Sports Medicine: Just the Facts

CHAPTER 65 • FOOT INJURIES 383

should be obtained to provide anatomic detail and

guide therapy.

• Fractures that are nondisplaced and without comminu-
  tion respond well to six weeks of nonweightbearing
  cast immobilization. Displacement, comminution, and
  delayed or nonunion fractures are indications for sur-
  gical open reduction internal fixation (Quirk, 1995;
  Eric, Coris, and John, 2003).

CALCANEALANTERIORPROCESSFRACTURE

• Fracture of the anterior process of the calcaneus is a
  common injury that is often misdiagnosed. It has been
  referred to as “the ankle sprain that does not heal”
  (Trnka, Zettl, and Ritschl, 1998).
  •Patients typically present following a twisting injury
  with immediate pain on the outer aspect of the mid
  portion of the foot and discomfort on weightbearing.
  If the diagnosis is missed initially they may present
  with prolonged disability and local pain at the calca-
  neocuboid joint.


• The mechanism can be avulsion of the bifurcate liga-
  ment with plantar flexion inversion or direct compres-
  sion with dorsiflexion eversion.
  •Physical examination is notable for swelling at the
  anterior lateral midfoot and tenderness to palpation at
  the anterior lateral process of the calcaneus. Standard
  anteroposteior(AP), lateral and oblique films should
  be obtained. The oblique projection is the most helpful.
  •For acute nondisplaced fractures the patient can be
  treated with a short-leg cast and no weightbearing for
  6–8 weeks. Displaced fractures may require open
  reduction and internal fixation or excision of the frag-
  ment and repair of the bifurcate ligament. Neglected
  injuries may lead to arthrosis of the calcaneocuboid
  joint (Roesen and Kanat, 1993).

SUBTALARDISLOCATION

• Subtalar dislocation is most often a result of high-
  energy trauma, such as motor vehicle accidents; how-
  ever, it can be a result of sports injuries as well. Eighty
  percent of dislocations are medial, 20% are lateral.
  Ten percent are open, and about half have associated
  fractures. Subsequent osteonecrosis of the talus
  occurs in about 5–10% of cases (Freund, 1989).


• Closed reduction is performed by flexing the knee and
  forefoot, applying gentle traction, accentuating and
  reversing the deformity while applying gentle pressure
  over the talar head. Reduction may be blocked by lon-
  gitudinally directed structures, the posterior tibial
  tendon in the case of lateral dislocations, extensor ten-
  dons in medial dislocation. After reduction, treatment is
  with a short-leg cast for 4 weeks. In the case of open
  dislocations operative repair followed by prolonged
  immobilization is required (Bohay and Manoli, 1990).

SUBTALARINSTABILITY

• Subtalar instability may contribute to lateral ankle insta-
  bility or may be its own entity. Instability can be pro-
  duced after lateral ankle sprain or subtalar dislocation
  by injury to the cervical ligament, lateral talocalcaneal
  ligament, intraosseous ligament and calcaneofibular lig-
  ament (Hertel et al, 1999).
  •Patients present with symptoms of lateral ankle insta-
  bility. Isolated or comorbid subtalar instability can be
  difficult to identify. Stress radiographs taken in AP
  subtalar neutral, AP supination stress, lateral Broden,
  and supination stress Broden can be helpful.


• May require anatomic reconstruction of the involved
  lateral ankle ligaments (Karlsson and Eriksson, 1997).

POSTERIORTALARPROCESSFRACTURE

•Avulsion fracture of the medial tubercle of the poste-

rior process of the talus occurs after forceful dorsi-

flexion-pronation of the ankle. Generally presents as

pain in the posterior medial ankle. The patient may

also have tenderness to palpation over the posterior

talar beak or pain with plantar flexion.

• Acute fractures that are nondisplaced can be treated
  by immobilization in a short leg cast. Displaced frac-
  tures may require open reduction and internal fixa-
  tion. Missed fractures do poorly and patients
  complain of persistent posteromedial ankle pain.
  •However, delayed operative excision of missed frac-
  tures yields good results (Kim, Berkowitz, and
  Pressman, 2003; Judd and Kim, 2002).

LATERALTALARPROCESSFRACTURE

• Lateral talar process fractures are another frequently
  underdiagnosed foot injury. Delay in diagnosis can
  lead to persistent pain and severe degeneration of the
  subtalar joint. Patients complains of lateral ankle dis-
  comfort and increased pain with activity particularly
  inversion and eversion of the ankle. The usual mecha-
  nism is inversion and dorsiflexion with axial load but
  they can also be caused by eversion load (snow-
  boarder’s fracture).


• Examination is characterized by swelling and tender-
  ness over the lateral talar process and pain with forced
  inversion and eversion. Lateral process fractures are
  easily missed on routine X-rays. Radiographs taken at
  30 ° plantar flexion and 45° internal rotation may
  reveal the fracture, but computed tomography(CT) is
  best.


• Nondisplaced fractures can be treated with immobi-
  lization in cast or boot. Displaced or intra-articular
  fractures may be treated surgically by excision of
  fragment or open reduction and internal fixation (Judd
  and Kim, 2002; Boon et al, 2001; Cantrell and
  Tarquinio, 1998).