CLASSIFICATION S SYSTEMS EPONYMS Bosworth Frx – Fibular frx with posterior dislocation of talus. Named after David Bosworth, Bosworth, an NY orthopedic surgeon surgeon who introduced streptomycin for bone and oint !B. Frx"dislocation involving the midtarsal oints. Chopart Frx – Frx"dislocation Francois #hopart, surgeon in $aris, whose amps through midtarsal oint was effective and resisted infection.
Cotton Frx – Frx of lateral and medial malleolus and frx of posterior process process of tibia. Fredrich #otton, #otton, Boston surgeon, surgeon, who illustrated his own %&%' boo(, Dislocations boo(, Dislocations and and Fractures Fractures. Danis-Weber Danis-Weber Cassi!i"ation – First described by )obert Danis, Belgian Belgian surgeon, in %&*&. +is pioneering wor( wor( in internal fixation led colleague aurice -. uller to assemble a study group in %&/ for clinical trials of internal fixation – 0rbeitsgemeinschaft 0rbeitsgemeinschaft fur 1steosynthesefragen 1steosynthesefragen 2013. 4ater, the system was imodified by Bernhard 5eorg 6eber a prominent orthopedic surgeon in 7wit8erland. 7wit8erland. D#p#$tren Frx – Distal fibular frx above lateral malleolus w" associated tear of tibiofibular tibiofibular and deltoid ligament. 4ateral displacement of talus and possible medial malleolus frx. 5uillaume Dupuytren, 9greatest French surgeon and meanest of men: of the %& th century, has his name associated w" %; different conditions"operations. conditions"operations. Essex-Lopresti Essex-Lopresti Cassi!i"ation – $eter 5ordon -ssex<4opresti, surgeon at Britain=s Birmingham 0ccident #enter during 6orld 6ar >>, was an expert in parachuting inuries. Freiber% In!ra"tion – )efers to deformity of head of second or third metatarsal from 0?N, presumably secondary to trauma. Named after 0lbert +enry Freiberg, $rofessor of 1rthopedic 7urgery at the @niversity of #incinnati, 1+>1. 1+>1. &ossein Frx – ?
physician, performed performed classic cadaver cadaver studies in in %&*'<'=s to elucidate mechanisms involved in an(le inuries. Le Fort Fx o! the An)e – ?ertical frx of the anterior medial portion of the distal distal fibular fibular with avulsion of the anterior tibiofibular ligament. 4eon #lement #lement 4e Fort, distinguished French surgeon and son< in
, and #arl 7chlatter was a professor of surgery in Curich 7wit8erland. 7wit8erland. Pott Frx – $artial dislocation of the an(le w" frx of the distal fibular shaft and rupture of the medial ligaments. ligaments. $ercival $ott $ott was a leading surgeon in 4ondon and described !B in the spine 2$ott=s Disease3. Sater-(arris Cassi!i"ation – )obert Bruce 7alter, currently a #anadian surgeon at the @niversity of !oronto. !oronto. )obert +arris is another #anadian orthopedic surgeon at the @niversity of !oronto. Shepar+ Frx – !he lateral tubercle of the posterior process of the talus frx may simulate simulate an os trigonum. Francis A. 7hepard 7hepard was from -ngland, but emigrated to #anada to become a prominent surgeon. surgeon. Tia#x Frx – 0n avulsion inury of the anterior tibial tubercle at the attachment of the distal anterior tibiofibular tibiofibul ar ligament. $aul Aules !illaux, French surgeon and anatomix, never clinically described frx, but did exuisite anatomic studies detailing results of experimentally produced an(le inuries.
OPEN F,ACT,ES . &STILLO AND ANDE,SON
T$pe I – 6ound %cm long, little 7! damage, no sign of crush, simple"transverse"obliue fx w" little comminution T$pe II – 6ound E%cm long, minor 7! damage, slight"moderate crush inury, moderate comminution T$pe III – -xtensive 7! inury, high degree of comminution IIIa – 7! coverage of bone is adeuate, trauma highnfection in the !reatment of %'; 1pen Fractures of 4ong Bones. J Bone Joint Surg Am. 1976 Jun;58(4!45"#8
CLOSED F,ACT,ES . TSC(E,NE T$pe C/ . 4ittle of no softnuries. Berlin, 5ermanyG 7pringer< ?erlag, %&/*, ppH
BONE ST,ESS IN',Y 0M,I1 . 2 I, &ra+e I – -ndosteal marrow edema &ra+e II – $eriosteal bone edema and endosteal edema &ra+e III – uscle edema, periosteal edema and endosteal marrow edema &ra+e I3 – Fracture line &ra+e 3 – #allus in cortical bone
T$pe I . +allux"sesamoid dislocation, no disruption of sesamoid apparatus, irreducible to closed reduction. T$pe IIa – closed reducible, disrupted intersesamoidal ligament T$pe IIb – closed reducible, transverse fx of sesamoids T$pe II" – open reduction, both >>a and >>b. Ja,ss %! Foot An/le 198*;1!15#)1
P,E-DISLOCATION SYND,OME . Y STA&E I – 7ubtle, mild edema with dorsal and plantar to lesser !$A. 0lignment of the digit unchanged compared to the contralateral digit. STA&E II – ild to oderate edema. Noticeable deviation of the digit. 4oss of toe purchase, noticeable in weight bearing STA&E III – oderate edema. $ronounced deviation"subluxation u. redislocation s:ndrome. rogressie sulu,alangeal 'oint.JA%A0 A>ril )**) A>r;9)(4!18)#99
6T( METATA,SAL BASE F,ACT,ES . STEWA,T CLASSIFICATION
T$pe I – 9Aones Fracture,: transverse fx of diaphyseal " metaphyseal unction. +ealing potential is poor. T$pe II – >ntraarticular avulsion fx T$pe III – -xtraarticular avulsion fx T$pe I3 – >ntraarticular comminuted fx T$pe 3 – 2peds3 -xtraarticular fx through epiphysis
$iuru %J. Bone Stress &n'uries. Acta adiol )**4; 45! "17#")6
F,ACT,E STABILITY . C(A,NLEY Most Stabe . transverse fx Potentia$ Stabe – short oblie fx, *J from transverse Least Stabe – long obliue, E*J, comminuted fxs
!ype >
#harnley, +,e -losed +reatment o -ommon An/le Fractures0 4 t, d0 2reen3ic, %edical %edia0 )**)
Ste3art &. Jones? racture! racture o t,e ase o t,e it, metatarsal. -lin rt,o> 196*; 16!19*#198
NON-NIONS . WEBE, 4 CEC( ($pertrophi" T$pe 2vascular, reactive3 %. -lephant=s foot ;. +orse=s hoof K. 1ligotrophic Atrophi" T$pe 2avascular, non
!ype >>
!ype >>>
!ype >?
!ype ?
NA3ICLA, F,ACT,ES . WATSON7'ONES CLASSIFICATION T$pe I – 0vulsion fx off tuberosity by $! tendon T$pe II – Dorsal lip fx, may resemble os supranaviculare T$pe IIIa – !ransverse fx, non
LISF,ANC8S F,ACT,ES - 9EN 4 2 SS CLASSIFICATION T$pe A – +omolateral"partial incongruity of 4isfranc=s oint T$pe B – >solateral"partial incongruity or 4isfranc=s oint T$pe C – Divergent fxL dislocation of 4isfranc=s oint uenu. 0 $uss 2. tude Sur les lu
LISF,ANC8S F,ACT,ES . (A,DCASTLE CLASSIFICATION T$pe A – either homolateral 2metatarsals displaced laterally3 or homomedial 2metatarsals displaced medially.3 T$pe B – $artial incongruityL not all metatarsals are displaced in the same direction. T$pe C – DivergentL %st metatarsal is medially dislocated, ;< are either partially or completely laterally dislocated.
5ST MP' DISLOCATIONS . 'A(SS CLASSIFICATION
Boher8s An%e< 9!uberosity Aoint 0ngle.: easures sagittal plane relationship of talus and calcaneus – compare to contralateral side. Normal M ;<*' degreesL angle is reduced when post. facet is depressed into the body of the calcaneus
ardcastle 0 et al. &n'uries to t,e tarsometatarsal 'oint. &ncidence0 -lassiication and +reatment.. J Bone and Joint Surg 198); 64B("!"49#56.
MYE,SON MODIFICATION TYPE A . !otal >ncongruity TYPE B5 – $artial >ncongruity, edial Dislocation TYPE B5 – $artial >ncongruity, 4ateral Dislocation TYPE C5 – Divergent, $artial Displacement TYPE C: – Divergent, !otal Displacement %:erson0 %0 FA&0 6; ))80 1986
Critia An%e o! &issane< easure of calcaneal strut that supports the lateral talar process. >s more specific for intra< articular distortion because it reveals the angular relationship of the calcaneal facets. Normal M %;<%*' degreesL >s increased greater than %/' degrees with displacement of the posterior facet in oint depression fractures night A, 5ross -0, Bradley 5, 4o?ecchio F. !he utility of Boehler=s angle and the critical angle of 5issane in diagnosing calcaneus fractures in the emergency department. Acad merg %ed . ;''L;G%%*<%%.
, OWE CLASSIFICATION T$pe Ia – plantar calcaneal tuberosity fx, secondary to eversion force 2medial tuberosity3 or inversion 2lateral tuberosity.3 ?iew w" axial calcaneal, lateral foot. T$pe Ib – shearing fx of the sustentaculum tali, secondary to inverted landing of heel. ?iew w" axial calcaneal. T$pe I" – anterior process fx, may appear similar to os calcaneum secundum. 1ccurs as a bifurcate ligament avulsion, secondary to adduction and plantarflexion. ?iew w" lateral, lat obliue isherwood. T$pe IIa – 9bea( fracture,: meaning a lift
extended and foot dorsiflexed. ?iew w" lateral foot radiograph. T$pe IIb – avulsion fx of the tendo 0chilles, same as a >>a but with complete dislocation.
T$pe IIIa – simple fx, obliue through calcaneal body not involving the 7!A. 1ccurs secondary to a fall, landing on both heels w" the feet inverted or everted. ?iew w" lateral foot, axial calcaneal.
CALCANEAL F,ACT,ES Si%ns 4 S$;pto;s< 0cute pain, edema about heel, pain w" compression"palpation, pain w" 7!A motion, fx blisters on s(in, plantar medial lateral ecchymosis 2 ;on+#r8s si%n3
T$pe IIIb – same as >>>a, but comminuted.
SANDE, 8S CLASSIFICATION 2NoteG !his classification system reuires the fracture to be visuali8ed w" coronal #! scan.3 T$pe I 20, B, and #3 – one part, nondisplaced articular fx.
T$pe I3a4b – same as type >>>, but w" 7!A involvement.
T$pe II 20, B, and #3 – two part fx of posterior facet.
T$pe 3a – intraarticular 7!A fx w" comminution and depression of the articular segment. T$pe 3b – intraarticular fx of the calcaneo
o3e -0 Sa/ellarides 0 Freeman ! Fractures o os calcis # a long#term ollo3#u> stud: one ,undred ort:#si< >atients. JA%A 196"; 184! 9)*#9)"
ESSE=-LOP,ESTI CLASSIFICATION Ton%#e T$pe . Axia oa+ panter!exe+ 'oint T$pe . Axia Loa+ Dorsi!exe+
T$pe III 20B, 0#, and B#3 – three part fx w" central depressed segment. T$pe I3 – comminuted fx of posterior facet.
sse<#Co>resti ! +,e mec,anism0 reduction tec,niue0 and results in ractures o t,e os calcis0 1951#5). -lin rt,o> 199" %a:; "#16
eratie treatment in 1)* dis>laced intraarticular calcaneal ractures. esults using a >rognostic com>uted tomogra>,: scan classiication. -lin rt,o> 199" %a:; 87#95
TALA, NEC2 F,ACT,ES . (AW2IN8S CLASSIFICATION !hese fxs are usually seen in ?0s or short
&ro#p I3 – 4ateral $rocess Fracture 2Feldborg3 &ro#p 3 – #rush inury – highly comminuted
a3/ins C! Fractures o t,e nec/ o t,e talus. JBJS 197*;5)A!991#1**)
TALA, DOME LESIONS . BE,NDT-(A,DY CLASSIFICATION Sta%e I – small area of compression in subchondral bone. Sta%e II – partially detached osteochondral fragment. Sta%e III – completely detached fragment, in crater. Sta%e I3 – complete fx, out of crater. $oor prognosis.
Sne>>en 0 -,rstensen SB0 $rogsoe 0 et al! Fractures o t,e od: o t,e talus. Acta rt,o> Scand 48! "17#")40 1977
LATE,AL TALA, P,OCESS - (AW2IN8S CLASSIFICATION T$pe I – 7imple fx from 0A articulation to 7!A T$pe II – #omminuted fx involving calcaneal fibular articulations T$pe III – #hip fx of anterior"inferior portion of lat process
DIAL a PIMP denotes the location of talar dome lesions – +orsiflexion internal rotation M anterior ateral lesion, plantarflexion inversion > ;edial posterior lesion. Me+ia Lesions< 2$>$, HO3 Deep, cup shaped, less li(ely to displace. Latera Lesions< 2D>04, **O 3 !hin, wafer shaped, easily displaced. Berndt0 A.C. art:0 %.! +ransc,ondral ractures o t,e talus. J Bone Joint Surg EAm 41! 988#1*)*0 1959
TALA, DOME LESION ?ONES ?ONE 5 ?ONE : ?ONE @ ?ONE ?ONE 6 ?ONE ?ONE ?ONE ?ONE F,ACT,ES OF T(E TALA, BODY - SNEPPEN &ro#p I – !alar Dome Fracture"1#D 2use Berndt<+ardy3 &ro#p II – 7hear Fracture – 'O 0?N, reuires 1)>F • #oronal • 7agittal • +ori8ontal &ro#p III – $osterior !ubercle Fracture – 7hepherd=s Fx
a3/ins C2! Fractures o t,e lateral >rocess o t,e talus. J Bone Joint Surg 1965; 47A! 117*#1175
EPIP(YSEAL F,ACT,ES . SALTE, -(A,,IS CLASSIFICATION
T$pe I – shearing force, separation of epiphysis from metaphysis w"o fx, seen at birth and in young children. T$pe II – fx line extends through physis and exits metaphysis. 7hearing or avulsion force, P !hurston +olland sign. Th#rston (oan+ Si%n – triangle shaped metaphyseal fx. T$pe III – fx line extends through physis and exits epiphysis 2intraarticular3. Due to shearing force. T$pe I3 – intraarticular fx through epiphysis, physis, and metaphysis. $rognosis is poor. T$pe 3 – compression fx, compacted germinal cells of physis die and cause premature closure. $oor prognosis. T$pe 3I 2)ang3 < contusion of perichondral ring of physis, acts li(e type ? if a bony bridge develops – prognosis good. T$pe 3II 21gden3 – epiphyseal fx not affecting physis T$pe 3III 21gden3 – partial fx of metaphysis, growth lines T$pe I= 21gden3 – degloving loss of periosteum on diaphysis B Salter0 arris &n'uries inoling t,e ei>,:seal >late. JBJS @ol 45. 196". > 587# 6")
DIAS-TAC(D'IAN CLASSIFICATION S#pination-In*ersion – grade > 203 S#pination-In*ersion – grade >> 2B3 S#pination-Pantar!exion 2#3
I3 – Fracture of third malleolus 2posterior tibia3 S#pination . Externa ,otation 0SE,1 I – )upture of ant inferior tibiontraerimental#surgical and e<>erimental#roentgenologic inestigations. Arc, Surg 195*; 6*!957#85
LATE,AL MALLEOLA, F,ACT,E . DANIS-WEBE, CLASSIFICATION
T$pe A – Fracture below the level of the tibial plafond T$pe B – Fracture at the level of the tibial plafond T$pe C – Fracture above the level of the tibial plafond Danis . Ces ractures malleolaires. &n! Danis (ed! +,eorie et >ractiue de lIosteos:nt,ese. aris0 %asson et -ie0 19490 >>1""#165 eer B2. Die @erletungen des oeren S>runggelen/es0 ed ). Bern0 Stuttgart0 ien0 @erlag ans uer0 197)
MEDIAL MALLEOLA, F,ACT,E – MLLE, CLASSIFCATION
T$pe A – 0vulsion of tip of medial malleolus T$pe B – 0vulsion at the level of the an(le oint T$pe C – 1bliue fx T$pe D – ?ertical orientation %uller %0 Allgo3er %0 Sc,eider 0 illenegger . %anual o &nternal Firinger#@erlag0 1991.
C(,ONIC TIBIOFIBLA, DIASTASIS . EDWA,DS 4 DELEE
S#pination-Ext ,otation – grade > 2D3 S#pination-Ext ,otation – grade >> 2-3 Pronation-E*ersion-Ext ,otation 2F3 '#*enie Tia#x Fra"t#re 253 Tripanar Fra"t#re 2+3
T$pe I . 7traight lateral subluxation of the fibula, w" medial clear space on x!F4 intact T$pe I3 – #omplete 0n(le Diastasis w" talus dislocated superiorly, wedged between the tibia and fibula. d3ards S0 DeCee -. An/le diastasis 3it,out racture. Foot An/le 1984;4!"*5#1)
Dias CS0 +ac,d'ian %! ,:seal in'uries o t,e an/le in c,ildren. -lin rt,o> elat es 1978;1"6!)"*G)""
AN2LE F,ACT,ES - LA&E-(ANSEN CLASSIFICATION !he first word in this classification denotes the position of the foot at time of inuryL the second word denotes the motion of the leg. !he numerical grades w"in each class occur each in chronological order and relate to the severity of trauma. S#pination . A++#"tion I – transverse fx of the lateral malleolus II – vertical fx of the medial malleolus Pronation . Ab+#"tion I – )upture of deltoid ligament"medial malleolar fx II – )upture of ant inferior tibio
MIDTA,SAL F,ACT,ES . MAIN 4 'OWETT 51 Medial Force 2K'O3 precursor to 7!A dislocation T$pe A < fla(e fx of dorsal talus or navicular and lateral calcaneus or cuboid T$pe B < medial displacement of FF w" !N and ## oints T$pe C < FF rotates medially around interosseous talocalcaneal lig w" !N disassociation and ##A intact :1 Longitudinal Force 2*'O3 worst prognosis of non
T$pe B < !NA displaces laterally w" comminution of ##A 1 Plantar Force 2IO3 T$pe A
PILON F,ACT,ES . , EDI 4 ALL&OWE, CLASSIFICATION T$pe 5< ild to moderate displacement no comminution, w"o maor disruption of an(le oint T$pe :< oderate displacement no comminution w" significant dislocation of an(le oint T$pe @< -xplosion fx, severe comminution displacement
LATE,AL AN2LE SP,AINS !he 0!F4 inured more freuently followed by the anterolateral an(le capsule, #F4, and then $!F4. !he 0!F4 is oriented so that it is under most tension during plantarflexion. !he angle between 0!F4 and #F4 in the sagittal plane is %' degrees. !he #F4 is stressed in dorsiflexion and also with frontal plane inversion of 7!A. !wo tests can be used test mechanical instability of the an(leG !he anterior +rawer test and taar tit.
Anterior Drawer Test< Castain%G
AO CLASSIFICATION 0MELLE, 1 T$pe A < extra articular T$pe B < partially articular T$pe C < completely articular All t,ree can inole! a. no comminution or im>action in articular or meta>,:seal surace . im>action inoling su>ra#articular meta>,:sic c. comminution im>action o articular surace 3it, meta>,:seal im>action
TALA, TILT TEST BonninG '' to %' M 0!F4 rupture. %' to K'' M 0!F4 and #F4 rupture. ore than K'' M 0!F4, #F4, and $!F4. 2arsson< ' to %'' E contralateral an(le or more than % ' unilaterally is abnormal. AN2LE SP,AIN . DIAS CLASSIFICATION &ra+e I – partial rupture of #F4 &ra+e II – complete rupture of 0!F4 &ra+e III – complete rupture of 0!F4, #F4, and"or $!F4 &ra+e I3 – complete rupture of all K lateral ligaments P partial rupture of deltoid ligament Dias CS. +,e lateral an/le s>rain! an e<>erimental stud:. J +rauma 1979;19(4!)66#9
AN2LE SP,AIN . O8DONO&(E CLASSIFICATION 5 De%ree – ligament stretch w" minimal disruption :n+ De%ree – partial ligament disruption w" oint instability @r+ De%ree – complete ligament disruption st
%uller %0 Haarian S0 $oc,0 et al.; S>ringer#@erlag0 Berlin. -lassiication A des ractures. 199*
IDonog,ue D! +reatment o &n'uries to At,letes. )nd ed. ,iladel>,ia0 a! B Saunders -o; 197*
AN2LE SP,AIN . LEAC( CLASSIFICATION
5st De%ree – partial or complete tear of 0!F4 :n+ De%ree – partial or complete tear of 0!F4 #F4 @r+ De%ree – partial or complete tear or 0!F4, #F4, $!F4 Ceac, 0 Hai/i 0 aul 20 Stoc/el J. Secondar: reconstruction o t,e lateral ligaments o t,e an/le. -lin rt,o> 198); ))6!169#7"
AN2LE SP,AIN . , ASMSSEN CLASSIFICATION Sta%e I – rupture of 0!F4 Sta%e II – rupture of superficial fibers of $!F4 Sta%e III – rupture of #F4 Sta%e I3 – rupture of deep fibers of $!F4 asmussen ! Stailit: o t,e an/le 'oint. Anal:sis o t,e unction and traumatolog: o t,e an/le ligaments. Acta rt,o> Scand Su>>l 1985; )11! 1#75
ST' DISLOCATION
Subtalar joint dislocations are commonly classifed according to the position o the oot in relation to the talus T$pe I – edial dislocation of 7!A or 90cuired clubfoot: T$pe II – 4ateral dislocation of 7!A or 90cuired flatfoot: T$pe III – 0nterior"posterior dislocation of 7!A Buc/ing,am Jr. Sutalar dislocation o t,e oot. J +rauma 197";1"!75"#765 S+AKS D-! Sutalar dislocation o t,e oot. J Bone Joint Surg 30: 4)70 19"5.
PTTD . 'O(NSON AND ST,OM Sta%e I – edial pain, tenosynovitis, mild wea(ness on heel< raise test Sta%e II – edial"lateral pain, tendon elongation, flexible pes planus, wea(ness on heel raise, P too many toes sign Sta%e III – edial"lateral pain, tendon degeneration, fixed pes planus, no inversion on heel raise, P too many toes sign Sta%e I3 – edial"lateral pain, tendon degeneration, flexed pes planus, no inversion on heel raise, P too many toes sign, 7!A arthritis
%ueller +J! Acuired latoot secondar: to tiialis >osterior d:sunction! Biomec,anical as>ects. J. Foot Surg. "*!)0 1991
PTTD . CONTI CLASSIFICATION 0M,I1 Sta%e I – 1ne or two fine, longitudinal tears Sta%e II – >ntramural degeneration, variable diameter, wide longitudinal tears Sta%e III – 7carring in tendon, complete tear
-onti S et al. -linical signiicance o %& in >re#o>eratie >lanning or reconstruction o >osterior tiial tendon ru>tures. Foot and An/le 199); 1"!)*8
PTTD . , OSENBE,& CLASSIFICATION 0M,I1 Sta%e I – +ypertrophic tears in tendon 2appears bulbous3 Sta%e II – 0trophic tears Sta%e III – #omplete tear osenerg LS0 et al! u>ture o >osterior tiial tendon! -+ and % imaging 3it, surgical correlation. adiolog: 1988;169!))9#)"5 Jo,nson $A0 Strom D. +iialis >osterior tendon d:sunction. -linical rt,o>edics. 1989;)"9!196#)*6
PTTD . MELLE, CLASSIFICATION Based on tiolog: T$pe I – Direct inury T$pe II – )upture secondary to systemic disease T$pe III – >diopathic T$pe I3 – )upture secondary to mechanical dysfunction
AC(ILLES , PT,E . 2 WADA CLASSIFICATION !he achilles is an conoined tendon that internally rotates to insertion. >t has a 9watershed: area at ;
at the area, with a palpable gap. $atients may present with an antalgic gait. T$pe I . $artial rupture of tendon T$pe II – #omplete rupture of tendon, Kcm gap T$pe III – #omplete rupture, Kture. -lin odiatr %ed Surg 1995;1)! 6""#5)
PE,ONEAL TENDON DISLOCATION - EC2E,T 4 DA3IS &ra+e I – retinaculum ruptured from cartilaginous lip to posterior lateral malleolus &ra+e II – distal %<;cm fibrous lip of malleolus is elevated w" retinaculum &ra+e III – a thin fragment of bone w" cartilage is avulsed from deep surface of peroneal retinaculum deep fascia &ra+e I3 0O+en1 – a mid
T$pe III – 1steo assoc w" vascular insufficiency T$pe I3 – #hronic osteo aldogel FA et al! steom:elitis! a reie3 o clinical eatures0 t,era>eutic considerations and unusual as>ects. H ngl J %ed 197* Jan )); )8)(4! 198#)*6
OSTEOMYELITIS . PAT?A2IS CLASSIFICATION ?one I – Distal metatarsal nec( 2most common3 ?one II – ! nec( to !A 2least common3 ?one III – calcaneus or talus ata/is J0 -al,oun J0 -iern: 20 oltom 0 %ader J+0 Helson -C S:m>osium! -urrent -once>ts in t,e %anagement o steom:elitis. #ontemporary 1rthopaedics 0 )8()! 157#185 >assim0 1994
TA,SAL COALITIONS . DOWNEY A '#*enie 0Osseo#s I;;at#rit$1 T$pe I – extra
T$pe II – intra
B A+#t 0Osseo#s Mat#rit$1 T$pe I – extra
T$pe II – intra
TA,SAL COALITIONS . PE,LMAN AND WE,T(EIME, CLASSIFICATION T$pe I – #ongenital coalition T$pe II – 0cuired coalition erlman %D0 ert,eimer SJ! +arsal coalitions. J Foot Surg 1986; )5(1! 58#67
TA,SAL COALITIONS . TAC(D'IAN CLASSIFICATION I Isoate+ Ano;a$ Ia – !#, #N, ##, or N# Ib – multiple combinations of >a I" – massive tarsal coalition
II Part o! Co;pex Ma!or;ation c/ert 0 Dais A Jr! Acute ru>ture o t,e >eroneal retinaculum. J Bone Joint Surg Am 1976 Jul; 58(5! 67*#)
OSTEOMYELITIS . BC2(OL? T$pe I – wound induced osteomyelitis Ia – open fx w" complete discontinuity I" – post
IIa – assoc w" other synostoses 2carpal coalition, synphalangism3 IIb – manifestation of a syndrome 20pert=s, Nievergelt<$erlman3
III Asso"iate+ w7 MaGor Li;b Abnor;aities POLYDACTYLY . 3ENN 4 WATSON
Ib – penetrating wound
T$pe II – mechanogenic infection IIa – implants, internal fixation IIb – contact instability"bone on bone apposition
T$pe III – physeal osteomyelitis T$pe I3 – ischemic limb disease T$pe 3 – combination osteo of types ><>? T$pe 3I – osteitis from septic arthritis T$pe 3II – chronic osteomyelitis Buc/,ol0 J% 1987. +,e surgical management o osteom:elitis! 3it, s>ecial reerence to a surgical classiication. J. Foot Surg. )6!S17#S)4
OSTEOMYELITIS . CIE,NY-MADE, CLASSIFICATION T$pe I – medullary osteo T$pe II – superficial osteo T$pe III – locali8ed osteo T$pe I3 – diffuse osteo T$pe A – good immune system and vascularity T$pe B – local or systemic immune compromise T$pe C – tx will be more harmful to patient than disease
0. 6ide etatarsal +ead B. !ol:dact:l: o t,e oot. rt,o> -lin Hort, Am 1976 ct; 7(4! 9*9#)7
POLYDACTYLY . TETAMY 4 MC2 SIC2 CLASSIFICATION ost#aol:dact:l: onl: T$pe A – #omplete digit that articulates w" th ! head or duplicate th ! T$pe B – 0ccessory digit w"o osseous attachment +etam: Sa0 %c$usic/ @A! S:no>sis o ,and malormations 3it, >articular em>,asis on genetic actors. Birt, Deects 5("!1)50 1969
POLYDACTYLY . BLAT( 4 OLASON CLASSIFICATION T$pe A – 0rrangement based on duplication distal to prox A5 – distal phalanx A@ – proximal phalanx
A: – middle phalanx A – metatarsal A6 – tarsal bone
-iern: 20 %ader J+! Adult c,ronic osteom:elitis. rt,o>aedics 1984; 7
T$pe B – !ransverse numbering of digits medial to lateral
OSTEOMYELITIS . WALD3O&EL CLASSIFICATION T$pe I – +ematogenous osteo T$pe II – 1steo secondary to contiguous source
Blaut, .0 lason A+ -lassiication o >ol:dact:l: o t,e. ,ands and eet. Arc,. rt,o>. +rauma. Surg.0 19880 1*70. ""4#"44
SYNDACTYLY . DA3IS 4 &E,MAN T$pe I – incomplete webbing between digits
T$pe II – complete webbing to ends of digits T$pe III – simple syndactyly, no phalangeal involvement T$pe I3 – complicated, phalangeal bones appear abnormal
@anore J@ et al. -linical ractice 2uideline First %etatarso>,alangeal Joint Disorders anel. Diagnosis and treatment o irst metatarso>,alangeal 'oint disorders. Section )! ,allu< rigidus. J Foot An/le Surg 4)!1)4#1"60 )**"
Dais JS0 2erman J (19"* S:ndact:lism. Arc, Surg )1 ! ")#. 75. 5
A3N OF T(E :ND METATA,SAL . F,EIBE,& T$pe I . no DAD, articular cartilage intact T$pe II – periarticular spurs, articular cartilage intact T$pe III – severe DAD, loss of articular cartilage T$pe I3 – epiphyseal dysplasia, multiple head involvement
C(A,COT FOOT . EIC(EN(OLT?H YH S(IBATA Sta%e / . swelling, warmth, w" oint instability Sta%e I – destructive phase w" oint laxity, subluxation, and osteochondral fragmentation Sta%e II – coalescenceL absorption of debris and fusion of larger fragments to adacent bone Sta%e III – remodelingL revasculari8ation and remodeling of bone and fragments ic,en,ol SH. -,arcot Joints. S>ringield! -,arles -. +,omas0 1966 u0 aluation and +reatment o Stage * -,arcot?s Heuroart,ro>at,: o t,e Foot and An/le. JA%A 9)(4! )1*#))*0 )**) S,iata0 esults o art,rodesis o t,e an/le in le>rotic neuro>at,: >ts. JBJS 199*
Freierg A! &nraction o t,e second metatarsal one0 a t:>ical in'ur:. Surg 2:n 1914; 19! 191#16"
A3N OF T(E :ND METATA,SAL . 2 ATC(E,IAN Le*e A . fissures noted in distal metaphysis or epiphysis Le*e B – increased fissuring w" bone resorbtion Le*e C – increased fissuring w" central collapse of ! head Le*e D – collapse fx w" fragments on either side of oint Le*e E – complete collapse of ! head $atc,erian DA! +reatment o FreiergIs Disease. rt,o> -lin Hort, Am )5! 690 1994
C(A,COT FOOT DEFO,MITY . ON3LEE Pattern A – $lano o 6* >atients. +,esis. +,e net,erlands! Kniersit: o Ceiden0 1998.
(ALL= LIMITS7, I&IDS . D,A&OH O,LOFF H AND 'ACOBS &ra+e I – Functional limitus +allux euinus"flexus, plantar subluxation of proximal phalanx, $-, no DAD, hyperextension of +>$A, pronatory architecture, oint )1 normal N6B, but is limited on 6B.
&ra+e II . 0daptationL proliferative"destructive oint change Flattening of %st ! head, pain on end )1, passive )1 limited, osteochondral defect"cartilage fibrillation erosion, small dorsal exostosis, subchondral eburnation, periarticular lipping or phalanx base and % st ! head
&ra+e III< Aoint deterioration"arthritis, established arthrosis 7evere flattening of %st ! head, osteophytosis dorsally, non
&ra+e I3 – 0n(ylosis"+allux )igidus 1bliteration of oint space w" loss of maority of articular surface, exuberant osteophytosis w" oint mice, less than %'J )1, deformity, malalignment Drago JJ0 lo C0 Jacos A%! A com>re,ensie reie3 o ,allu< limitus. J Foot Surg )"! )1"0 1984
(ALL= LIMITS7, I&IDS . , E&NALD CLASSIFICATION 5st De%ree – 4imitation of % st $A )1 to *'J, pain at end )1, narrowing of oint space, flattening of ! head, periarticular spurring, no sesamoidal d8 :n+ De%ree – 0rthrosis, enlargement of oint, loss of )1, painful )1, crepitus, narrowing of oint space, flattening of ! head, periarticular spurring, sesamoid hypertrophy @r+ De%ree – 0n(ylosis, crepitus, little or no )1, pain, loss of oint space, mar(ed hypertrophy of oint, oint mice, mar(ed involvement of sesamoids egnauld B. allu< rigidus. &n +,e Foot0 >> "45#"590 edited : B egnauld0 S>ringer# @erlag0 Berlin0 1986
(ALL= LIMITS 7, I&IDS . MODIFIED , E&NALD7O,LOFF CLASSIFICATION Sta%e I – Functional hallux limitus No DAD, no pain on end )1, limited )1 on 6B but normal N6B
Sta%e II – Aoint adaptation $ain on end )1, flattening of % st ! head, small dorsal osteophyte
Sta%e III – Aoint deterioration #repitus on )1, non
Sta%e I3 – 0n(ylosis 1bliteration of oint space, osteophyte fragmentation, minimal to no )1
COMPLE= , E&IONAL PAIN SYND,OME . IASP 05@1 C,PS t$pe I 0,SD1 . regional pain, sensory changes, abnormalities of temperature, abnormal sudomotor activeity, edema, and abnormal s(in color C,PS t$pe II 0"a#sa%ia1 . 0ll former symptoms in addition to a peripheral nerve lesion. einders. -om>le< regional >ain s:ndrome t:>e &! use o t,e international association or t,e stud: o >ain diagnostic criteria deined in 1994. -lin J. ain 18! )*7#)150 )**).
NE,3E IN',Y . SEDDEN Ne#ropraxia – interruption of nerve impulse due to extrinsic pressure, resulting in pinpoint segmental demyelination Axonot;esis . severance of individual nerve fibers, resulting in partial severance of nerve Ne#rot;esis – complete severance of nerve, resulting in wallerian degeneration Seddon J! +,ree t:>es o nere in'uries. Brain 194"; 66! )"7
NE,3E IN',Y . SNDE,LAND CLASSIFICATION 5 De%ree – disruption of nerve impulses w"o wallerian degeneration :n+ De%ree – disruption of axon, w" wallerian degeneration distal to the point of inury @r+ De%ree – fibrosis of nerve, regrowth w" fusiform swelling th De%ree – incomplete severance of nerve 6th De%ree < complete severance of nerve st
Sunderland S! A classiication o >eri>,eral nere in'uries >roducing loss o unction. Brain 74!491#5160 1951
FOOT LCE,ATION . WA&NE, &ra+e / – 7(in is intact, no open lesions. &ra+e 5 – 7(in only lesion, large or small, dirty or clean &ra+e : – Deeper lesion involving tendon, muscle, or bone &ra+e @ – 5rade ; w" infection 2abscess, osteomyelitis3 &ra+e – $artial gangrene in the forefoot &ra+e 6 – -ntire foot is gangrenous, no procedures possible agner F Jr. +,e diaetic oot. rt,o>edics 1987;1*!16"#7)
TSA CLASSIFICATION &ra+e / – pre or post ulcerative lesion, epitheliali8ed &ra+e 5 – superficial wound, w" out tendon, capsule or bone &ra+e : – wound penetrating to capsule, tendon, or bone &ra+e @ – wound penetrating to bone or oint T$pe A – #lean, vascular wound T$pe B – >nfected, vascular wound T$pe C – #lean, ischemic wound T$pe D – >nfected, ischemic wound Caer: CA0 Armstrong D20 ar/less CB. -lassiication o diaetic oot 3ounds. J Foot An/le Surg. 1996 Ho#Dec;"5(6!5)8#"1
0mputation of distal phalanx 2including D>$A3
B,N CLASSIFICATION 5 De%ree – superficial, involving outer layer of s(in, erythema, no blisters :n+ De%ree – superficial or deep, may or may not have blisters assoc w" erythema, anesthetic @r+ De%ree – fullncludes electric burns, radiation burns, and frostbite. #an lead to physeal growth arrest. Minor – %'O !B70 in adultsL O !B70 in children or elderlyL ;O full
joints; signifcant associated injuries (eg, racture, other major trauma) – Reereral to Burn Center J Burn Care Rehabil 1990;11:98-104 and from Guidelines for the Operations of Burn nits! Resour"es for Optimal Care of the #n$ured %atient: 1999& Committee on 'rauma& (meri"an Colle)e of *ur)eons!
MALI&NANT MELANOMA . CLA,2 Le*e 5 – epidermis to dermal"epidermal unction Le*e : – papillary dermis Le*e @ – to reticular dermis Le*e – reticular dermis Le*e 6 – subcutaneous fat -lar/0 ..0 Jr.! A classiiation o malignant melanoma in m an correlated 3it, ,istogenesis and iologic e,aior. &n %ontagna 0 u F (eds! Adances in Biolog: and S/in0 @ol 80 +,e igmentar: S:stem0 ergamon ress0 He3 or/0 1966! 61)#647
MALI&NANT MELANOMA . B,ESLOW 8S CLASSIFICATION 0S,3I3IAL , ATES1 Le*e 5 < '.Imm /K<%''O Le*e : – '.IH<%.mm KI<&'O Le*e @ – %.%<;.;mm KIt, o inasion in t,e >rognosis o cutaneous melanoma. Ann Surg 197*;17)!9*)#9*8
NAIL IN',IES . , OSENT(AL ?one 5 – to distal phalanx !xG w"o bony exposure, let granulate if %cm, graft if E%cm inury >f bony exposure, treat as 8one ; i nury
?one : – distal to lunula 7tasoy"utler pedicle flaps after wound is clean
?one @ – proximal to lunula
osent,al A. +reatment o ingerti> and nail ed in'uries0 rt,o> -lin Hort, Am 14!675#6970 198"
