Dislocations of the foot bones - symptoms of injury, first aid and treatment, rehabilitation - Department of Traumatology of the Central Clinical Hospital of the Russian Academy of Sciences

Foot dislocations are uncommon and account for about 2% of all traumatic injuries to the lower extremities of humans. In most cases, these injuries are accompanied by ligament rupture and often in combination with fractures. The most common are incomplete ankle dislocations (subluxations), which are not accompanied by fractures. It is much less common to encounter isolated (complete) dislocations of the ankle joint; as a rule, they are accompanied by fractures and ligament ruptures.

Dislocations in the joints of the foot are divided into:

Subtalar foot dislocations (talocaleonavicular joint)
Foot dislocations at the Chopart joint (transverse tarsal joint)
Dislocations of the metatarsal bones in the Lisfranc joint (a fairly rare injury, in addition to severe pain and swelling, is accompanied by a noticeable widening and shortening of the foot)
Dislocations of the phalanges of the toes

Each has its own distinctive features (almost all of them occur with the displacement of the foot).

Causes of injury.

Such injuries often occur for the following reasons:

turning the foot inward
sharp turn of the foot
direct blow to the metatarsus or toes
an unfortunate fall or jump to your feet from a great height

It is extremely important to seek qualified medical help in a timely manner, otherwise the consequences of a foot dislocation can be disastrous: there is a high probability of developing diseases such as arthritis or arthrosis; mobility of the damaged joint after its healing may be difficult; partial or complete muscle atrophy and impaired circulation in the limb are possible.

Symptoms of dislocation

Fortunately, damage can be diagnosed immediately after it appears. One of the very first signs of injury will be the appearance of a characteristic crunch at the moment of dislocation. Minor symptoms that indicate the need to see a doctor include:

Acute pain. Pain may vary depending on the degree of dislocation. Grade 1-2 injuries cause discomfort when trying to move the leg or lean on it. Dislocations accompanied by bone fractures cause severe pain even at rest.
Hematomas and swelling. Swelling usually appears in the ankle area and increases within 24 hours after the injury. The more severe the damage, the more pronounced the swelling and discoloration of the skin will be.
Changing the position of the foot. Most often, a leg frozen in an unnatural position with no way to change it signals a ligament rupture.
Crunch. When trying to move the leg, the patient may hear clicking sounds indicating ankle displacement.

If at least one of the above symptoms occurs, you should immediately consult a doctor. After all, only an experienced specialist can determine the nature of the injury and prescribe appropriate treatment methods.

Diagnostics.

After an accident, the victim must be immediately taken to the traumatology department, and he must not make any leg movements (active or passive). Upon admission of the patient, the doctor performs a detailed examination of the injured limb and takes a complete anamnesis. The main method for diagnosing foot dislocations remains radiography. Only with the help of X-rays can a traumatologist make an accurate diagnosis (determine the type of dislocation) and begin appropriate treatment. In the case of complicated dislocations with fractures, surgical intervention may be required.

Treatment.

Treatment should only be carried out by a qualified traumatologist.

Reduction of dislocated foot bones using local or general anesthesia
Fixation of the reduced joint with a plaster splint
The immobilization period ranges from 8 to 12 weeks (depending on the type of dislocation and the severity of associated injuries)
Prescribing painkillers (if necessary)
In the first days, it is necessary to provide the patient with an elevated position of the leg and cold
During the entire treatment period, it is strictly forbidden to lean on or touch the injured limb.

Tibiofibular syndesmosis rupture

Rupture of the tibiofibular syndesmosis occurs in 0.5% of cases of injuries to the ligamentous apparatus of the ankle joint, and in 13% of cases of ankle fractures. Like many other types of ligamentous injuries, it is often missed during primary care. With untimely and illiterate treatment, it leads to the formation of chronic instability of the ankle joint, osteochondral damage to the talus and tibia, and the rapid formation of severe deforming arthrosis of the ankle joint. Syndesmosis rupture often accompanies Weber type B and C ankle fractures, damage to the peroneal tendons, fracture of the base of the 5th metatarsal, fracture of the anterior process of the calcaneus, fracture of the external and posterior processes of the talus.

Rupture of the tibiofibular syndesmosis most often occurs with excessive external rotation and dorsiflexion of the foot. Other mechanisms are possible, but their contribution to the overall picture of damage is much less significant.

Most often, this mechanism is found in sports such as rugby, football, American football, basketball, volleyball, and athletics (jumping). In non-athletes, the injury is more often associated with an ankle fracture.

The distal tibiofibular syndesmosis consists of the following anatomical structures:

Anteroinferior tibiofibular ligament. It connects the anterior external tubercle of the tibia (Chaput's tubercle) and the anterior tubercle of the fibula (Wagstaffe's tubercle). The posteroinferior tibiofibular ligament connects the posterior tubercle of the tibia (Volkmann's tubercle) and the posterior surface of the lateral malleolus. It is the most powerful component of the tibiofibular syndesmosis.

In addition to these structures located anterior and posterior to the tibia, directly between them are: the transverse tibiofibular ligament, the interosseous membrane, the interosseous ligament and the inferior transverse ligament.

The main biomechanical function of the syndesmosis is to resist the forces of axial load, rotation and external translation of the talus. The tibiofibular syndesmosis has a certain degree of elasticity; during normal walking, the tibiofibular gap can expand up to 1 mm. The deltoid ligament is an indirect stabilizer of the tibiofibular syndesmosis.

-pain on the anterior outer surface of the ankle joint

-pain in the projection of the deltoid ligament (to the bottom from the top of the inner malleolus)

-pain with axial load

During examination, it is necessary to palpate all the anatomical components of the syndesmosis; pain in any of them indicates its damage. Compression test (Hopkin's test) compression of the tibia at the level of the middle of the shin causes pain in the projection of the syndesmosis. External rotation test (pain in the syndesmosis during dorsiflexion and external rotation of the foot) with the knee and hip joint flexed 90°. Cotton's Test - Lateral translation of the fibula during anterior and posterior ankle drawer produces pain in the syndesmosis projection. With a long period of time elapsed since the damage, functional tests become less informative.

In addition to a thorough history, examination and functional tests, instrumental methods play an important role in the diagnosis of injuries to the tibiofibular syndesmosis. First of all, radiographs are taken in the frontal and lateral projections of the lower leg throughout, to exclude high ankle fractures.

The second important point is to take pictures with the tibiofibular “groove” removed (Mortise projection, 15-20° internal rotation of the tibia).

Its information content increases significantly when performing radiographs with a load and simultaneously of both lower extremities. In addition to the “slot” radiograph, in diagnostically ambiguous cases, stress radiographs with external rotation are performed.

Signs indicating a rupture of the tibiofibular syndesmosis are:

-reduced mutual overlap of the tibia, normally >6 mm on the anterior and >1 mm on the “groove” radiographs.

-increased medial clear space >4 mm.

-increased tibiofibular clear space, normal

If the clinical picture is suspicious for a rupture of the tibiofibular syndesmosis and the results of radiography are negative, CT or MRI is recommended. They allow you to identify partial damage. Also, their role is invaluable in assessing the quality of elimination of tibiofibular diastasis after surgery.

In the absence of diastasis on radiography and clinically not expressed instability, a conservative treatment method can be used - immobilization in a U-shaped splint and walking with crutches without weight for 3 weeks from the moment of injury, followed by walking in an orthosis that limits external rotation of the foot.

In the vast majority of cases, there is a need for surgical treatment. The classic technique consists of fixing the syndesmosis with positional screws. For this purpose, 3.5 or 4.5 mm syndesmotic screws are suitable, passed through 3 or 4 cortical layers 2-5 cm above the distal tibial plateau.

It is better to install screws in the position of dorsiflexion of the foot, which helps prevent “overtightening”. In the postoperative period, 6-12 weeks of walking with crutches without putting weight on the operated limb will be required, followed by removal of the screws.

An alternative option is to install “button” fixators using autografts or synthetic ligaments.

The advantages of this method include the possibility of earlier axial loading and the absence of the need to remove the clamps.

In cases where syndesmosis fixation is performed for Weber type C ankle fractures, there is a high probability (10%) of the formation of tibiofibular synostosis.

If you are a patient who suspects that you or a loved one may have a tibiofibular syndesmosis tear and would like to receive highly qualified medical care, you can contact the staff at the Foot and Ankle Surgery Center.

If you are a doctor and you have doubts that you can independently solve a particular medical problem associated with a rupture of the tibiofibular syndesmosis, you can refer your patient for a consultation with the staff of the Foot and Ankle Surgery Center.

A clinical example of the treatment of a rupture of the distal tibiofibular syndesmosis in our clinic.

Patient D., 27 years old, injured as a result of an unsuccessful landing after a star jump in shallow water. The foot moved outward relative to the fixed shin. There was a fracture of the fibula in the middle third with a rupture of all components of the distal tibiofibular syndesmosis and an avulsion fracture of the medial malleolus.

This type of ankle fracture is considered very severe and belongs to category 44C2 according to the classification of the Association of Osteosynthesis. It would seem that only 2 bones are broken, and the fractures are not particularly severe in their morphology, why is this type of ankle fracture considered extremely severe?

It's all about soft tissue damage, primarily the rupture of all 4 components of the distal tibiofibular syndesmosis - the anterior and posterior inferior tibiofibular ligaments, interosseous ligament and interosseous membrane. Together with the avulsion of the medial malleolus, this makes the fracture completely unstable and requires surgery in 100% of cases.

Add to this significant damage to all other soft tissues - rupture of the joint capsule, damage to lymphatic and venous vessels, we get pronounced edema, which leaves its mark both on infectious risks and on tissue healing in the postoperative period.

In this case, the foot becomes like a pillow; often in this period (from 6 hours to 7 days from the injury), due to pronounced swelling, the epidermis can peel off with the formation of conflicts. If this happens, the optimal tactic may be to temporarily switch to an external fixation device - in which the displacement of the talus is eliminated, and delay the operation after the swelling has subsided after 7-14 days.

The purpose of the operation is, first of all, to restore normal relationships in the ankle joint. If in case of an ordinary fracture of the ankles the operation begins with osteosynthesis of the lateral malleolus, then in this case it is better to start, on the contrary, with the medial malleolus, or with a fracture of the posterior edge (if it is broken and it is possible to perform osteosynthesis).

This is due to the fact that the distal portion of the fibula is completely unstable in the tibial notch, and it is technically extremely difficult to catch its correct position without stabilizing the medial or posterior malleolus.

The actual fixation of the distal tibiofibular syndesmosis is possible both with screws and with button clamps. It is better to fix it through a small piece of 1/3 tubular plate in order to distribute the load over a larger area. Otherwise, there is a risk of subsequent fracture of the fibula along the screw, since it will concentrate the entire load on itself.

If fixation is performed with a screw or screws, it is better to use the tricortical method, since it provides less rigid fixation and allows the fibula its normal physiological movements in the notch. Quadcortical screws lock the fibula more rigidly. And prevent dorsiflexion of the foot. After the start of loading, quadricortical screws often break for the same reason.

In the postoperative period, it is advisable to “secure” the fixation with a plaster cast for the first 2 weeks. And after removing the postoperative sutures, use a circular bandage for another 4 weeks. The bandage allows a dosed load - the weight of the limb.

During the operation, it is necessary to revise the tibiofibular fissure from the same lateral approach. This is necessary: firstly, to control the adequate elimination of displacement, secondly, to eliminate the interposition of the ligaments forming the DMBS and small bone fragments in the fibular notch, and thirdly, to prevent malposition of the fibula when applying a bone cap and when installing syndesmotic screws.

It is extremely important to control the position of the fibula on the true lateral view, since the most common mistake is to translate it anteriorly when installing the bone pin.

If all of the above nuances are observed, it is possible to adequately eliminate the subluxation and return the fibula to its normal anatomical position, which ultimately ensures the maximum possible restoration of function.

Preventive measures.

Full weight bearing on the leg is allowed no earlier than after a month (for uncomplicated dislocations) or after three (for severe injuries). Crutches may be used during this time if necessary.
After an ankle injury, the patient must wear orthopedic shoes with arch support for a year
Regular physical activity to strengthen the muscles of the lower extremities
Compliance with safety precautions at work, when playing sports, when moving on slippery surfaces
Your daily diet should include foods rich in vitamins and calcium.

Foot structure

The foot is a complex anatomical formation. It is based on a bone frame represented by the talus, calcaneus, navicular, cuboid and sphenoid bones (tarsal complex), metatarsal bones and fingers.

Bone base

The talus serves as a kind of “adapter” between the foot and the lower leg, due to its shape providing mobility to the ankle joint. It lies directly on the heel bone.
The calcaneus is the largest bone that forms the foot. It is also an important bony landmark and attachment point for the muscle tendons and aponeurosis of the foot. Functionally, it performs a supporting function when walking. In front it comes into contact with the cuboid bone.
The cuboid bone forms the lateral edge of the tarsal part of the foot; the 3rd and 4th metatarsals are directly adjacent to it. With its medial edge, the described bone is in contact with the scaphoid bone.
The navicular bone forms the medial part of the tarsal region of the foot. Lies anterior and medial to the calcaneus. In front, the scaphoid bone is in contact with the sphenoid bones - lateral, medial and medial. Together they form a bony base for attaching the metatarsal bones.
Metatarsal bones are related in shape to the so-called tubular bones. On the one hand, they are motionlessly connected to the bones of the tarsus, on the other, they form movable joints with the toes.

There are five toes, four of them (from the second to the fifth) have three short phalanges, the first - only two. Looking ahead, the toes perform an important function in the walking pattern: the final stage of pushing the foot off the ground is possible only thanks to the first and second toes.

Ligamentous apparatus

The listed bones are strengthened by the ligamentous apparatus; they form the following joints among themselves:

Subtalar – between the talus and calcaneus bones. It is easily injured when the ankle ligaments are sprained, with the formation of a subluxation.
Talon-calcaneonavicular - around the axis of this joint it is possible to perform pronation and supination of the foot.
In addition, it is important to note the tarsometatarsal, intermetatarsal and interphalangeal joints of the foot.

The most significant for the formation of the correct arch of the leg are the muscles located on the plantar side of the leg. They are divided into three groups:

external;
internal;
average.

The first group serves the little finger, the second group – the thumb (responsible for flexion and adduction). The middle muscle group is responsible for flexing the second, third and fourth toes.

Biomechanically, the foot is designed in such a way that, with proper muscle tone, its plantar surface forms several arches:

external longitudinal arch - passes through a mentally drawn line between the calcaneal tubercle and the distal head of the fifth phalangeal bone;
internal longitudinal arch - passes through a mentally drawn line between the calcaneal tubercle and the distal head of the first metatarsal bone;
transverse longitudinal arch - passes through a mentally drawn line between the distal heads of the first and fifth metatarsal bones.

In addition to the muscles, the powerful plantar aponeurosis, mentioned above, takes part in the formation of such a structure.