or proximal phalanx:

i. Mechanism: Transverse plane torque (stubbing) resulting in a push-off
fracture of the medial or lateral condyle of either the distal phalangeal base
or the head of the proximal phalanx
ii. Treatment of displaced fracture (most common): First attempt closed
reduction, and if successful pad 1st interspace with felt or cotton and tape
to the 2nd toe. If closed reduction fails, ORIF larger fragments and excise
smaller fragments. Reese© shoe for 4-6 weeks

d. Proximal phalanx shaft fracture:

i. Mechanism: Direct or indirect trauma resulting in a transverse oblique
fracture
ii. Treatment of displaced fracture: Closed reduction (with or without
percutaneous pinning), splinting, Reese© shoe
iii. Treatment of nondisplaced fracture: Buddy splinting to 2nd toe and
Reece© shoe

e. First MPJ intra-articular condylar fractures of the proximal phalanx:

i. Mechanism: Transverse plane torque resulting in avulsion of the insertion of
the medial or lateral intrinsics
ii. Treatment of displaced fracture: ORIF followed by Reece© shoe for 6
weeks
(smaller fragments maybe excised and the intrinsics reinserted)
iii. Treatment of nondisplaced: If no change in hallux abductus, then buddy
splint to the 2nd toe, if the hallux abductus changed, consider surgical repair.

2. Fractures of the lesser toes:

a. Fractures of the distal and intermediate phalanges: Rare unless crush type

b. Non-articular proximal phalangeal fractures:

i. Mechanism: Direct or indirect trauma (stubbing most common) resulting in
a transverse, oblique or spiral fracture appearing sub-capitally, mid-shaft, or
at the base or epiphysis
ii. Treatment of displaced fracture (less common): Closed reduction followed
by buddy splinting, or ORIF for gross reduction failures
iii. Treatment of nondisplaced fractures (common): Buddy splinting

c. PIPJ intra-articular proximal phalangeal fractures:

i. Mechanism: Usually a stubbing injury with axial forces resulting in an
oblique push off or comminuted fracture
ii. Treatment of displaced and non-displaced fractures: Closed reduction
aimed at restoring alignment, followed by buddy splinting. If failure then
primary arthroplasty.
d. MPJ intra-articular proximal phalangeal fractures: i. Mechanism: Usually a
stubbing injury
ii. Treatment of displaced fracture: ORIF depending on the size of the
fragment and comminution
iii. Treatment of nondisplaced fracture: Reece© shoe for 6 weeks

1st MPJ Trauma

1. Turf Toe:
a. Mechanism: Hyperdorsiflexion, hyperplantarflexion, hyperadduction, or
hyperabduction stress resulting in a - 1st MTPJ sprain without alignment
changes
b. X-ray evaluation: Rule out dislocation, osteochondral injury, or sesamoid
fracture (take MO, LO, Lateral, AP, plantar axial)
c. Treatment: Ice, rest, Reece© shoe, modify the athletic shoe.

2. First MTPJ dislocation:

a. Mechanism: Hyperdorsiflexion
b. X-ray evaluation: Rule out osteochondral fracture and sesamoid fracture
(take AP, lateral, plantar axial)
c. Classification (Jahss):
i. Type 1:
 Joint capsule torn transversely under the metatarsal neck
 Proximal phalanx, plantar capsule, and sesamoids dislocated dorsally on
the first metatarsal head
 First metatarsal protrudes through the capsule, depressed plantarly by the
retrograde forces of the hallux
 Hallux IPJ is flexed
 Usually not reducible by closed technique
ii. Type 2A:
 Same as type 1 except that rather than the entire plantar capsule and
sesamoid apparatus dislocated dorsally, the intersesamoidal ligament
ruptures and the sesamoids sublux to each side of the metatarsal head
 Easier to reduce than type 1
iii. Type 2B:
 Same as type 2A except sesamoid fractures occur instead of the
intermetatarsal ligament rupturing
 Easier to reduce than type 1

3. Treatment:
a. Type 1: Open reduction
 NOTE* Closed reduction can be tried under anesthesia as follows: traction
and increase dorsiflexion, then push the proximal phalanx into contact
with the metatarsal head, then push (don't pull) the proximal phalanx
into the reduced position, maintaining contact with the metatarsal head
b. Type 2A: Closed reduction followed by Reece shoe or BK walking cast
c. Type 2B: Closed reduction followed by Reece shoe or BK NWB cast
(sesamoid may have to be excised at a later date prn symptoms) or open
reduction with excision of the fractured sesamoid

3. Sesamoid fractures:
a. Mechanism: Fall from a height, repetitive direct trauma (dancing), and
repetitive indirect trauma (traction of the intrinsics)
b. Presentation:
i. Sesamoid involved: Tibial more than fibular (tibial is larger), rarely both
injuried, almost never bilateral
ii. Clinical presentation: Pain on direct palpation and pain on hallux
dorsiflexion
iii. Differential diagnosis of pain in the sesamoid area: Joplins neuroma,
sesamoiditis, osteochondritis dissecans, osteochondrosis, ruptured bipartite
sesamoid, turf toe, DJD/eroded crista, hypertrophic sesamoid, and fractured
sesamoid
c. X-ray evaluation: Order bilateral AP, lateral and plantar axial (MO for tibial
and LO for fibular sesamoid) 75% of bipartite sesamoids are unilateral. Bone
scan if in doubt
d. Normal sesamoids:
 Ossification appears at 8-10 years
 Bipartite sesamoids more common in tibial than in fibular
 Sesamoids may be multipartite

Nail Bed Trauma

1. Classification (S. Malay):
a. Primary onycholysis:
i. A separation of the nail plate from the bed
ii. Partial avulsions cause posterior nail fold friction injury, subungual
bleeding, and digital sepsis especially in compromised patients
iii. Removal of the nail plate, antisepsis, and antibiotics (prn)
iv. No adverse sequelae
b. Subungual hematoma:
i. Blood clot under the nail plate
ii. Must check for fractures of the plate from impaction
iii. Treat like open fractures, the nail plate must be removed from the tissue
to decompress the area
iv. X-rays should be taken to r/o fracture
v. The nail plate can be removed if the hematoma comprises more than 25%
of the nail plate
vi. Drill holes can be made if feasible
c. Simple nail. bed laceration:
i. Tetanus coverage
ii. Systemic antibiotics
iii. Surgical cleansing and lavage (no epinephrine utilized in seriously
traumatized digits)
iv. If you are avulsing a salvagable nail plate, remove it in one piece and save
for subsequent splinting
v. Nail bed injuries are usually repaired with a 6-0 absorbable suture on an
atraumatic needle
vi. The root and the bed must be accurately aligned on the toe
vii. Periosteal irregularities must be debrided
viii. Reusing the nail plate involves scraping all soft tissue from the nail plate,
drilling holes through the body, then soaked in Betadine until the bed repair
is accomplished, and then the nail plate is replaced on the nail bed and
anchored with Steri-strips®
ix. Avulsive lacerations of the bed are treated with intermediate thickness
skin graft
d. Complex nail bed laceration: As above plus
i. If a major segment of the proximal nail fold over the matrix is avulsed with
a skin defect, rotational flaps are utilized

e. Nail bed laceration with phalangeal fracture: As above plus

i. Subungual fractures must be accurately reduced
ii. Remove all bone spicules and nail fragments

2. Complications:
a. Split nail
b. Adhesions of the skin fold to the nail root
c. Chronic ingrown nails
d. Widening of the nail
e. Narrowing of the nail
f. Protruding or non-adherent nail
g. Malaligned nail

Toe Tip Injuries With Tissue Loss

These injuries are secondary to crush forces, and should be considered and
treated like open fractures. Tissue loss increases the likelihood of poor
cosmetic result
1. Classification (Rosenthal): According to the level and direction of
tissue
loss
a. Level of nail bed tissue loss
i. Zone 1: distal to bony phalanx
ii. Zone 2: distal to the lunula
iii. Zone 3: proximal to the distal end of the lunula
b. Direction of tissue loss
i. Dorsal oblique
ii. Transverse guillotine
iii. Plantar oblique
iv. Tibial or fibular axial
v. Central or gouging

2. Treatment:
a. Zone 1:
i. Flush, debridment and appropriate wound closure (usually secondary
intention)
ii. Occasionally skin graft large defects (split thickness less durable, full
thickness more durable)
b. Zone 2:
i. Reduction of bone with debridement of necrotic tissue
ii. Coverage of nail bed and phalanx tip usually achieved by local
neurovascular advancement flap
c. Zone 3:
i. Not suitable to initial treatment in ER or office
ii. Usually complete nail bed loss
iii. OR debridement of necrotic tissue and matrix
iv. Delayed revision of the digit
v. Attempt to maintain tendon function
v. Terminal Symes may be necessary

Dog and Cat Bites

Both dog and cat bites are susceptible to infection because of direct
inoculation of bacteria from the animals into the bite wound. In addition to
tearing of tissue, dogs can also cause a crushing injury. Most patients with
bite wounds harbor bacteria, so that aggressive therapy should be
undertaken initially.
1. Pasturella multocida (gram negative bacillus) is present in 50% of cat bites
and 25% of dog bites Other organisms should also be considered:
Pseudomonas, Staphylococcus, and beta streptococcus

2. Some authors believe that the culture of the bite wound offers little
information because of the multiplicity of organisms found and the absence
of an established infection

3. X-rays of the involved area should be obtained

4. Thorough and aggressive debridement and irrigation (manual lavage using

Ringer's lactate or dilute Betadine®)

5. Elevation and immobilization with the ankle at 900, and after 72 hours
improvement occurs, then initiate ROM and adjunctive PT

6. Leave any potentially contaminated wound open for 4-6 days, and at that
time, if the wound is clean, without redness or swelling, it is reasonably safe
to perform primary closure

7. The use of prophylactic antibiotics is still controversial

a. For cat bites, dicloxicillin, penicillin, or Augmentin® is recommended
(erythromycin in penicillin allergy)
b. For dog bites dicloxicillin, cephalexin, or Augmentin® is adequate (one
study showed a 95% cure of infected dog bites with cephadrine)

8. Rabies is of concern with any animal bite. See Chapter 6, Infectious

Disease, section on Rabies