019 Foot and Ankle Classifications

CLASSIFICATION SYSTEMS EPONYMS Hunter. “Radiologic History Exhibit” Musculoskeletal Eponyms: Who Are Those Guys? Radiographics 2000: 20:819-836

Bosworth Frx – Fibular frx with posterior dislocation of talus. Named after David Bosworth, an NY orthopedic surgeon who introduced streptomycin for bone and joint TB. Chopart Frx – Frx/dislocation involving the midtarsal joints. Francois Chopart, surgeon in Paris, whose amps through midtarsal joint was effective and resisted infection.

Cotton Frx – Frx of lateral and medial malleolus and frx of posterior process of tibia. Fredrich Cotton, Boston surgeon, who illustrated his own 1910 book, Dislocations and Fractures. Danis-Weber Classification – First described by Robert Danis, Belgian surgeon, in 1949. His pioneering work in internal fixation led colleague Maurice E. Muller to assemble a study group in 1958 for clinical trials of internal fixation – Arbeitsgemeinschaft schaft fur Osteosynthesefragen (AO). Later, the system was imodified by Bernhard Georg Weber a prominent orthopedic surgeon in Switzerland. Dupuytren Frx – Distal fibular frx above lateral malleolus w/ associated tear of tibiofibular and deltoid ligament. Lateral displacement of talus and possible medial malleolus frx. Guillaume Dupuytren, “greatest French surgeon and meanest of men” of the 19th century, has his name associated w/ 12 different conditions/operations. Essex Essex-Lopresti Classification – Peter Gordon EssexLopresti, surgeon at Britain’s Birmingham Accident Center during World War II, was an expert in parachuting injuries. Freiberg Infraction – Refers to deformity of head of second or third metatarsal from AVN, presumably secondary to trauma. Named med after Albert Henry Freiberg, Professor of Orthopedic Surgery at the University of Cincinnati, OHIO. Gosselin Frx – V-shaped shaped frx of distal tibia that extends into the tibial plafond and divides plafond into anterior and posterior fragments. Leon Athanese Gosselin was chief of surgery at the Hopital La Charite in Paris. Jones Frx – Base of fifth metatarsal distal to metarsal tuberosity. Described by Sir Robert Jones in 1902 after injurying himself dancing, he was the leading British orthopedic surgeon of the period. Lauge-Hansen Classification – Niel Lauge-Hansen, a prominent Danish

physician, performed classic cadaver cada studies in 1940-50’s to elucidate mechanisms involved in ankle injuries. Le Fort Fx of the Ankle – Vertical frx of the anterior medial portion of the distal fibular with avulsion of the anterior tibiofibular ligament. Leon Clement Le Fort, distinguished distinguis French surgeon and sonin-law law to Joseph Francois Malgaigne (Fx of the pelvis), was best known for discovering direct communication between bronchial and pulmonary blood vessels and uterine prolapse surgery. Lisfranc Frx – Refers to frxdislocation or frx-subluxation f of TMT joint. Jacques Lisfranc De Saint Martin, surgeon in Napoleon’s army, who described a 1-minute 1 amputation method that saved a portion of the foot after distal injury or frostbite. Also described scalene tubercle on the first rib at insertion nsertion of the scalenus anterior muscle, Lisfranc’s tubercle. Masionneuve Frx – spiral frx of the upper third of fibular w/ tear of distal tibiofibular syndesmosis and interosseous membrane. Also, associated frx of medial malleolus or rupture of the deepp deltoid ligament. Jaceuqes Gilles Maisonneuve was a student of Dupuytren. Osgood-Schlatter Schlatter Disease – Term used to describe chronic fatigue injury that affects growth and development of tibial apophysis at site of attachment of patellar tendon to the tibial ial tuberosity. Robert B. Osgood was a Boston orthopedic surgeon during World War I, and Carl Schlatter was a professor of surgery in Zurich Switzerland. Pott Frx – Partial dislocation of the ankle w/ frx of the distal fibular shaft and rupture of the medial ial ligaments. Percival Pott was a leading surgeon in London and described TB in the spine (Pott’s Disease). Salter-Harris Harris Classification – Robert Bruce Salter, currently a Canadian surgeon at the University of Toronto. Robert Harris is another Canadian orthopedic surgeon at the University of Toronto. Shepard Frx – The lateral tubercle of the posterior process of the talus frx may simulate an os trigonum. Francis J. Shepard was from England, but emigrated to Canada to become a prominent surgeon. Tillaux Frx – An avulsion injury of the anterior tibial tubercle at the attachment of the distal anterior tibiofibular ligament. Paul Jules Tillaux, French surgeon and anatomix, never clinically described frx, but did exquisite anatomic studies detailing results result of experimentally produced ankle injuries.

OPEN FRACTURES – GUSTILO AND ANDERSON Type I – Wound 1cm 1cm long, minor ST damage, slight/moderate crush injury, moderate comminution Type III – Extensive ST injury, high degree of comminution IIIa – ST coverage of bone is adequate, trauma high high-energy IIIb – extensive ST damage requiring free-flap flap for coverage, coverage assoc w/ periosteal stripping and ST contamination IIIc – any open fx w/ arterial injury requiring immediate repair Gustilo & Anderson Prevention of Infection in the Treatment of 1025 Open Fractures of Long Bones. J Bone Joint Surg Am. 1976 Jun;58(4):453-8 Gustilo. Problems in the Management of Type III (severe) Open Frx: A New Classification of Type III Open Frx. J. Trauma. 24:8 1984.

COMPARTMENTS OF THE FOOT – MANOLI AND WEBER Hindfoot (1) – CALCANEUS: quadratus plantae, posterior tibial artery, vein, and nerve, lateral plantar artery, vein, nerve, medial plantar artery, vein, nerve, communicates with deep leg Forefoot (5) – INTEROSSEUS (X4): interossei; ADDUCTOR: adductor hallucis Full Length (3) – MEDIAL: flexor hallucis, abductor ha hallucis; LATERAL: abductor digiti quinti, flexor digiti minimi; SUPERFICIAL: flexor digitorum brevis, lumbricals (4), flexor digitorum longus tendons, medial plantar nerve

Type IIa – closed reducible, disrupted intersesamoidal ligament Type IIb – closed reducible, transverse fx of sesamoids Type IIc – open reduction, both IIa and IIb. Jahss MH: Foot Ankle 1980;1:15-21

PRE-DISLOCATION SYNDROME – YU Stage I – Subtle, mild edema with dorsal and plantar to lesser MTPJ. Alignment of the digit unchanged compared to the contralateral digit. Stage II – Mild to Moderate edema. Noticeable deviation of the digit. Loss of toe purchase, noticeable in weight wei bearing Stage III – Moderate edema. Pronounced deviation/subluxation Yu. Predislocation syndrome. Progressive subluxation/dislocation of the lesser metatarsophalangeal joint.JAPMA, JAPMA, April 2002 Apr;92(4):182-99

5TH METATARSAL BASE FRACTURES – STEWART Type I – “Jones Fracture,” transverse fx of diaphyseal / metaphyseal junction. Healing potential is poor. Type II – Intraarticular avulsion fx Type III – Extraarticular avulsion fx Type IV – Intraarticular comminuted fx Type V – (peds) Extraarticular fx through epiphysis

Manoli and Weber. Fasciotomy of the foot: an anatomical study with special rreference to release of the calcaneal compartment of the foot. FAI 10(5):267-75, 10(5):267 1990

CLOSED FRACTURES – TSCHERNE Type C0 – Little of no soft-tissue injury Type CI – Superficial abrasion and mild to moderately severe fracture configuration Type CII – Deep contaminatd abrasion with local contusional damage to skin or muscle and moderately severe facture configuration Type CIII – Extensive skin contusion or crushing or muscle destruction and severe fracture. Tscherne H, Gotzen L: Fractures With Soft Tissue issue Injuries. Berlin, Germany: Springer SpringerVerlag, 1984, pp6-7.

BONE STRESS INJURY (MRI) – KIURU Grade I – Endosteal marrow edema Grade II – Periosteal bone edema and endosteal edema Grade III – Muscle edema, periosteal edema and endosteal marrow edema Grade IV – Fracture line Grade V – Callus in cortical bone Kiuru MJ. Bone Stress Injuries. Acta Radiol 2004; 45: 317-326 326

FRACTURE STABILITY – CHARNLEY Most Stable – transverse fx Potentially Stable – short obliqe fx, 45°, comminuted fxs Charnley, The Closed Treatment of Common Ankle Fractures, 4th Ed, Greenwich Medical Media, 2002

NON-UNIONS – WEBER & CECH Hypertrophic Type (vascular, reactive) 1. Elephant’s foot 2. Horse’s hoof 3. Oligotrophic Atrophic Type (avascular, non-reactive) 1. Torsion wedge 2. Comminuted 3. Defect 4. Atrophic Weber BG, Cech O. Pseudarthrosis; Grune and Stratton, 1976

1ST MPJ DISLOCATIONS – JAHSS CLASSIFICATION Type I – Hallux/sesamoid dislocation, no disruption of sesamoid apparatus, irreducible to closed reduction.

Type I

Type II

Type III

Type IV

Type V

Stewart I. Jones’ fracture: fracture of the base of the fifth metatarsal. Clin Orthop 1960; 16:190-198

5TH METATARSAL FRACTURES - TORG Stage I – Acute fracture on chronic process, evidence of periosteal reaction, plantar-based plantar facture line, absence of medullary sclerosis Stage II – Similar to Stage I with additional presences of medullary sclerosis and narrowing; delayed union Stage III – Obliteration of medullary canal; non-union non Torg, JS; Balduini, FC; Zelko, RR; Pavlov, H; Peff, TC; Das, M: Fractures of the base of the fifth metatarsal distal to the tuberosity. J. Bone Joint Surg. 66-A:209, 1984.

NAVICULAR FRACTURES – WATSON/JONES CLASSIFICATION Type I – Avulsion fx off tuberosity by PT tendon Type II – Dorsal lip fx, may resemble os supranaviculare Type IIIa – Transverse fx, non-displaced non Type IIIb – Transverse fx, displaced Type IV – Stress fx Watson-Jones Jones R: Fractures and Joint Injuries. Vol 2. 4th ed. Baltimore, Md: Williams & Wilkins; 1955

LISFRANC’S FRACTURES - QUENU & KUSS CLASSIFICATION Type A – Homolateral/partial incongruity of Lisfranc’s joint Type B – Isolateral/partial incongruity or Lisfranc’s joint Type C – Divergent fx; dislocation of Lisfranc’s joint Quenu. E, Kuss G. Etude Sur les luxations du metatarse. Reb Chir 39: 281, 1909.

LISFRANC’S FRACTURES – HARDCASTLE CLASSIFICATION Type A – either homolateral (metatarsals displaced laterally) or homomedial (metatarsals displaced d medially.) Type B – Partial incongruity; not all metatarsals are displaced in the same direction. Type C – Divergent; 1st metatarsal is medially dislocated, 2-5 2 are either partially or completely laterally dislocated.

Critial Angle of Gissane: Measure of calcaneal strut that supports the lateral talar process. Is more specific for intraarticular distortion because it reveals the angular relationship of the calcaneal facets. Normal = 125-140 125 degrees; Is increased greater ater than 180 degrees with displacement of the posterior facet in joint depression fractures Knight J, Gross EA, Bradley G, LoVecchio F. The utility of Boehler’s angle and the critical angle of Gissane in diagnosing calcaneus fractures in the emergency department. de Acad Emerg Med. 2005;2:114-115.

Hardcastle PH, et al. Injuries to the tarsometatarsal joint. Incidence, Classification and Treatment.. J Bone and Joint Surg 1982; 64B(3):349-56.

LISFRANC’S FRACTURES – MYERSON MODIFICATION TYPE A – Total Incongruity TYPE B1 – Partial Incongruity, Medial Dislocation TYPE B1 – Partial Incongruity, Lateral Dislocation TYPE C1 – Divergent, Partial Displacement TYPE C2 – Divergent, Total Displacement Myerson, M, FAI, 6; 228, 1986

SUBTLE LISFRANC’S INJURY – NUNLEY & VERTULLO STAGE 1 - 2-5mm 5mm diastasis, no collapse of arch. STAGE 3 – >2-5mm 5mm diastasis, collapse of arch.

ROWE CLASSIFICATION Type Ia – plantar calcaneal tuberosity fx, secondary to eversion force (medial tuberosity) or inversion (lateral tuberosity.) View w/ axial calcaneal, lateral foot. Type Ib – shearing fx of the sustentaculum tali, secondary to inverted landing of heel. View w/ axial calcaneal. Type Ic – anterior process fx, may appear similar to os calcaneum secundum. Occurs as a bifurcate ligament avulsion, secondary to adduction and plantarflexion. pla View w/ lateral, lat oblique isherwood. Type IIa – “beak fracture,” meaning a lift-off off of the posterior superior surface of the calcaneus; some cortex still intact. Occurs when heel strikes ground w/ knee extended and foot dorsiflexed. View w/ lateral foot radiograph. Type IIb – avulsion fx of the tendo Achilles, same as a IIa but with complete dislocation.

Nunley. Vertullo. Classification, investigation, and management of Midfoot Sprains: Lisfranc Injuries in the Athlete. Am J Sports Med. 2002; 30:871 30:871-878.

CALCANEAL FRACTURES Signs & Symptoms: Acute pain, edema about heel, pain w/ compression/palpation, pain w/ STJ motion, fx blisters on skin, plantar medial &lateral ecchymosis (mondur’s mondur’s sign) sign Bohler’s Angle: “Tuberosity Joint Angle.” Measures sagittal plane relationship of talus and calcaneus – compare to contralateral side. Normal = 25-40 40 degrees; angle is reduced when post. facet is depressed into the body of the calcaneus

Type IIIa – simple fx, oblique through calcaneal body not involving the STJ. Occurs secondary to a fall, landing on both heels w/ the feet inverted or everted. View w/ lateral foot, axial calcaneal. Type IIIb – same as IIIa, but comminuted.

Type IVa&b – same as type III, but w/ STJ involvement.

Type Va – intraarticular STJ fx w/ comminution and depression of the articular segment. Type Vb – intraarticular fx of the calcaneo-cuboid cuboid joint.

Rowe CR, Sakellarides H, Freeman P: Fractures of os calcis - a long-term long follow-up study one hundred forty-six patients. JAMA 1963; 184: 920-923 923

ESSEX-LOPRESTI CLASSIFICATION Tongue Type – Axial load planterflexed Joint Type – Axial Load Dorsiflexed

Type III (AB, AC, and BC) – three part fx w/ central depressed segment. Type IV – comminuted fx of posterior facet.

-The The current standard for non-articular non calcaneal fractures is the Rowe system. For intra-articular intra calcaneal fractures, a coronal CT scan is indicated, and the Sanders system is typically used to classify. -The he goal of ORIF for intraarticular calcaneal fractures is to increase the height, decrease the width, return to neutral, and restore anatomy and articular surface. Essex-Lopresti Lopresti P: The mechanism, reduction technique, and results in fractures of the os calcis, 1951-52. Clin Orthop 1993 May; 3-16

SANDER’S CLASSIFICATION (Note: This classification system requires the fracture to be visualized w/ coronal CT scan at widest width of calcaneus) Type I (A, B, and C) – one part, nondisplaced articular fx.

Type II (A, B, and C) – two part fx of posterior facet.

Sanders R, Fortin P, DiPasquale T: Operative treatment in 120 displaced intraarticular calcaneal neal fractures. Results using a prognostic computed tomography scan classification. Clin Orthop 1993 May; 87-95

TALAR NECK FRACTURES – HAWKIN’S CLASSIFICATION These fxs are usually seen in MVAs or short--height falls Type I – minimal displacement, 7-15% 15% chance of AVN Type II – STJ subluxation, 35-50% 50% chance of AVN Type III – ankle dislocation, 85% chance of AVN Type IV – STJ/ankle/TNJ dislocation, 100% chance of AVN Hawkin’s Sign – subchondral lucency of the body of the talus talu following fx; appears 6-8 8 weeks post fx; = revascularization

Hawkins L: Fractures of the neck of the talus. JBJS 1970;52A:991-1002 1970;52A:991

TALAR DOME LESIONS – BERNDT-HARDY CLASSIFICATION Stage I – small area of compression in subchondral bone. Stage II – partially detached osteochondral fragment. Stage III – completely detached fragment, in crater. Stage IV – complete fx, out of crater. Poor prognosis.

DIAL a PIMP denotes the location of talar dome lesions – dorsiflexion internal rotation = anterior lateral ateral lesion, plantarflexion inversion = medial posterior osterior lesion. Medial Lesions: (PIMP, 56%) 6%) Deep, cup shaped, less likely to displace. Lateral Lesions: (DIAL, 44% ) Thin, wafer shaped, easily asily displaced.

Sneppen O, Chrstensen SB, Krogsoe O, et al: Fractures of the body of the talus. Acta Orthop Scand 48: 317-324, 1977

LATERAL TALAR PROCESS - HAWKIN’S CLASSIFICATION Type I – Simple fx from AJ articulation to STJ Type II – Comminuted fx involving calcaneal & fibular articulations Type III – Chip ip fx of anterior/inferior portion of lat process

Hawkins LG: Fractures of the lateral process of the talus. J Bone Joint Surg 1965; 47A: 1170-1175 EPIPHYSEAL FRACTURES – SALTER-HARRIS CLASSIFICATION

Berndt, A.L. & Harty, M.: Transchondral fractures of the talus. J Bone Joint Surg [Am] 41: 988-1020, 1959

FRACTURES OF THE TALAR BODY - SNEPPEN Group I – Talar Dome Fracture/OCD (use Berndt Berndt-Hardy) Group II – Shear Fracture – 50% AVN, requires ORIF • Coronal • Sagittal • Horizontal Group III – Posterior Tubercle Fracture – Shepherd’s Fx Group IV – Lateral Process Fracture (Fjeldborg) Group V – Crush injury – highly comminuted

Type I – shearing force, separation of epiphysis from metaphysis w/o fx, seen at birth and in young children.

Type II – fx line extends through physis and exits metaphysis. Shearing or avulsion force, + Thurston Holland sign. Thurston Holland Sign – triangle shaped aped metaphyseal fx. Type III – fx line extends through physis and exits epiphysis (intraarticular). Due to shearing force. Type IV – intraarticular fx through epiphysis, physis, and metaphysis. Prognosis is poor. Type V – compression fx, compacted germinal cells of physis die and cause premature closure. Poor prognosis. Type VI (Rang) - contusion of perichondral ring of physis, acts like type V if a bony bridge develops – prognosis good. Type VII (Ogden) – epiphyseal fx not affecting physis Type VIII (Ogden) – partial fx of metaphysis, growth lines Type IX (Ogden) – degloving loss of periosteum on diaphysis RB Salter, WR Harris Injuries involving the eiphyseal plate. JBJS Vol 45. 1963. p 587587 632

DIAS-TACHDJIAN CLASSIFICATION Supination-Inversion – grade I (A) Supination-Inversion – grade II (B) Supination-Plantarflexion (C)

II – Spiral oblique ique fx of lateral malleolus (extending anterior inferior to posterior superior.) III – Rupture of post inferior tibio-fibular tibio ligament IV – Deltoid rupture/fx of medial malleolus Pronation – External Rotation (PER) I – Rupture of deltoid ligament/medial malleolar fx II – Rupture of ant inferior tibio-fibular tibio ligament, Intra-osseous osseous ligament, intra-osseous intra membrane III – Spiral fx above syndesmosis (high fibular fx) IV – Rupture of post inferior tibio-fibular tibio ligament All external rotation injuries may cause DIASTASIS – separation of the tibio-fibular fibular syndesmosis. Lauge-Hansen Hansen N. Fractures of the ankle. II Combined experimental-surgical experimental and experimental-roentgenologic roentgenologic investigations. Arch Surg 1950; 60:957-85 60:957

LATERAL MALLEOLAR FRACTURE – DANIS-WEBER CLASSIFICATION

Type A – Fracture below the level of the tibial plafond Type B – Fracture at the level of the tibial plafond Type C – Fracture above the level of the tibial plafond Danis R. Les fractures malleolaires. In: Danis R (ed): Theorie et practique de l'osteosynthese. Paris, Masson et Cie, 1949, pp133-165 pp133 Weber BG. Die Verletzungen des oberen Sprunggelenkes, ed 2. Bern, Stuttgart, Wien, Verlag Hans Huber, 1972 MEDIAL MALLEOLAR FRACTURE – MULLER CLASSIFCATION

Type A – Avulsion of tip of medial malleolus Type B – Avulsion at the level of the ankle joint Type C – Oblique fx Type D – Vertical orientation Muller M, Allgower M, Scheider R, Willenegger H. Manual of Internal Fixation. 3rd Ed. Springer-Verlag, 1991. CHRONIC TIBIOFIBULAR DIASTASIS – EDWARDS & DELEE

Supination-Ext Rotation – grade I (D) Supination-Ext Rotation – grade II (E) Pronation-Eversion-Ext Rotation (F) Juvenile Tillaux Fracture (G) Triplanar Fracture (H)

Type I – Straight lateral subluxation of the fibula, w/ medial clear space on x-ray ray (due to interposition of delroid ligament) Type II – Lateral fibular subluxation w/ plastic or angular deformity (due to fibular bular microfracture) Type III – Posterior rotatory subluxation of distal fibula behind talus w/ PITFL intact Type IV – Complete Ankle Diastasis w/ talus dislocated superiorly, wedged between the tibia and fibula. Edwards S, DeLee C. Ankle diastasis without fracture. Foot Ankle 1984;4:305-12

Dias LS, Tachdjian MO: Physeal injuries of the ankle in children. Clin Orthop Relat Res 1978;136:230–233

ANKLE FRACTURES - LAUGE-HANSEN CLASSIFICATION The first word in this classification denotes the position of the foot at time of injury; the second word denotes the motion of the leg. The numerical grades w/in each class occur each in chronological order and relate to the severity of trauma. Supination – Adduction I – transverse fx of the lateral malleolus II – vertical fx of the medial malleolus Pronation – Abduction I – Rupture of deltoid ligament/medial malleolar fx II – Rupture of ant inferior tibio-fibular fibular ligament III – Bending fx of fibula 1cm proximal to plafond Pronation – Dorsiflexion I – Fx of medial malleolus II – Large anterior lip fx of tibia III – Fracture of superior lateral malleolus IV – Fracture of third malleolus (posterior tibia) Supination – External Rotation (SER) fibular ligament I – Rupture of ant inferior tibio-fibular

MIDTARSAL FRACTURES – MAIN & JOWETT 1) Medial Force (30%)
precursor to STJ dislocation Type A - flake fx of dorsal talus or navicular and lateral calcaneus or cuboid Type B - medial displacement of FF w/ TN and CC joints Type C - FF rotates medially around interosseous talocalcaneal lig w/ TN disassociation and CCJ intact 2) Longitudinal Force (40%) worst prognosis of non-crush non Type A - maximally PF ankle giving a characteristic pattern of through and through navicular navicu compression fracture A1 - force through 1st ray: crushes medial 3rd w/ tuberosity displaced medially A2 - force thru 2nd ray: crushes middle 3rd w/ middle 3rd & tuberosity displaced medially A3 - force thru 3rd ray: crushes lateral 3rd w/ medial 2/3 & tuberosity displaced medially Type B - submaximally PF ankle resulting in dorsal displacement of superior navicular, n crush of inferior on x-ray 3) Lateral Force (17%) Type A - FF forced ced into valgus w/ fx of navicular tuberosity or dorsal talus and compression fx of CCJ (Nutcracker fx) Type B - TNJ displaces laterally w/ comminution of CCJ 4) Plantar Force (7%) Type A -avulsion avulsion fx of dorsal navicular or talus & ant process Type B - impaction fracture of inferior CCJ

5) Crush Injury (6%) PILON FRACTURES – RUEDI & ALLGOWER CLASSIFICATION Type 1- Mild to moderate displacement & no comminution, w/o major disruption of ankle joint Type 2- Moderate displacement & no comminution w/ significant dislocation of ankle joint Type 3- Explosion fx,, severe comminution & displacement

sagittal plane is 105 degrees. The CFL is i stressed in dorsiflexion and also with frontal plane inversion of STJ. Two tests can be used test mechanical instability of the ankle: The anterior drawer test and talar tilt. tilt ANTERIOR DRAWER TEST Castaing: 5-88 mm of anterior displacement = ATF rupture 10-15 mm = ATF, CF > 15 mm = ATF, CF, PTF

Ruedi T, Allgower M. Fractures of the lower end of the tibia into the ankle joint. Injury, 1969; 1: 92-99.

TALAR TILT TEST Bonnin: 00 to 150 = ATFL rupture. 150 to 300 = ATFL and CFL rupture. More than 300 = ATFL, CFL, and PTFL. Karlsson: 50 to 100 > contralateral ankle or more than 150 unilaterally is abnormal. ANKLE SPRAIN – DIAS CLASSIFICATION Grade I – partial rupture of CFL Grade II – complete rupture of ATFL Grade III – complete rupture of ATFL, CFL, and/or PTFL Grade IV – complete rupture of all 3 lateral ligaments + partial rupture of deltoid ligament

Main and Jowett. Injuries of the Midtarsal Joint. J Bone Joint Surg Br 57-B (1): 89.

AO CLASSIFICATION (MUELLER) Type A - extra articular Type B - partially articular Type C - completely articular All three can involve: a. no comminution or impaction in articular or metaphyseal surface b. impaction involving supra-articular metaphysic c. comminution & impaction of articular surface with metaphyseal impaction

Dias LS. The lateral ankle sprain:: an experimental study. J Trauma 1979;19(4):266-9 1979;19(4):266

ANKLE SPRAIN – O’DONOGHUE CLASSIFICATION 1st Degree – ligament stretch w/ minimal disruption 2nd Degree – partial ligament disruption w/ joint instability 3rd Degree – complete ligament disruption O'Donoghue DH: Treatment of Injuries to Athletes. 2nd ed. Philadelphia, Pa: WB Saunders Co; 1970

ANKLE SPRAIN – LEACH CLASSIFICATION 1st Degree – partial or complete tear of ATFL 2nd Degree – partial or complete tear of ATFL & CFL 3rd Degree – partial or complete tear or ATFL, CFL, & PTFL Leach RE, Naiki O, Paul GR, Stockel J. Secondary reconstruction of the lateral ligaments of the ankle. Clin Orthop 1982; 226:169-73 226:169

STJ DISLOCATION Subtalar joint dislocations are commonly classified according to the position of the foot in relation to the talus Type I – Medial dislocation of STJ or “Acquired clubfoot” Type II – Lateral dislocation of STJ or “Acquired flatfoot” Type III – Anterior/posterior dislocation of STJ Buckingham WW Jr. Subtalar dislocation of the foot. J Trauma 1973;13:753-765 STRAUS DC: Subtalar dislocation of the foot. J Bone Joint Surg 30: 427, 1935.

Muller ME, Nazarian S, KochP, et al.; Springer-Verlag, Verlag, Berlin. Classification AO des fractures. 1990

LATERAL ANKLE SPRAINS The ATFL injured more frequently followed by the anterolateral ankle capsule, CFL, and then PTFL. The ATFL is oriented so that it is under most tension during plantarflexion. The angle between ATFL and CFL in the

PTTD – JOHNSON AND STROM Stage I – Medial pain, tenosynovitis, mild weakness on heelheel raise test Stage II – Medial/lateral pain, tendon elongation, flexible pes planus, weakness on heel raise, + too many toes sign Stage III – Medial/lateral pain, tendon degeneration, fixed pes planus, no inversion on heel raise, + too many toes sign, STJ arthritis

Stage IV – Medial/lateral pain, tendon degeneration, fixed pes planus, no inversion on heel raise, + too many toes sign, STJ arthritis, Valgus talus, Ankle arthritis

Rosenberg ZS, et al:: Rupture of posterior tibial tendon: CT and MR imaging with surgical correlation. Radiology 1988;169:229-235 1988;169:229

Johnson KA, Strom DE. Tibialis posterior tendon dysfunction. Clinical Orthopedics. 1989;239:196-206 Myerson, MS. Adult acquired flatfoot deformity: Treatment o dysfunction of the posterior tibial tendon. Instr. Course Lecture, AAOS. 1997; 46: 393 393-405.

PTTD – MUELLER CLASSIFICATION Based on Etiology Type I – Direct injury Type II – Rupture secondary to systemic disease Type III – Idiopathic Type IV – Rupture secondary to mechanical dysfunction

ACHILLES RUPTURE – KUWADA CLASSIFICATION The achilles is an conjoined tendon that internally rotates to insertion. It has a “watershed” area ar at 2-6cm proximal to insertion. The vascular supply is received at the myotendinous junction, osseous insertion, and paratenon anteriorly. anteriorly Use the Daughter Daughter-Thompson Test (passive plantarflexion) to diagnosis rupture. Patients will recall a “Pop” sensation sens and feel “stuck”. There will be pain and edema at the area, with a palpable gap. Patients may present with an antalgic gait. Type I – Partial rupture of tendon Type II – Complete rupture of tendon, 6cm gap Kuwada GT. Diagnosis and treatment of Achilles tendon rupture. rupture Clin Podiatr Med Surg 1995;12: 633-52

Mueller TJ: Acquired flatfoot secondary to tibialis posterior dysfunction: Biomechanical aspects. J. Foot Surg. 30:2, 1991

PTTD – CONTI CLASSIFICATION (MRI) Stage I – One or two fine, longitudinal tears Stage II – Intramural degeneration, variable diameter, wide longitudinal tears Stage III – Scarring in tendon, complete tear Conti S et al. Clinical significance of MRI in pre-operative planning for reconstruction of posterior tibial tendon ruptures. Foot and Ankle 1992; 13:208

PTTD – ROSENBERG CLASSIFICATION (MRI) Stage I – Hypertrophic tears in tendon (appears bulbous) Stage II – Atrophic tears Stage III – Complete tear

RADIOPAQUE LESIONS OF THE TENDO ACHILLES__________ Type I: I Localized to the Achilles tendon insertion and the posterosuperior aspect of the calcaneus Type II:: Localized to the distal 1 to 3 cm of the Achilles tendon Type IIIA:: Intratendinous, involving a large portion of the tendon Type IIIB:: Intratendinous, involving ALL of the tendon from the myotendinous junction ion to the insertion. Morris KL, Giacopelli JA, Granoff D. Classifications of adiopaque lesions of the tendo Achilles. J Foot Surg 1990;29:533-542. 542.

PERONEAL TENDON DISLOCATION - ECKERT & DAVIS Grade I – retinaculum ruptured from cartilaginous lip to posterior lateral malleolus Grade II – distal 1-2cm 2cm fibrous lip of malleolus is elevated w/ retinaculum Grade III – a thin fragment of bone w/ cartilage is avulsed from deep surface of peroneal retinaculum & deep fascia Grade IV (Oden) – a mid--substance tear

Ib – secondary arthritis, tx w/ triple arthrodesis

Type II – intra-articular articular coalition IIa – no secondary arthritis, tx w/ triple or isolated arthrodesis IIb – secondary arthritis, tx w/ triple arthrodesis Downey, MS: Tarsal coalitions: a surgical classification. classi J Am Podiatr Med Assoc 81:187-197, 1991

TARSAL COALITIONS – PERLMAN AND WERTHEIMER CLASSIFICATION Type I – Congenital coalition Type II – Acquired coalition Perlman MD, Wertheimer SJ: Tarsal coalitions. coalitions J Foot Surg 1986; 25(1): 58-67

TARSAL COALITIONS TIONS – TACHDJIAN CLASSIFICATION I. Isloated Anomaly Ia – TC, CN, CC, or NC Ib – multiple combinations of Ia Ic – massive tarsal coalition

II. Part of Complex Malformation IIa – assoc w/ other synostoses (carpal coalition, synphalangism) IIb – manifestation of a syndrome (Apert’s, Nievergelt-Perlman) Nievergelt Eckert WR, Davis EA Jr: Acute rupture of the peroneal retinaculum. J Bone Joint Surg Am 1976 Jul; 58(5): 670-2

OSTEOMYELITIS – BUCKHOLZ Type I – wound induced osteomyelitis Ia – open fx w/ complete discontinuity Ic – post-op infection

Ib – penetrating wound

Type II – mechanogenic infection IIa – implants, internal fixation IIb – contact instability/bone on bone apposition

Type III – physeal osteomyelitis Type IV – ischemic limb disease Type V – combination osteo of types I-IV Type VI – osteitis from septic arthritis Type VII – chronic osteomyelitis Buckholz, JM 1987. The surgical management of osteomyelitis:: with special reference to a surgical classification. J. Foot Surg. 26:S17-S24

OSTEOMYELITIS – CIERNY-MADER CLASSIFICATION Type I – medullary osteo Type II – superficial osteo Type III – localized osteo Type IV – diffuse osteo Type A – good immune system and vascularity Type B – local or systemic immune compromise Type C – tx will be more harmful to patient than disease

III. Associated w/ Major Limb Abnormalities POLYDACTYLY – VENN & WATSON A. Wide Metatarsal Head B. T-shaped shaped Metatarsal Head C. Y-shaped shaped Metatarsal Head D. Digital Duplication E. Complete Duplication Venn-Watson Watson EA: Problems in polydactyly of the foot. Orthop Clin North Am 1976 Oct; 7(4): 909-27 909

POLYDACTYLY – TETAMY & MCKUSICK CLASSIFICATION Post-axial axial polydactyly only Type A – Complete digit that articulates w/ 5th MT head or duplicate 5th MT Type B – Accessory digit w/o osseous attachment Tetamy Sa, McKusick VA: Synopsis of hand malformations with particular emphasis on genetic factors. Birth Defects 5(3):125, 1969

POLYDACTYLY – BLAUTH & OLASON CLASSIFICATION Type A – Arrangement based on o duplication distal to prox A1 – distal phalanx A3 – proximal phalanx

A2 – middle phalanx A4 – metatarsal A5 – tarsal bone

Type B – Transverse numbering of digits medial to lateral

Cierny G, Mader JT: Adult chronic osteomyelitis.. Orthopaedics 1984; 7

Blauth W., Olason AT Classification of polydactyly of the. hands and feet. Arch. Orthop. Trauma. Surg., 1988, 107,. 334-344

OSTEOMYELITIS – WALDVOGEL CLASSIFICATION Type I – Hematogenous osteo Type II – Osteo secondary to contiguous source Type III – Osteo assoc w/ vascular insufficiency Type IV – Chronic osteo

SYNDACTYLY – DAVIS & GERMAN Type I – incomplete webbing between digits Type II – complete webbing to ends of digits Type III – simple syndactyly, no phalangeal involvement Type IV – complicated, phalangeal bones appear abnormal

Waldvogel FA et al:: Osteomyelitis: a review of clinical features, therapeutic considerations and unusual aspects. N Engl J Med 1970 Jan 22; 282(4): 198-206 198

Davis JS, German WJ (1930) Syndactylism. Arch Surg 21 : 32-. 32 75. 5

OSTEOMYELITIS – PATZAKIS CLASSIFICATION Zone I – Distal metatarsal neck (most common) Zone II – MT neck to MTJ (least common) Zone III – calcaneus or talus Patzakis PJ, Calhoun JH,, Cierny G, Holtom P, Mader JT, Nelson CL Symposium: Current Concepts in the Management of Osteomyelitis. Contemporary Orthopaedics, Orthopaedics 28(2): 157-185 passim, 1994

TARSAL COALITIONS – DOWNEY A. Juvenile (Osseous Immaturity) Type I – extra-articular coalition Ia – no secondary arthritis, tx w/ badgley procedure Ib – secondary arthritis, tx w/ resection, triple arthrodesis

Type II – intra-articular coalition IIa – no secondary dary arthritis, tx w/ resection or triple arthrodesis IIb – secondary arthritis, tx w/ triple arthrodesis

B. Adult (Osseous Maturity) Type I – extra-articular coalition Ia – no secondary arthritis, tx w/ resection or triple arthrodesis

CHARCOT FOOT – EICHENHOLTZ, SHIBATA, YU Stage 0 – swelling, warmth, w/ joint instability Stage I – destructive phase w/ joint laxity, subluxation, sublux and osteochondral fragmentation Stage II – coalescence; absorption of debris and fusion of larger fragments to adjacent bone Stage III – remodeling; revascularization and remodeling of bone and fragments Eichenholz SN. Charcot Joints. Springfield: Charles C C. Thomas, 1966 Yu, Evaluation and Treatment of Stage 0 Charcot’s Neuroarthropathy of the Foot and Ankle. JAPMA 92(4): 210-220, 2002 Shibata, Results of arthrodesis of the ankle in leprotic neuropathy pts. JBJS 1990

CHARCOT FOOT DEFORMITY – ONVLEE Pattern A – Plano-valgus--abductus foot Pattern B – Rocker bottom foot Pattern C – Ankle deformity in varus direction Pattern D – Extremely flat foot.

Onvlee GJ. The Charcot Foot. A critical review and an observational study of a group of 60 patients. Thesis. The netherlands: University of Leiden, 1998.

CHARCOT ANATOMIC CLASSIFICATION Zone 1 – Distal and proximal interphalangeal joints, metatarsophalangeal joints Zone 2 – Tarsometatarsal joints (Lisfrancs) Zone 3 – Naviculo-cunieform joints, talo-navicular joint, calcaneocuboid joint Zone 4 – Ankle joint, subtalar joint Zone 5 – Calcaneus Sanders LJ, Frykberg RG. The Charcot Foot. In: Frykberg RG, ed. The high risk foot in diabetes mellitus. First edition. New york: Churchill Livingstone, 1991: 325-335.

HALLUX LIMITUS/RIGIDUS – DRAGO, ORLOFF, AND JACOBS Grade I – Functional limitus Hallux equinus/flexus, plantar subluxation of proximal phalanx, MPE, no DJD, hyperextension of HIPJ, pronatory architecture, joint ROM normal NWB, but is limited on WB.

Grade II – Adaptation; proliferative/destructive joint change Flattening of 1st MT head, pain on end ROM, passive ROM limited, osteochondral defect/cartilage fibrillation & erosion, small dorsal exostosis, subchondral eburnation, periarticular lipping or phalanx base and 1st MT head

Grade III- Joint deterioration/arthritis, established arthrosis Severe flattening of 1st MT head, osteophytosis dorsally, non-uniform narrowing of joint space, degeneration of articular cartilage, erosions, creptius, subchondral cysts, pain on ROM, assoc inflammatory arthritis

Grade IV – Ankylosis/Hallux Rigidus Obliteration of joint space w/ loss of majority of articular surface, exuberant osteophytosis w/ joint mice, less than 10° ROM, deformity, malalignment Drago JJ, Oloff L, Jacobs AM: A comprehensive review of hallux limitus. J Foot Surg 23: 213, 1984

HALLUX LIMITUS/RIGIDUS – REGNAULD CLASSIFICATION 1st Degree – Limitation of 1st MPJ ROM to 40°, pain at end ROM, narrowing of joint space, flattening of MT head, periarticular spurring, no sesamoidal dz 2nd Degree – Arthrosis, enlargement of joint, loss of ROM, painful ROM, crepitus, narrowing of joint space, flattening of MT head, periarticular spurring, sesamoid hypertrophy 3rd Degree – Ankylosis, crepitus, little or no ROM, pain, loss of joint space, marked hypertrophy of joint, joint mice, marked involvement of sesamoids

Type III – severe DJD, loss of articular cartilage Type IV – epiphyseal dysplasia, multiple head involvement Freiberg AH: Infraction of the second metatarsal bone, a typical injury. Surg Gyn Ob 1914; 19: 191-163

AVN OF THE 2ND METATARSAL – KATCHERIAN Level A – fissures noted in distal metaphysis or epiphysis Level B – increased fissuring w/ bone resorbtion Level C – increased fissuring w/ central collapse of MT head Level D – collapse & fx w/ fragments on either side of joint Level E – complete collapse of MT head Katcherian DA: Treatment of Freiberg's Disease. Orthop Clin North Am 25: 69, 1994

COMPLEX REGIONAL PAIN SYNDROME – IASP (1993) CRPS type I (RSD) – regional pain, sensory changes, abnormalities of temperature, abnormal sudomotor activeity, edema, and abnormal skin color CRPS type II (causalgia) – All former symptoms in addition to a peripheral nerve lesion. Reinders. Complex regional pain syndrome type I: use of the international association for the study of pain diagnostic criteria defined in 1994. Clin J. Pain 18: 207-215, 2002.

NERVE INJURY – SEDDEN Neuropraxia – interruption of nerve impulse due to extrinsic pressure, resulting in pinpoint segmental demyelination Axonotmesis – severance of individual nerve fibers, resulting in partial severance of nerve Neurotmesis – complete severance of nerve, resulting in wallerian degeneration Seddon HJ: Three types of nerve injuries. Brain 1943; 66: 237

NERVE INJURY – SUNDERLAND CLASSIFICATION 1st Degree – disruption of nerve impulses w/o wallerian degeneration 2nd Degree – disruption of axon, w/ wallerian degeneration distal to the point of injury 3rd Degree – fibrosis of nerve, regrowth w/ fusiform swelling 4th Degree – incomplete severance of nerve 5th Degree - complete severance of nerve Sunderland S: A classification of peripheral nerve injuries producing loss of function. Brain 74:491-516, 1951

No DJD, no pain on end ROM, limited ROM on WB but normal NWB

FOOT ULCERATION – WAGNER Grade 0 – Skin is intact, no open lesions. Grade 1 – Skin only lesion, large or small, dirty or clean Grade 2 – Deeper lesion involving tendon, muscle, or bone Grade 3 – Grade 2 w/ infection (abscess, osteomyelitis) Grade 4 – Partial gangrene in the forefoot Grade 5 – Entire foot is gangrenous, no procedures possible

Stage II – Joint adaptation

Wagner FW Jr. The diabetic foot. Orthopedics 1987;10:163-72

Pain on end ROM, flattening of 1st MT head, small dorsal osteophyte

UTSA CLASSIFICATION Grade 0 – pre or post ulcerative lesion, epithelialized Grade 1 – superficial wound, w/ out tendon, capsule or bone Grade 2 – wound penetrating to capsule, tendon, or bone Grade 3 – wound penetrating to bone or joint Type A – Clean, vascular wound Type B – Infected, vascular wound Type C – Clean, ischemic wound Type D – Infected, ischemic wound

Regnauld B. Hallux rigidus. In The Foot, pp 345-359, edited by B Regnauld, SpringerVerlag, Berlin, 1986

HALLUX LIMITUS/RIGIDUS – MODIFIED REGNAULD/ORLOFF CLASSIFICATION Stage I – Functional hallux limitus

Stage III – Joint deterioration Crepitus on ROM, non-uniform joint space narrowing, subchondral sclerosis and cyst formation, osteophytosis, severe flatting of 1st MT head

Stage IV – Ankylosis Obliteration of joint space, osteophyte fragmentation, minimal to no ROM Vanore JV et al. Clinical Practice Guideline First Metatarsophalangeal Joint Disorders Panel. Diagnosis and treatment of first metatarsophalangeal joint disorders. Section 2: hallux rigidus. J Foot Ankle Surg 42:124-136, 2003

HALLUX VALGUS DEFORMITIES Mild – Hallux Valgus 16, MPJ significant subluxation, fibular sesamoid displaced 100% Couglin MJ and Mann RA. Chapter 6: Hallux Valgus. Surgery of the Foot & Ankle, 8th edition. Mosby Elsevier, Philadelphia: 2007.

AVN OF THE 2ND METATARSAL – FREIBERG Type I – no DJD, articular cartilage intact Type II – periarticular spurs, articular cartilage intact

Lavery LA, Armstrong DG, Harkless LB. Classification of diabetic foot wounds. J Foot Ankle Surg. 1996 Nov-Dec;35(6):528-31

BURN CLASSIFICATION 1st Degree – superficial, involving outer layer of skin, erythema, no blisters 2nd Degree – superficial or deep, may or may not have blisters assoc w/ erythema, anesthetic 3rd Degree – full-thickness destruction of skin, can extend to bone and is anesthetic. Includes electric burns, radiation burns, and frostbite. Can lead to physeal growth arrest.

Minor –