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Foot and ankle trauma: often recognized too late

MEDICAL REPORT

Marathon for troubled feet: every person covers an average of 120,000 km in the course of their life. The foot apparatus has to withstand 1,000 tons of stress per day. Photo: Leukotape®
The Society for Foot Surgery is dedicating an international symposium to everyday and sports injuries.

Due to sustained forces and loads in the course of life, changes occur in the foot, which can lead to pronounced deformities and fatigue fractures. In the case of accident injuries, lesions in the area of ​​the foot or ankle are often overlooked and thus diagnosed late. In around 20 percent of cases, especially in polytrauma patients, foot injuries are often only diagnosed years after the event, reported Univ.-Doz. Dr. med. Gerolf Peicha (Graz) in Munich. Dr. med. Alexander Sikorski (Aachen) at the 13th International Symposium on Foot Surgery in Munich. Therefore, if there is the slightest suspicion of an injury to the lower extremity, a specialist doctor should examine the foot.
Football shoes do not protect against excessive force
Imaging procedures are a prerequisite for a reliable diagnosis. X-rays often have to be supplemented by CT or MRI. In the case of a navicular fracture (scaphoid bone, navicular bone), CT is a must, emphasized Dr. med. Matthew Rockett (Houston). Navicular fracture is the most common metatarsal fracture. In 47 percent of the cases, the dorsal navicular area is affected, in 24 percent it is a fracture of the cusp directed towards the plantar (tuberositas ossis navicularis). Other metatarsal fractures affect the ankle bone (Os talus) and the tarsal bone (Ossa tarsi). Because the blood circulation in the metatarsal area is not good, healing is often delayed.
Metatarsal injuries of all kinds are typical for paragliders, but the rate has also risen sharply among footballers. The new models of soccer shoes are more impressive than "light sneakers with studs, which may be ideal for an artistic style of play, but do not protect the foot from greater force", complained Priv.-Doz. Dr. med. Markus Walther (Munich).
Mainly the Lisfranc ligament complex is injured. The 2nd metatarsal is dislocated dorsally and the ligaments are torn. Initially, the clinical picture does not differ from that of an ankle joint distortion. Those affected complain of metatarsal pain. If the swelling is in the metatarsal area, the injured cannot put weight on the foot, and the symptoms persist for the fifth day after the event, suspicion of an injury to the Lisfranc ligament should be very high.
In the diagnosis, X-rays of the unloaded foot are the first to rule out fractures. If the results are not conclusive enough, X-rays of the loaded foot should follow (dorsal and lateral) in comparison with the healthy foot. If there is still uncertainty, an MRI can clarify the situation. This makes the band complex visible. The dislocations of the foot bones that can be seen in the X-ray image - such as the divergence of the first and second rays and the sinking of the medial ray (in the lateral view) - are sometimes accompanied by a bone fragment (stain sign), an erosion of the ligament attachment. Depending on the severity of the injury, treatment is conservative with immobilization, boot casts, walking casts or bed casts, or surgically with the help of Kirschner wires and a stabilizing screw.
The main problem with this injury is that it is detected too late; often they are not diagnosed until months after the injury, since patients do not see a doctor until then. Diagnostic local anesthesia can corroborate the suspicion. If conservative treatment is unsuccessful, long-term arthrodesis of the tarsometatarsal joint is indicated. However, pain-free healing is often no longer possible. Permanent pain is then inevitable. Post-traumatic osteoarthritis often develops.
Often pseudoarthroses after metatarsal fractures
According to Dr. med. Thorsten Randt (Osterode), metatarsal fractures must always be treated surgically if it can be concluded from the healing process or the accident picture that there is a malalignment. These include, for example, the elevation position of the first ray and the massive shortening of a metatarsal bone.
The fifth metatarsal ray is relatively often affected by a fracture, either as a fracture of the tuberosity or as a shaft fracture. This “Jones fracture”, described by Jones for the first time in 1902, can be the result of tiptoe walking with inversion of the foot. Usually athletes are affected. Central pain in the area of ​​the lateral edge of the foot is typical.
Conservative therapy requires long immobilization and discharge, the rate of pseudoarthroses and refractures is high. Surgical stabilization is therefore recommended. During the operation in the supine or lateral position, the fracture is screwed, reported Dr. Fabrice Alexander Külling (Münsterlingen / Switzerland). Above all, the sural nerve must be spared. Access is between the two tendons of the peranaeus brevis muscle. Usually the osteosynthesis is performed with a malleolar screw or a large fragment screw. The patients can be discharged two days later. You should still wear Hallux or Künzle shoes for about four weeks. After around eight weeks, the fracture is healed radiologically. Then the patients are fully resilient again in terms of sport.
A comprehensive functional diagnosis of the lower extremity includes early detection of foot mechanics disorders, stress or changes in the bones and soft tissues. Photo: Grünenthal
Detect tendon ruptures by MRI and sonography
A trauma that apparently occurs again and again in fencing, but is otherwise rare, is the tendon rupture of the tibialis anterior muscle. It can occur as a partial or complete rupture as a result of lunging movements, reported Dr. med. Konstantinos Anagnostakos (Homburg / Saar). Sonography and MRI are suitable diagnostic imaging methods. If the defect is smaller than four centimeters, a plastic can be tried. In the case of larger defects, it is recommended to use a semitendinosus interposal. Strong mechanical stress in the repulsion phase could lead to a rupture of the Achilles tendon, mostly in the area of ​​the calcaneus (heel bone, os calcis), explained Dr. med. Xenophon Baraliakos (St. Anna Hospital, Herne).
A good indication of this trauma is a dorsal hematoma. After conservative therapy, up to 34 percent of patients suffer a reruption of the tendon, after surgical treatment it is only about 5.4 percent. According to the literature, the sural nerve is injured in more than nine percent of cases during open surgery. The safest method is the percutaneous Achilles tendon suturing technique. After that, only around three percent re-ruptures occur. After the percutaneous suturing, the patients are able to work again after about six weeks. However, you should only start exercising 20 weeks after the procedure. Another message from Boraliakos: The time of the plaster cast should finally be over.
Chronic ankle ligament instability
Broken ankles are one of the most common fractures in sports. In ball sports, the upper ankle joint (ankle joint) often suffers from a supination or adduction trauma. Even more common is the "sprained ankle" after being represented on uneven ground. These trauma can conceal capsule-ligament lesions, fractures and / or dislocations. The most common trauma to the ankle is a fibular capsule-ligament rupture. A strip-shaped hematoma on the edge of the foot around 24 hours after the trauma suggests a complete ligament rupture. Massive swelling, hypoplasia and bimalleolar compression pain indicate a distal fibular fracture or a bi- or trimalleolar dislocation fracture of the ankle joint.
In contrast to simple and mild cases, in which conservative treatment with cooling, compression and relief is called for, surgical treatment is used for complicated ligament injuries, bony involvement or severe instability. Univ.-Doz. Dr. med. Ernst Orthner (Wels) the post-traumatic osteoarthritis and the chronic ligament instability. In contrast, patients with osteochondrosis dissecans are rare. Depending on the type of joint processes, arthrodesis is also indicated. Siegfried Hoc
Foot and ankle trauma: often recognized too late

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