новая папка / Apley 938-988

for a week or two is the easiest way. If the toe is dislocated, it should be reduced by traction and manipulation; the foot is then protected in a short walking cast for a few weeks.

FRACTURED TOES

A heavy object falling on the toes may fracture phalanges. If the skin is broken, it must be covered with a sterile dressing, and antibiotics are given; a contaminated wound will require formal surgical washout and exploration. The fracture is disregarded and the patient encouraged to walk in a supportive boot or shoe. If pain is marked, the toe may be splinted by strapping it to its neighbour for 2–3 weeks.

FRACTURED SESAMOIDS

One of the sesamoids (usually the medial) may fracture from either a direct injury (landing from a height on the ball of the foot) or sudden traction; chronic, repetitive stress is more often seen in dancers and runners.

The patient complains of pain directly over the sesamoid. There is a tender spot in the same area and sometimes pain can be exacerbated by passively hyperextending the big toe. X-rays will usually show the fracture (which must be distinguished from a smooth-edged bipartite sesamoid).

Treatment

Treatment is often unnecessary, though a local injection of lignocaine helps for pain. If discomfort is marked, the foot can be supported in a removable boot/splint for 2–3 weeks. An insole with differential padding or cut-out under the sesamoid might also speed a return to sporting activities. Occasionally, intractable symptoms call for excision of the offending ossicle; care should be taken not to disrupt the flexor attachment to the proximal phalanx as this may result in great toe deformity.

FURTHER READING

Bajammal S, Tornetta P 3rd, Sanders D, Bhandari M.

Displaced intra-articular calcaneal fractures. J Orthop Trauma 2005; 19: 360–4.

Bosse MJ, McCarthy ML, Jones AL, et al. Lower Extremity Assessment Project (LEAP) Study Group. The insensate foot following severe lower extremity trauma: an indication for amputation? J Bone Joint Surg 2005; 87A: 2601–8.

Broström L. Sprained ankles. Surgical treatment of ‘chronic’ ligament ruptures. Acta Chir Scand 1966; 132: 551–65.

Buckley R, Tough S, McCormack R, et al. Operative compared with non-operative treatment of displaced intraarticular calcaneal fractures: a prospective, randomized, controlled multicenter trial. J Bone Joint Surg 2002; 84A: 1733–44.

Coetzee JC. Making sense of Lisfranc injuries. Foot Ankle Clin 2008; 13: 695–704.

Coetzee JC, Ly TV. Treatment of primarily ligamentous Lisfranc joint injuries: primary arthrodesis compared with open reduction and internal fixation. Surgical technique. J Bone Joint Surg 2007; 89A(Suppl 2 Pt 1): 122–7.

Eastwood DM, Gregg PJ, Atkins RM. Intra-articular fractures of the calcaneum. Part 1: Pathological anatomy and classification. J Bone Joint Surg 1993; 75B: 183–8.

Eastwood DM, Langkamer VG, Atkins RM. Intraarticular fractures of the calcaneum. Part 2: Open reduction and internal fixation by the extended lateral transcalcaneal approach. J Bone Joint Surg 1993; 75B: 189–95.

Griffin D, Parsons N, Shaw E, et al. Operative versus non-operative treatment for closed, displaced, intraarticular fractures of the calcaneus: randomised controlled trial. BMJ 2014; 349: 4483.

Lauge-Hansen N. Fractures of the ankle. II. Combined experimental-surgical and experimental-roentgenologic investigations. Arch Surg 1950; 60: 957–85.

Muller ME, Allgöwer M, Schneider R, Willeneger H.

Manual of Internal Fixation (3rd edn). Berlin: Springer, 1991, pp. 598–600.

Pearce CJ, Wong KL, Calder JD. Calcaneal fractures: selection bias is key. Bone Joint J 2015; 97-B: 880–2.

Pearse EO, Klass B, Bendall SP. The ‘ABC’ of examining foot radiographs. Ann R Coll Surg Engl 2005; 87: 449–51.

Tarkin IS, Clare MP, Marcantonio A, Pape HC. An update on the management of high-energy pilon fractures. Injury 2008; 39: 142–54.

32

foot and ankle the of Injuries