# Multiple open/perc midfoot fractures and dislocations!



## martnel (Jun 30, 2015)

Please, pretty please!  Anybody out there that has extra time available, this is intense, and I need somebody to check on me please?  Thank you in advance!!

POSTOPERATIVE DIAGNOSIS:
1.	Right foot and ankle trauma. 
2.	Right foot homolateral Lisfranc fracture-dislocation of all five tarsal metatarsal joints. 
3.	Multiple midfoot fractures. 
4.	Second and third metatarsal fractures. 
5.	Unstable ankle joint.  

PROCEDURE:
1.	Open reduction and internal fixation of homolateral Lisfranc fracture-dislocation. 
2.	Open reduction and internal fixation of first second, third and fourth tarsometatarsal joints.
3.	Closed reduction and percutaneous pinning of fifth tarsometatarsal joint with fixation of fractures of second and third metatarsals. 
4.	Open reduction and internal fixation of intercuneiform instability between medial and middle cuneiform. 
5.	Open reduction and internal fixation of syndesmosis with a TightRope 

IMPLANTS: 
1.	Arthrex TightRope. 
2.	Synthes cannulated screws. 

BRIEF HISTORY:
22-year-old female status post pedestrian versus motor vehicle. She was seen by one of my partners and found to have a Lisfranc fracture-dislocation. She was placed into a splint. She was sent to me for definitive management. CT scan was obtained. It showed a homolateral severe Lisfranc fracture-dislocation with multiple midfoot fractures and metatarsal fractures. I was also concerned about a potential unstable ankle injury. We got full length tibia-fibula films. It did not show any obvious proximal fibula fracture. We discussed the possibility of having to perform a stress exam under anesthesia and fixing the syndesmosis if it was proved to be unstable. We have been waiting for her soft tissues to calm down prior to surgical treatment. Risks and benefits were discussed at length. She wished to proceed. 

PROCEDURE IN DETAIL:
The patient was met in the holding area. The operative extremity was marked. Risks and benefits of surgery were discussed at length. All questions were answered She underwent a block with anesthesia. She was taken to the operating room and underwent general without difficulty. A tourniquet was placed on the right thigh. She was prepped and draped normal, sterile fashion. 

I began by marking out our incisions using fluoroscopic imaging. An incision was made to the first and second metatarsal, as well as to the third and fourth metatarsal. I attempted to maximize skin bridge as much as possible. Next, the leg was elevated. I chose not to exsanguinate to facilitate visualization of neurovascular structures. The tourniquet was inflated. The incision between the first and second metatarsals was first made. The neurovascular bundle was protected. The deep capsule was incised and the first and second tarsometatarsal joints were identified. They were noted to be dislocated. There were some small chondral flecks present in the first/second interspace, but overall of the joints appeared to be in good condition. Because of this, I elected to fix these rather than do a primary fusion. We had a lot of difficulty in reducing the second metatarsal anatomically. It was found to have a tendon interposed plantarly. Once this was moved out of the way the metatarsal went back into an anatomic position. Next, an incision was made over the third and fourth metatarsals. Hemostasis was achieved with Bovie electrocautery. The fracture-dislocation sites were identified. The third metatarsal was able to be reduced into position. There was some dorsal comminution of both the third and fourth metatarsals. I began by reducing the first metatarsal and pinning it into place. I then used a point-to-point reduction clamp to reduce the second metatarsal back anatomically. I did this with the third  metatarsal, as well. Next, I used guidewires and cannulated screws to get fixation. For the second and third metatarsal fractures, I made sure to incorporate the fracture site so we could fix those as well. The guidewires were placed. They were evaluated under fluoroscopic imaging, measured, drilled, and then screws were placed. This was done for the first, second and third tarsometatarsal joints. We also performed fixation between the medial cuneiform ad middle cuneiform, because tere was instability there. I also performed fixation from the medial cuneiform to the base of the second metatarsal. I went to the lateral incision to visualize the fourth metatarsal base. It was reduced under direct visualization. I elected to pin it for internal fixation. The fifth metatarsal was reduced and also pinned into the cuboid for internal fixation. The tourniquet was released at 2 hours and 10 minutes. Hemostasis was achieved with pressure and Bovie electrocautery. The capsule was repaired with 2-0 Vicryl, subcutaneous tissues were closed with 3-0 Vicryl, skin was closed with 3-0 nylon. 

At the conclusion of the fixation, a stress fluoroscopic imaging with external rotation stress was undertaken. There was obvious widening of the syndesmosis, as well as the medial clear space. Thus, I elected to perform fixation of the syndesmosis. A clamp was placed across the syndesmosis. An incision was made and dissected down to the bone. An Arthrex TightRope was passed. It was then tightened down. This caused no more instability of the medial clear space or syndesmosis. The wounds were copiously irrigated. Subcutaneous tissues closed with 2-0 Vicryl, skin was closed 3-0 nylon. 

This is what I got:  (I just need some-one to check on me please!)

ORIF 1ST, 2ND,3RD,4TH TARSOMETATARSAL
		28615 RT	             838.03	BCBS 
 		28615-59 RT	838.03	 
 	 	28615-59 RT	838.03	 
 	 	28615-59 RT	838.03	 
 	CLS 5TH TARSOMETATATARSAL	
                          28606-59 RT	838.03	 
 	PERC. METATARSAL FX 	
                          28476 RT	825.25	 
 	             28476-59 RT	825.25	 
 	CUNEIFORM BONES	
                          28555 RT	838.01	 
 	SYNDESMOSIS	
                          27829 RT	837.0	

 	 	L8699	ALL


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