跖骨骨折

APandlateralradiograph（正、侧位）ofhomolateralLisfranc(tarso跗骨,-metatarsaljoint跖关节)dislocation脱臼,转位FluoroscopicradiographX线透视的intheoperatingroomWithadduction内收thetarso-metatarsaljointsfallintogeneralalignment.However,thereisstillsignificantdorsaldisplacementwhichispalpable.Theincisionisplacedbetweenthesecondandthirdmetatarsals.Thisallowsaccessfromthesecondtothefourthtarsalmetatarsaljoints,aswellasthelateralaspectofthefirstmetatarsaljoint.Thisincisionispreferredasopposedtoanincisionbetweenoneandtwo,whichiswherethedorsalispedisarteryislocated.DORSALISPEDISARTERYObliqueviewofthefoot,demonstratingtheincision.Theskinincisionisbroughtdownthroughthelevelofthesubcutaneoustissue.Theshortextensormusclesareretractedbluntly.LATERALCUNEIFORM3rdMETATARSALBASE2ndMETATARSALBASEWithverylittledissectionrequired,thedislocatedtarso-metatarsaljointsareobvious.Thisfiguredemonstratesthebaseofthesecondandthirdmetatarsals,dorsallydisplacedfromthemiddleandlateralcuneiform.Notethatthesecondmetatarsalbaseislocatedmoreproximallythanthethird,andisthekeystoneoftheconfiguration.Withmanipulationofthefootanddirectpressureonthemetatarsalbases,areductionisusuallyeffective.REDUCTIONThereductionofthesecondandthirdmetatarsalbasesbacktotheirassociatedcuneiforms.Closeupofthereductionofthesecondmetatarsalbasetothemiddlecuneiformandthethirdmetatarsalbasetothelateralcuneiform.3rdMETATARSALBASELATERALCUNEIFORM2ndMETATARSALBASEMIDDLECUNEIFORMOncethereductionisobtained,aK-wireisplacedacrossthereductioninanareathatwillnotinterferewithscrewfixation.LOCATIONFORTEMPORARYK-WIREPLANNEDLOCATIONOFSCREW2ndMETATARSALBASEMIDDLECUNEIFORMK-WIRETAPAfterdrillingacrossfromthebaseofthesecondmetatarsalintothemiddlecuneiform,theentireholeistapped.Thisscrewisapositionscrew,notalagscrew,thusnooverdrillingofthemetatarsalbaseisrequired.K-WIRETAPItisveryimportanttokeepthehandalmostparallelwiththedorsalaspectofthefootinordertoplacethescrewinthecenterofthecuneiform.NoticetheK-wireplacedinapositionthatdoesnotinterferewithscrewplacement.Becauseoftheverysharpanglewithrespecttothebone,thecountersinkshouldbeusedtocreateaholeinthemetatarsalbase.Ifthisisnotdone,thentheposterioraspectofthescrewheadwillabutthebaseofthemetatarsalbeforeitisengagedintheholeandhasthepotentialtodisplacethejoint.Thescrewbeingplacedintothecountersunkhole.Thescrewonceseated.Asecondscrewhasbeenplacedbetweenthethirdmetatarsalbaseandthelateralcuneiform.REDUCTIONSCREWIN2ndMETATARSALSCREWIN3rdMETATARSALOncethedorsalincisionhasbeenutilizedtogaingoodstabilityofthe2ndand3rd(dependingonthecase)metatarsalbonesbacktothecuneiforms,theremaystillbeinstabilityonthemedialaspectofthefoot.REDUCTIONSCREWIN2ndMETATARSALSCREWIN3rdMETATARSALInthiscase,thefirsttarsalmetatarsaljointwasunstableandwasaddressed.Asecondincision,whichisveryshort,ismadedirectlyoverthetarsalmetatarsaljointmedially.REDUCTIONSCREWIN2ndMETATARSALSCREWIN3rdMETATARSALCloseupofthefirstmetatarsalbaseandmedialcuneiformjoint.MEDIALCUNEIFORM1stMETATARSALBASEThereductionisobtained.Insimilarfashiontothedorsalincision,aK-wireisplaced,thenscrewfixationisachieved.Thereductionisobtained.Insimilarfashiontothedorsalincision,aK-wireisplaced,thenscrewfixationisachieved.≈60oThefifthmetatarsalbaseisreducedandpinnedtothecuboidusingaK-wirefromthemetatarsalintothecuboidmoreproximalthantheplannedscrewImagingintheobliqueradiographhelpswithpinplacement.Asviewedfromthetopofthefoot,theK-wireanddrillshouldbeapproximately60ofromthehorizontalaxis.≈60oThisisnecessaryasthebaseofthefifthmetatarsalislocatedsignificantlyinferiortothecuboid.≈60oAsviewedfromtheside,theangleisapproximately30-45ofromdistaltoproximalthroughthebaseofthemetaphysisofthefifthmetatarsal.CUBOIDDRILLK-WIREX-raydemonstratingtheK-wireholdingthereductionandthepercutaneouslyplaceddrill,whichisacrossthecenterofthefifthtarso-metatarsaljoint.Thisdrillholeisthentapped,andanappropriate-lengthscrewisplaced.CUBOIDDRILLK-WIREStandard-layerclosureofthefootisperformed,typicallyusingnylonsuturesfortheskin.Thepatientisplacedinashort-legcast.PostoperativeAPandlateralradiographsdemonstratinganatomicreductionandstableinternalfixationofthetarsalmetatarsaljoints.