Fractures of the clavicle are one of the most common fractures in orthopedics. They typically occur following a fall onto the shoulder and the majority of clavicle fractures occur in the middle third of the clavicle. Since the bone is subcutaneous, the fracture is often evident on inspection. Most clavicle fractures can be treated nonoperatively with a sling, range of motion exercises, and gradual return to normal activities. Fractures that are significantly displaced and shortened, or that penetrate the skin, are treated with open reduction internal fixation, typically with plate and screw fixation.
Distal clavicle fractures are less common and may occur along with coracoclavicular ligament ruptures. These injuries can be more troublesome and are at risk for nonunion if the bone ends are not in contact. If there is displacement of the fracture, surgical management is often recommended.
Acromioclavicular (AC) joint injuries occur from either a fall directly onto the shoulder or onto an outstretched hand and can result in tears of the acromioclavicular and coracoclavicular ligaments. A step-off, or separation, of the AC joint may be apparent on radiographs. The majority of these injuries can be treated with a sling and gentle range of motion. Injuries resulting in severe displacement of the clavicle may require open reduction and surgical repair.
The sternoclavicular (SC) joint is the only articulation between the upper extremity and the axial skeleton, and injuries to this joint are rare. Anterior dislocations occur more frequently and closed reduction can be attempted, followed by sling immobilization. Posterior SC joint dislocations can be dangerous, resulting in pulmonary or neurovascular compromise, and closed reduction under general anesthesia is recommended with a vascular surgeon present in case of vascular injury.
Fractures of the scapula often result from significant trauma and can be associated with injuries to the head, lungs, ribs, and spine. Most scapula fractures are treated nonoperatively with the exception of fractures to the glenoid. As with most intra-articular fractures, displacement of the articular surface of the glenoid is an indication for open reduction and internal fixation.
The shoulder is one of the most commonly dislocated joints and most dislocations are anterior. They are often associated with injuries to the labrum (Bankart lesion), impression fractures of the humeral head (Hill-Sachs lesion), and rotator cuff tears. Posterior dislocations are associated with seizures or electric shock. Adequate radiographs are required to diagnose a shoulder dislocation, with the axillary view being the most critical. If proper X-rays are not performed then dislocations can be missed and can result in significant debilitation of the shoulder. Dislocation of the shoulders can be managed with closed reduction followed by a short period of sling immobilization.
Proximal Humerus Fractures
Proximal humerus fractures occur most frequently in elderly patients following a fall onto the shoulder, though they can also occur following high-energy trauma. They have historically been classified by the number of fracture fragments using the Neer classification, which divides the proximal humerus into 4 parts: the humeral head, greater and lesser tuberosities, and the humeral shaft. Treatment is determined by the displacement of the fracture fragments, the amount of angulation of the fracture, and the amount of comminution (which means multiple fracture fragments). If there is suspicion of an intra-articular fracture, a computerized tomography (CT) scan is often indicated. The majority of proximal humerus fractures is minimally displaced and can be treated with sling immobilization, followed by early shoulder motion and pendulum exercises. Displaced fractures and fractures involving the humeral head are at increased risk for osteonecrosis and therefore surgery is often recommended. If there is adequate bone stock and the fracture can be successfully reduced, open reduction internal fixation with plate and screw fixation is the treatment of choice. Older patients with osteoporotic bone and comminuted fractures are typically treated with a prosthetic replacement of the humeral head, or a hemiarthroplasty.
Humeral shaft fractures occur from direct trauma to the arm or from a fall on an outstretched arm, especially in elderly patients. The radial nerve spirals around the humeral shaft and is at risk for injury, therefore a careful neurovascular exam is important. Most radial nerve injuries are neuropraxias, or stretching of the nerve, and function typically returns in 3 to 4 months. The majority of humeral shaft fractures can heal with nonsurgical management if they are within an acceptable degree of angulation. They are treated with a coaptation splint or functional bracing, which consists of a plastic clamshell brace with Velcro straps. Close follow-up with serial radiographs is important to verify healing of the fracture, and gentle motion exercises are begun within 1 to 2 weeks. Fractures with significant angulation are most commonly treated with open reduction and plate fixation, with care to protect the radial nerve as it often lies close to the fracture site. Intramedullary nailing can also be performed, though it carries the risk of shoulder pain from the nail insertion.
Fractures of the distal humerus result from falls onto the elbow or onto an outstretched arm. Supracondylar fractures are most common, occurring above the elbow joint and do not involve the articular surface. Those minimally displaced can be treated with a posterior long arm splint, with the elbow typically flexed to 90 degrees. Fractures involving the articular surface are treated with plate fixation, and depending on the fracture pattern may require 2 plates, one placed medially and one posterolaterally. As with other intra-articular fractures, the goals of treatment are anatomic reduction of the joint surface with stable fixation, restoration of the anatomic alignment of the joint, and early range of motion. Severely comminuted fractures, especially in the elderly, may be treated with a total elbow replacement, which involves replacing the joint surfaces of the distal humerus, proximal ulna, and radial head with prosthetic components. Fractures about the elbow are notorious for developing stiffness and therefore early motion of the elbow is paramount to a successful outcome. Range of motion should be started as soon as the patient can tolerate therapy.
Dislocations of the elbow are common and typically occur posteriorly after a fall on an outstretched hand. A dislocation results in injury to the joint capsule and rupture of the lateral collateral ligament, though the medial collateral ligament can also be involved. They may even be associated with a fracture of the radial head, coronoid, or the epicondyles of the humerus. Simple elbow dislocations should be urgently reduced with the patient under sedation and treated briefly in a posterior long arm splint. Stiffness of the elbow is a common complication following elbow dislocations and therefore short-term immobilization (about 7–10 days) and early range of motion is recommended.
Dislocations associated with fractures may be treated surgically if there is any instability of the elbow joint. A severe injury, known as the “Terrible Triad,” includes an elbow dislocation, a radial head fracture, and a coronoid fracture. These are unstable injuries and require repair of the torn lateral collateral ligament (LCL), fixation or replacement of the radial head, and possible fixation of the coronoid depending on the size of the fracture fragment.
Most fractures of the radial head can be treated nonoperatively, simply with a sling for 1 to 2 days followed by motion exercises. However, if there is a displaced fracture or if the fracture blocks pronation or supination of the forearm, then surgery is recommended. If the fracture can be well reduced, it is fixed with 1 or 2 screws. If the radial head is fractured into multiple pieces, the treatment of choice is a radial head replacement with a metallic implant. Excision of the radial head can also be performed, but this is reserved for elderly patients with limited demands and may contribute to elbow instability or wrist symptoms over time.
Olecranon fractures occur following a fall directly onto a flexed elbow. Nondisplaced fractures are treated with a splint in 45 to 90 degrees of flexion for a short time followed by range of motion exercises to prevent stiffness. Because the triceps inserts on the olecranon, the pull of the muscle often displaces the fracture, causing a loss of the ability to actively extend the elbow, and therefore should be fixed surgically. Simple transverse fractures can be fixed with a tension band construct, which consists of cerclage wiring passed through the ulna and wrapped in a figure-of-8 fashion around 2 pins placed proximally into the olecranon, creating a compressive force across the fracture to promote healing. Comminuted fractures are treated with plate and screw fixation. Because of the subcutaneous location of the olecranon, this hardware can be irritating to the patient and may need to be removed after the fracture has healed.
Forearm fractures are common injuries that result from high energy trauma or from falls onto an outstretched arm. Both bone forearm fractures often require surgery with plate and screw fixation. The radius has a bow and rotates around the straight ulna for proper pronation and supination of the forearm, and therefore this anatomic relationship needs to be restored to maintain function. An isolated fracture of the ulna shaft, or a “nightstick fracture,” occurs from a direct blow to the side of the forearm. These can usually be treated in a cast, though fractures that are angulated or displaced can be treated with open reduction and plate fixation. A Monteggia fracture is an ulna shaft fracture along with a radial head dislocation. The radial head dislocation may be missed without radiographs of the elbow and therefore a fracture of the ulna should raise suspicion of this injury. These injuries require surgery to fix the ulna fracture with plate and screw fixation and to reduce radial head. A Galeazzi fracture is a radial shaft fracture with disruption of the distal radioulnar joint (DRUJ) at the wrist. After the radius is fixed with plate and screw fixation, the DRUJ is assessed for stability and may need wires placed across the joint temporarily.
Pelvic fractures are indicative of high energy trauma and are associated with head, chest, abdominal, and urogenital injuries. Hemorrhage from pelvic trauma can be life threatening and patients can present with hemodynamic instability, requiring significant fluid resuscitation and blood transfusions. The bleeding that occurs is often due to injury to the venous plexus in the posterior pelvis, though it can also be due to a large vessel injury such as a gluteal artery. Immediate resuscitation is critical and these patients may require surgical exploration or interventional radiology embolization to stop the bleeding. An important first-line treatment in the emergency room is the application of a pelvic binder or sheet that is wrapped tightly around the pelvis to help control bleeding. An external fixator may also be placed in the operating room. Other associated injuries are bladder and urethral injuries that manifest with bleeding from the urethral meatus or blood in the catheter and need to be assessed with a retrograde urethrogram.
The pelvis is a ring structure made up of the sacrum and the two innominate bones that are held together by strong ligaments. Because it is a ring, displacement can only occur if the ring is disrupted in two places. This may occur either from fractures of the bones or tears of the ligaments. There are three main fracture patterns that occur from trauma to the pelvis. An anteroposterior force to the pelvis causes an “open book” injury pattern in which the pelvis springs open, hinged on the intact posterior ligaments with widening of the pubic symphysis. A lateral compression pattern results from a crush injury that causes fractures to the ileum, sacrum, and pubic rami. Vertical shear injuries are very unstable since they result from disruption of the strong posterior pelvic ligaments and are associated with significant blood loss and visceral injuries. Fractures of the sacrum may be difficult to see on x-ray and therefore CT scans are often needed to visualize the fracture pattern. The sacral nerves pass through foramen in the sacrum and therefore fractures that are close to this foramen can result in nerve injuries.
Treatment of pelvic fractures depends on the fracture pattern. Stable, minimally displaced fractures can be treated nonoperatively with protected weight bearing. Open book injuries in which the pubic symphysis is widened and the posterior pelvic ligaments are also injured need to be fixed surgically, which is typically performed with screws placed percutaneously through the ileum into sacrum to stabilize the pelvis posteriorly and a plate and screws over the pubic symphysis to stabilize it anteriorly. Displaced sacral fractures and iliac wing fractures are treated with screws or plates, while pubic rami fractures can usually be managed nonoperatively. While most pelvic fractures are caused by high energy trauma, elderly patients with osteoporotic bone can also suffer pelvic fractures after a fall, usually fracturing the pubic rami. Since these are stable injuries, they can be managed nonoperatively with protected weight bearing.
The acetabulum forms the socket of the hip joint, and fractures occur when the femoral head is driven into it in the setting of high energy trauma. CT scans are important to visualize the fracture pattern. These fractures often require surgery in order to restore a congruent, stable acetabulum, because incongruity of the hip can lead to early degenerative changes and osteoarthritis. These are best treated in the hands of experienced orthopedic trauma surgeons.
Hip dislocations almost always result from high energy trauma and most commonly occur posteriorly. They can cause injury to the sciatic nerve, which runs directly posterior to the hip joint, and may be associated with a fracture of the acetabulum or femoral head. Hip dislocations need to be emergently reduced because of the risk of osteonecrosis of the femoral head when reduction is delayed. They can usually be reduced in the emergency room with adequate sedation and muscle relaxation, but sometimes patients need general anesthesia to aid in the reduction. If this is unsuccessful, or if a fracture fragment gets trapped inside the joint, then an open reduction is performed. Hip dislocations that are associated with a femoral head fracture are at increased risk for osteonecrosis of the femoral head and posttraumatic osteoarthritis.
Hip fractures are an extremely common injury seen in orthopedics and are associated with significant morbidity and mortality. They most often occur in elderly patients after grounds level falls, are much more common in women than men, and occur more commonly in patients with osteoporosis. Patients who suffer hip fractures are at increased risk for many complications, including deep vein thrombosis, pulmonary embolism, pneumonia, deconditioning, pressure sores, and even death, as the mortality rate in the first year following a hip fracture is around 25%. One of the most important reasons for performing surgery is to prevent these complications, and getting patients out of bed and walking as soon as possible diminishes their risk. Therefore, surgery is almost always the treatment of choice for hip fractures, and the type of surgery performed is determined by the anatomic location of the fracture and the fracture pattern. Surgery should be performed as soon as possible, typically within 24 to 48 hours; however, since many of these patients suffer other comorbidities, they must be properly medically optimized before surgery. The goals of surgery are to minimize pain, restore hip function, and allow early mobilization, the importance of which cannot be overemphasized. The functional outcome for patients following a hip fracture is largely based on their level of mobility and independence before their injury. Many patients become less independent, may require assistive devices to help them walk, and some may require a long-term nursing or rehabilitation facility.
Femoral neck fractures occur with the capsule of the hip joint. The blood supply to the femoral neck and head comes from branches of the medial and lateral femoral circumflex arteries, which run along the femoral neck, and therefore fractures in this area put the vascular supply at risk and can lead to osteonecrosis. Femoral neck fractures that are nondisplaced have a low risk of disruption of blood flow and therefore can be treated with in situ internal fixation. Three cancellous screws are placed through a small incision over the lateral proximal femur, directed up through the femoral neck and into the femoral head. Patients can usually begin protected weight bearing immediately after surgery. Displaced femoral neck fractures will likely disrupt the blood supply and therefore need to be treated with a prosthetic replacement. Most commonly a hemiarthroplasty is performed in which the femoral neck and head are replaced with a metal stem into the femoral canal and a metal head (Fig. 43-5A). Patients who have severe osteoarthritis of the hip joint and had significant arthritic hip pain before their fracture may receive a total hip replacement, in which the acetabulum is also replaced with a prosthesis, typically a plastic cup inside a metal shell (Fig. 43-5B). Patients can begin weight bearing immediately after surgery.
A. Failed hip hemiarthroplasty (periprosthetic fracture). B. Periprosthetic fracture repaired with modular femoral component.
Intertrochanteric Hip Fractures. Intertrochanteric hip fractures occur between the greater and lesser trochanters of the proximal femur. Because the blood supply to this area is abundant, osteonecrosis is uncommon and therefore these fractures can be fixed with internal fixation. Displaced fractures need to be realigned, and this involves placing the patient on a fracture table where traction and rotation can be applied to the affected leg to reduce the fracture. There are two devices that can be used. A sliding hip screw includes a large screw placed from the lateral cortex of the proximal femur across the fracture and into the femoral neck and head, followed by a side plate along with lateral cortex of the femur, which is then fixed to the shaft with screws. A cephalomedullary nail includes a nail placed down the medullary canal from the piriformis fossa and a large screw that engages the nail as it is passed from the lateral cortex up into the neck and head. Both devices form stable constructs (though the cephalomedullary nail is preferred for certain fracture patterns) and allow protected weight bearing postoperatively.
Subtrochanteric Hip Fractures. Subtrochanteric hip fractures occur in the proximal femoral shaft just distal to the lesser trochanter in an area of high biomechanical stresses. While they can occur in elderly patients after a fall, they are also seen in high energy trauma. Because of the forces of muscles attached to the fractured segments, they tend to be significantly displaced and it can be difficult to reduce these fractures. They are most often treated with a long cephalomedullary nail that includes a screw distally to lock the nail in place and prevent rotation of the femur. Fractures that cannot be reduced closed on a fracture table or that are severely comminuted require open reduction followed by a cephalomedullary nail or by a plate and screws that is placed over the lateral cortex of the femoral shaft. In most cases, protected weight bearing can begin soon after surgery.
Fractures of the femoral shaft are caused by high energy trauma and may be associated with other severe injuries. Long bone fractures, such as femoral shaft fractures, put these patients are risk for complications such as thromboembolic events and acute respiratory distress syndrome (ARDS), and therefore it is important to fix these quickly, typically within 24 hours. They are most commonly fixed with an intramedullary nail that can be placed antegrade (from the piriformis fossa or greater trochanter down the canal) or retrograde (through an incision into the knee joint and up the canal), with screws placed through proximal and distal holes to lock the nail in place, creating a stable fixation to allow weight bearing. Trauma patients who are hemodynamically unstable or who have other life-threatening injuries are treated temporarily with an external fixator until they can safely undergo surgery.
Distal femur fractures are the result of a fall from a height or from high-energy trauma. They can also occur in elderly patients with osteoporotic bone after a fall onto the knee. While nondisplaced fractures in the elderly may be treated nonoperatively with a hinged knee brace and motion exercises, most require surgery. These fractures can involve the articular surface of the knee joint, so anatomic reduction of the joint surface is crucial. They are fixed with plates and screws placed over the medial or lateral cortex, depending on the fracture pattern, and early knee range of motion is encouraged to prevent stiffness. These intra-articular fractures require the patient to be nonweight bearing until the fracture shows signs of healing.
Dislocation of the knee is a rare but devastating injury that can be limb-threatening. When the knee dislocates, the anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) are torn, and various degrees of injury occur to the LCL, medial collateral ligament (MCL), posterolateral corner, joint capsule, and menisci. The danger however is due to the close proximity of the popliteal artery that runs directly behind the knee, which may kink or suffer a tear of the intimal wall when the knee dislocates. A neurovascular exam is extremely important, followed by immediate reduction of the knee and repeat exam of the pulses. If there is evidence of diminished or absent pulses, an angiogram must be performed, and vascular surgery may need to perform emergent vascular repair. With regard to the ligamentous injuries, an MRI will identify what structures have been torn. Because a dislocation causes so much damage to the knee, multiligamentous reconstruction is recommended in order to stabilize the knee joint. Stiffness and instability of the knee are common complications after this injury.
Patella/Extensor Mechanism Injuries
The extensor mechanism is comprised of the quadriceps tendon, the patella, and the patella ligament and functions to extend the knee. Injuries can result after a fall directly onto the knee or from forcible contraction of the quadriceps. It is important to examine the knee for the ability to actively extend the knee, since quadriceps tendon ruptures, patella fractures, or patella ligament ruptures can result in a loss of active knee extension, requiring surgery. Nondisplaced patella fractures can be treated nonoperatively with a cast or knee immobilizer, holding the knee in full extension, and weight bearing is permitted. Displaced or comminuted fractures require surgery with either tension band wiring or screws. Acute osteochondral fractures can be managed with internal fixation (Fig. 43-6A and B). Quadriceps tendon and patella ligament ruptures with loss of active knee extension are treated with suture repair. After surgery, the knee is held in extension and knee flexion is slowly increased over several weeks using a hinged knee brace.
A. Osteochondral Patella Fracture. B. Internal fixation of osteochondralpatellar fracture.
Patella dislocations are common injuries that occur when the femur is forcibly internally rotated on an externally rotated tibia while the foot is planted on the ground. They typically dislocate laterally and often relocate spontaneously. Patients present with a significant knee effusion and on physical exam may elicit a positive apprehension test, in which a lateral force to the patella elicits pain and the sensation of an impending dislocation. Dislocated patellas can be reduced by extending the knee and manual reduction, and are treated with temporary knee immobilization. There is a high risk for recurrent dislocations, which may require surgical intervention. Osteochondral injuries to the trochlear groove and patella may be managed with the Draenert technique of autologous osteochondral transplant (Fig. 43-7A and B).
A. Knee traumatic articular lesion (trochlear groove). B. Lesion repaired with Draenert technique (autologous osteochondral transplant).
The tibial plateau is comprised of the articular surfaces and underlying cancellous bone of the medial and lateral plateaus of the proximal tibia. Fractures of the plateau result from axial loads sustained in falls from a height or high energy trauma, and are often associated with injuries to the menisci and cartilage of the knee. Fractures can involve the medial, lateral, or both plateaus with significant comminution, angulation, and depression, creating a challenging injury to fix. A CT scan is important to visualize the intra-articular involvement of the fracture. Minimally displaced fractures may be treated nonoperatively with strict nonweight bearing until the fracture heals. Fractures associated with displaced articular fragments require surgery in order to restore the smooth contour of the articular surface. They are treated with plates and screws placed medially, laterally, or both. Since there is often a depression of the cancellous bone, bone graft or bone substitutes may be needed to buttress the articular surface and restore the anatomic alignment of the tibia. Patients are kept strictly nonweight bearing for several weeks until the fracture begins to heal, though early range of motion is encouraged. Repair of ligament or meniscus injuries may also be indicated at the time of surgery. Knee stiffness and osteoarthritis are common complications of these injuries.
Tibial shaft fractures are the most common long bone fractures and they occur following high energy trauma, direct blows, and severe twisting injuries. Trauma and direct blows to the tibia result in transverse or comminuted fracture patterns, while torsional injuries cause spiral fractures. Fractures with minimal angulation can be treated with reduction and casting, followed by transition to a functional brace and slow return to weight bearing, and may need to be immobilized for several months since these fractures can be slow to heal. Most tibial shaft fractures, especially comminuted and angulated fractures, are treated with an intramedullary nail placed down the tibial canal, with interlocking screws placed proximally and distally, and weight bearing can begin soon after surgery. Plate and screw fixation can also be used, however since the tibia is subcutaneous, hardware placed along the shaft can increase the risk of wound breakdown, and therefore intramedullary nailing is the preferred treatment. Fibula shaft fractures often occur along with tibial shaft fractures, though they usually heal well without surgery.
Tibial Plafond (Pilon) Fractures
The tibial plafond is the distal tibial articular surface of the ankle joint. Pilon fractures are typically high energy injuries from axial compression or a shear force. These injuries can cause significant soft tissue injury, severely comminuted intra-articular fragments, and wound healing problems, making these fractures very difficult to treat. Due to the soft tissue injury, these fractures are initially treated with external fixation until the swelling subsides, which may take several days to weeks. The goals of surgery are to restore the articular surface, fix the fibula in order to maintain and establish anatomic length, bone graft any cancellous bone defects, and stabilize the distal tibia with plate and screw fixation. Patients are kept nonweight bearing for many weeks until the fracture heals. Despite best efforts, patients may suffer from ankle pain and stiffness, arthritis, wound healing problems, infection, nonunion, and some patients eventually need ankle fusion in the future.
The ankle joint is a complex hinge joint comprised of the distal tibial plafond, medial malleolus, and lateral malleolus and their articulation with the talus. Several ligaments also contribute to the stability of the ankle joint, including the deltoid ligament medially, the syndesmotic ligaments between the tibia and fibula, and the anterior talofibular, posterior talofibular, and calcaneofibular ligaments laterally. Dislocations of the ankle joint result from a severe twisting injury and often occur with fractures. At times, dislocations can place significant pressure on the overlying skin and can cause neurovascular compromise, therefore prompt reduction is extremely important followed by splinting.
Ankle fractures are very common and result from a twisting injury to the ankle. The patterns of ankle fractures depend on the direction of force and the position of the foot and ankle at the time of injury. The goals of treating ankle fractures are to restore the anatomy of the ankle joint and to restore the length and rotation of the fibula. Initial treatment includes closed reduction and placement of a well-padded splint in order to protect the skin. Swelling can be a significant problem so elevation of the foot is encouraged. If surgery is to be performed, it is usually delayed 1 to 2 weeks until the swelling decreases to limit the risk of wound healing problems.
Lateral Malleolus Fractures
Isolated fractures of the lateral malleolus require anatomic reduction of the fracture in order to restore normal ankle joint congruity. The talus can sublux laterally following lateral malleolus fractures, and even 1 millimeter of talar shift decreases the surface contact between the talus and the tibia by 40%, increasing the risk of developing arthritis. Closed reduction and casting can be successful, however if the fracture cannot be adequately reduced, then open reduction internal fixation of the fibula is done with plate and screw fixation.
Medial Malleolar Fractures
An isolated fracture of the medial malleolus is usually an avulsion-type injury. Minimally displaced fractures can be treated with a cast or walking boot, while displaced fractures are fixed with screws placed up through the tip of the malleolus.
Fractures to both the medial and lateral malleoli often require surgery. These injuries are more unstable and the talus will often sublux or completely dislocate laterally. They are treated by reducing and fixing both malleoli during surgery. Occasionally, the posterior articular surface of the distal tibia, or posterior malleolus, can be fractured as well, resulting in a trimalleolar ankle fracture. Often it is a small fragment and does not need to be fixed, however if it involves >25% of the articular surface it should be fixed with screws placed either anteriorly or posteriorly.
The syndesmosis is comprised of several ligaments between the distal tibia and fibula that provide stability to the ankle joint by resisting axial, rotational, and translational forces. The syndesmosis can be disrupted at the time of ankle fractures and requires special attention. Widening of the space between the distal tibia and fibula after fixing the fractures is indicative of a syndesmosis injury and it is treated with 1 or 2 screws placed laterally from the fibula into the tibia, parallel to the ankle joint. Patients are kept non-weight bearing for several weeks. The screws are often removed after 12 weeks, though they can be left in place and are typically asymptomatic.
Calcaneal fractures occur following a fall from a height and are often associated with other injuries, including lumbar spine fractures. These injuries are often intra-articular and can result in collapse of weight-bearing posterior facet of the calcaneous. CT scans are useful to better visualize the fracture pattern. Most fractures can be treated nonoperatively in a well-padded splint and patients are kept nonweight bearing for up to 12 weeks. Displaced intraarticular fractures can be treated surgically once the swelling subsides with lag screws or with a thin plate and screw fixation. Despite adequate treatment, calcaneal fractures can be debilitating injuries, leading to significant heel pain and arthritis.
Fractures of the talus commonly result from forced dorsiflexion of the ankle, causing the talar neck to impact on the anterior distal tibia. The blood supply to the talus can be jeopardized after a fracture and may lead to osteonecrosis, which is an unfortunately common complication following talus fractures. Nondisplaced fractures are treated with a cast and have a 15% risk of osteonecrosis, while displaced fractures are often treated surgically with screw fixation. There is a high risk of osteonecrosis, ranging from 30% to 100%, and a high risk of arthritis.
The tarsal bones, including the navicular, the cuboid, and the three cuneiform bones, link the hind foot to the metatarsals and provide mechanical stability to the arch of the foot. Isolated fractures to these bones are rare and are often treated nonoperatively with a cast or boot. The Lisfranc ligament, which connects the 2nd metatarsal head to the medial cuneiform, is an important stabilizer of the midfoot. Lisfranc injuries can be seen following torsional forces to the foot or from crush injuries. These injuries often require surgery since anatomic reduction is extremely important for a successful outcome. Metatarsal fractures similarly result from twisting or crush injuries and most can be treated nonoperatively with a hard-soled shoe and weight bearing as tolerated. The base of the 5th metatarsal, however, warrants close attention. Fractures at the metaphyseal-diaphyseal junction of the proximal 5th metatarsal (Jones fractures) can jeopardize blood flow and are at risk for nonunion. Therefore, Jones fractures need close follow-up to assess for healing and may need screw fixation. Injuries to the metatarsal-phalangeal joints and phalangeal fractures can be treated symptomatically or with buddy taping with weight bearing as tolerated in a hard-soled shoe.