Tarsal Coalition

Tarsal coalition is fusion of the tarsal bones that leads to a ridged flat foot, foot pain and multiple ankle sprains. Tarsal coalition is a congenital anomaly. There are two types of tarsal coalition are talocalcaneal coalition and calcaneonavicular coalition. Talocalcaneal coalition is a coalition between the talus and the calcaneus. Calcaneonavcular coalition is a coalition between the calcaneus and the navicular. When talocalcaneal coalition occurs, it usually happens around 12-15 years of age. The calcaneonavicular coalition presents at an earlier age. 50% of coalitions are bilateral. About 20% have multiple coalition in the same foot. Coalition may be fibrous, cartilaginous or bony. It occurs due to failure of segmentation. It could be associated with fibular hemimelia or Apert’s syndrome. The patient usually complains of a painful foot, a history of repeated ankle sprains, as well as flatfoot deformity. Tarsal coalition may result in peroneal spastic flat foot. You may also find hind foot valgus. On toe standing the arch does not reconstitute. Heel cord contracture might also be evident during the examination. Furthermore, there might be restricted subtalar joint range of motion. Always check both feet, the condition may be bilateral.

The best study is CT scan. It can determine the size and location of the coalition. MRI is also useful in detecting a fibrous or cartilaginous coalition. AP, lateral, and oblique x-ray views should be obtained. On lateral view x-rays, the calcaneonavicular coalition will show the characteristic “anteater nose sign” which is an elongation of the anterior calcaneal process. The lateral view of a talocalcaneal coalition may show talar beaking which is a type of traction spur that occurs due to limited motion of the subtalar joint. Additionally, the C sign is a radiological sign which may be seen on lateral radiographs. It is the outline of the talar dome and the sustentaculum. A 45 degree oblique view is the best for showing calcaneonavicular coalition. No operative treatment usually consists of NSAIDS, modified activities, or the use of a brace or cast. Surgical treatment for calcaneonavicular coalition usually consists of resection with interposition of the extensor digitorum brevis muscle or a fat graft no matter what the size of the coalition is. Talocalcaneal coalitions that involve less than 50% of the subtalar joint are also resected. A triple arthrodesis is performed for large coalitions, failed resections, or advanced conditions.

Diabetic Ankle Fractures

There are some problems associated with diabetic ankle fractures. The biggest problem occurs when what is believed to be a simple ankle fracture is actually a Charcot ankle. The condition of Charcot ankle may not be diagnosed and my lead to a bad outcome such as possible amputation. Diabetic neuropathy often occurs with the loss of protective sensationis and is a risk factor for Charcot ankle. Diabetic ankle fractures have a lot of complications (40% complication rate). The amputation rate is about 6% for closed injuries and about 40% for open injuries. Most significant factor in patients with ankle fractures who are diabetic is a high risk of infection (up to 20% in diabetic patients). There is an increased risk of superficial and deep wound infections. Peripheral neuropathy is the most significant risk factor for post-operative complications. If the patient is treated with a splint or a cast, this must be padded very well in order to avoid ulcers or skin complications. Keep the diabetic patient with an ankle fracture non-weight bearing for longer period of time. The amount of time spent non-weight bearing is double the time for a diabetic patient. Diabetic patients with an ankle fracture usually have a higher incidence of nonunions, malunions, and hardware failures than with nondiabetic patients. Examine the pulses and check the circulation. In general, surgery is better for treatment. It is going to take longer for the fracture to heal, so a good stable fixation is needed that will support the fracture until it heals (fixation will not be traditional). In regard to fixation, add more fixation; more screws with the screws going from the fibula to the tibia. Use spanning external fixator, and use K-wires from the calcaneus to the tibia. I personally like to use minimally invasive techniques. I try not to open the fracture in diabetic patients unless necessary (do it percutaneously with small incision). I start with getting the fibular length. Next, I fix the medial malleolus percutaneously. The syndesmosis could also be fixed percutaneously. Red blood cells contain hemoglobin and when the hemoglobin binds with glucose in the blood, it becomes glycated. When the hemoglobin binds to oxygen, the cells appear red. The term HbA1c refers to the glycated hemoglobin. We find that HbA1c levels appear to be predictive of risk and complication rates in the surgical treatment and outcome of diabetic patients with ankle fractures. Complication rates are higher among patients with elevated HbA1c which is more than 6.5%. The normal range of HbA1c is 4-6%. More than 7% is high. For diabetic ankle fractures, recognize the Charcot ankle, make sure to examine the circulation and the pulses, and cast or splint must be well padded. There is a high risk of complication that may lead to amputation. Loss of protective sensation and peripheral neuropathy is an important risk factor for Charcot ankle. Delay weight bearing because the fracture does not heal quickly. When surgery is done, use percutaneous techniques or good fixation that will allow non-failure of the hardware during healing time.

Femoral Triangle

The femoral triangle is a superficial triangular space located on the anterior aspect of the thigh just inferior to the inguinal ligament. The boundaries of the femoral triangle include the lateral border, medial border, and base. The lateral border is formed by the medial border of the Sartorius M. The Sartorius muscle is a thin, small muscle going that goes from lateral to medial. The Sartorius muscle inserts on the medial side of the proximal tibia. The medial border of the femoral triangle is formed by the medial border of the adductor longus M. The adductor longus muscle goes from medial to lateral direction. The base of the femoral triangle is formed by the inguinal ligament. The floor of the triangle is formed by the iliacus M., psoas major M., pectineus M., and the adductor longus M. The roof of the femoral triangle is covered by skin, superficial and deep fascia. The femoral triangle contains three important structures. From lateral to medial, it is the femoral nerve, femoral artery, and femoral vein, which contains deep inguinal lymph nodes. The femoral nerve lies within the groove between the iliacus and psoas major muscles. Two other nerves are located within the femoral triangle, and they are the lateral cutaneous nerve on the thigh and the femoral branch of the genitofemoral nerve. The lateral cutaneous nerve of the thigh crosses the lateral corner of the triangle. It supplies the skin on the lateral part of the thigh. The femoral branch of the genitofemoral nerve runs in the lateral compartment of the femoral sheath. It supplies the majority of the skin over the femoral triangle. The femoral triangle also contains the femoral sheath which is a funnel shaped sleeve of fascia enclosing the upper 4 cm of the femoral vessels. The neurovascular bundle is medial to the sartorius muscle. Therefore, in the anterior approach to the hip, it is always safe to go lateral to the sartorius muscle in order to avoid the important structures within the femoral triangle. Do not go medial to the sartorius muscle. You will injure the structures if you go medial to the sartorius muscle. It is important to remember when performing this approach to avoid the lateral cutaneous nerve of the thigh. The sartorius muscle is almost like the teres minor muscle in the shoulder. Do not go inferior to the teres minor muscle in the shoulder, you will injure the axillary nerve and the posterior circumflex artery.

Jone's Fracture

Jones Fracture is a fracture of the proximal fifth metatarsal bone. Sir Robert Jones (British surgeon) sustained an acute fracture at the base of the fifth metatarsal bone while dancing and the fracture was then named after him. The Jones fracture occurs at the metaphyseal/diaphyseal junction and it extends into the intermetatarsal joint proximal to the metatarsocuboid joint. The joints are connected to the base of the fifth metatarsal bone. One joint articulates with the cuboid bone (metatarsocuboid) and the second joint (intermetatarsal) articulates with the fourth metatarsal. For the Jones fracture to be called “Jones Fracture,” the fracture must enter the intermetatarsal joint (fracture must be distal to the metatarsocuboid joint and must enter the intermetatarsal joint). The Jones fracture occurs about 1 ½ cm distal to the tuberosity of the fifth metatarsal bone. The metatarsal bone is divide into the head, neck, shaft, and the tuberosity. Jones fractures of the proximal fifth metatarsal occurs in the watershed area within 1.5 cm of the tuberosity. The area where the Jones fracture occurs is an area of limited blood supply. There are multiple metaphyseal arteries in the tuberosity. There is a nutrient artery with intramedullary branches provides retrograde blood flow to the proximal fifth metatarsal. Fracture distal to the tuberosity will disrupt the nutrient artery supply resulting in relative avascularity.

The Peronius Tertius tendon is inserted into the dorsal metaphysis of the fifth metatarsal bone . The Peroneus Brevis tendon is inserted into the tuberosity of the fifth metatarsal bone. The plantar fascia is connected of the fifth metatarsal bone. When a Jones fracture occurs, the tendons will pull the fracture apart and prevent healing. This fracture could be mistaken for sprain, because a sprain is common on this side of the foot. There are three types of fractures at the proximal fifth metatarsal bone.

Fracture in zone I which is the tubersority avulsion fracture. Fracture in zone II which is the two Jones fracture. Laslty, fracture in zone III which is the stress fracture.  In zone I avulsion fractures (psuedo Jones fracture). The Peroneus Brevis insertion site and one treats that fracture conservatively. If one takes fracture in zone II, that is the two Jones fracture. They are usually acute fractures that occur at the metaphyseal-diaphyseal junction and involve  the fourth and fifth metatarsal articulation. Zone III stress fractures are chronic fractures that occur distal to the foruth and fifth metatarsal articulation and may be associated with cavovarus foot deformity. In children, it is important not to make the wrong diagnosis of a fracture of the proximal fifth metatarsal base while looking at a normal growth plate. The growth plate is usually present between the ages of 9-14 years of age and it is parallel and lateral to the metatarsal.

During radiology, x-rays will show the fracture and its location. An acute jones fracture will have sharp margins with no intramedullary sclerosis. A stress fracure will have a wide fracture line with medullary sclerosis. Treatment of Jones fracture, if the fracture is nondisplaced one should use a boot or a cast. A person should be nonweight baring for 6-8 weeks and 75% will heal. In athletes or if the fracture is displaced, a screw fixation of the fracture should be performed. This technique is a very popular one. In the lateral view, the canal appears to be straight and narrow. In the AP view, the fifth metatarsal appears to be curved (lateral bow). Lateral bow of the fifth metatarsal may cause complications during surgery. There is vulnerability at the midshaft for perforation of the medial cortex. The canal us narrower in the dorsal view plantar dimension, which is narrow in the lateral view. The point of entry for the wire or the screw is not centered. The fifth metatarsocuboid joint blocks the proximal canal projection and this situation can cause complications. Each paitent’s metatarsal  should be evlauated indivdually for proper screw selection. For surgery and screw placement, drill parallel with the shaft in the lateral plane and avoid the plantar direction and avoid the Sural nerve. One will probably need to use a 4.5 mm cancellous screw. The appropriate length of the screw that should be used is usually around 40-50 mm. The diameter of the screw depends on the width of the canal. Smaller screw fixation is unstable and a larger screw may displace the fracture. The screw threads must cross the fracture site. Failure of the procedure is attributed to poor blood supply or return of the athlete to activity before complete radiographic union.