Open fracture dislocation of the calcaneocuboid and naviculocuneiform joints: A case report.

Combined fracture and dislocation of the calcaneocuboid (CC) and naviculocuneiform (NC) joints is a very rare injury; therefore, it is under-reported. We present a case of rare open fracture and dislocation of the CC and NC joints by discussing the diagnosis, evaluation, management and prognosis.

Introduction

Chopart injuries are traumatic injuries and dislocations of the mid-foot that result from high-energy trauma and can be classified into different types [1], [2]. In particular, combined fracture and dislocation of the calcaneocuboid (CC) and naviculocuneiform (NC) joints is a very rare injury; therefore, it is under-reported [3]. The uncommonness of this injury and its relation to high-energy trauma are attributable to the robust bony support and firm ligamentous attachments surrounding the CC and NC joints [3], [4], [5], [6], [7], [8], [9], [10], [11], [12], [13]. Combined fracture and dislocation of the CC and NC joints were reported by eight studies previously [4], [5], [6], [7], [8], [9], [10]. However, only one study has reported an associated open fracture [6]. The current report aims to present the case of rare open fracture and dislocation of the CC and NC joints by discussing the diagnosis, evaluation, management and prognosis.

Case presentation

A 25 year old healthy male presented to the casualty department of the Level II trauma center in Kuwait with a left foot open fracture on the 27th of January 2021. The patient sustained a crush injury due to a large sized forklift loaded with about 10 to12 tons of pipes backing into his left foot while he was standing behind it. The back tire of the forklift went over the patient's foot once. The patient's foot was flat on the ground, and he made no attempt to remove it during the incident. No other injuries were sustained. The patient was immediately unable to bear weight on his foot and reported significant blood loss and bluish discoloration of the foot; no resuscitative measures were performed. He was brought to the emergency department (ED) immediately via his own transport.

Upon arrival at the ED, the patient was alert, conscious, vitally stable, and complained of severe pain in his left foot. On examination, his left foot was deformed. He had two open wounds on the medial side; one approximately 10 cm in length just anterior to the medial malleolus, and the other around 15 cm long at the medial aspect of the heel (Fig. 1). Bone was also visible through the wounds. X-rays revealed a fracture dislocation of the CC and CN joints (Fig. 1). The patient underwent a successful closed reduction in the operating room (Fig. 2). The wounds were washed with 9 ML normal saline and approximated by surgical clips, a triple antibiotic was administered. The patient was also put in a below-knee cast, admitted, and scheduled for surgical fixation.

Fig. 1

Emergency room clinical images and radiographs: a) clinical photograph showing left foot deformity and the two open wounds on the medial side. Radiographs showing open fracture dislocation of the calcaneocuboid and naviculocuneiform joints: b) ankle x-ray oblique view, c) ankle x-ray AP view, d) foot x-ray AP view, e) foot x-ray oblique view, f) foot x-ray lateral view, and g) CT scan showing fracture of the anterior process of the calcaneus.

Fig. 2

Post closed reduction foot radiographs of open fracture dislocation of the calcaneocuboid and naviculocuneiform joints: a) foot AP view, and b) foot lateral view.

During the hospital stay and prior to surgery, the patient developed an infection after becoming febrile on the 3rd of February 2021; 7th day post admission, and his wounds began to ooze a greenish discharge along with a surge of inflammatory markers; therefore, the patient has been taken to the OR, and I&D was performed, then a wound culture was taken. Antibiotics were given. The wound culture yielded insignificant bacterial growth; after consulting with the Infectious Diseases and Microbiology Department, the patient received a course of antibiotics: Amikin 50 mg/ 12 h for five days.

Five weeks after injury/admission, on the 2nd of March 2021, and after the infection subsided where the inflammatory markers normalized and wound discharge ceased, the patient underwent open reduction and internal fixation surgery of the naviculocuneiform and calcaneocuboid joints. The surgical approach involved creating a 5 cm dorsomedial incision and exposing the navicular-medial cuneiform (NC-1) and navicular-lateral cuneiform (NC-2) joints via the interval between the tibialis anterior and extensor hallucis longus and lateral aspect of the extensor hallucis longus, respectively. Edema was noted. However, there was a noticeable satisfactory callus formation around the joints. There was also acceptable joint stability. A K-wire was inserted through an inter-cuneiform approach, after which a 32 mm cannulated screw was introduced. A 2.4 mm tarsometatarsal plate was placed over the NC-1 joint, and another was fixed over the NC-2 joint. Finally, a K-wire was inserted through the calcaneocuboid joint. X-ray and CT scan showed a marginal impaction of the calcaneus, about one-third of the joint. Due to the restricted mobility of the CC joint, it has been decided to leave it and place a K-wire to permit midfoot ligamentous tissue healing. Placement of all hardware was confirmed with x-rays at every step, and the final postoperative radiographs revealed ideal fixation (Fig. 3). After skin closure and the application of spray dressing (Opsite), a vacuum dressing was placed over the dorsomedial incision site. The patient's foot was not casted as he had already undergone successful closed reduction previously, and the time elapsed between the injury and the operative intervention was lengthy.

Fig. 3

Foot radiographs post open reduction and internal fixation of open fracture dislocation of the calcaneocuboid and naviculocuneiform joints: a) foot AP view and b) foot lateral view.

Post-operatively, the patient recovered well and was given strict non-weight bearing orders; full weight-bearing was to be initiated at three weeks post-operation. At the fourth week postoperative follow-up, the patient reported no pain on dorsiflexion or plantar flexion. However, there was noticeable swelling of the foot, and K-wires were in place. He was instructed to start weight-bearing with a walking boot two weeks later and commence physiotherapy. The physiotherapy plan involved increasing his weight-bearing potential in increments of 25% over a period of four weeks, and use of the walking boot would stop at 50% weight-bearing.

At three and a half months postoperatively, on the 5th of May 2021, the patient presented to the clinic with a plantigrade foot. His Visual Analogue Scale (VAS) was 2/10, ankle dorsiflexion 0–5°, plantar flexion 0–15°, hindfoot valgus 5°, and no forefoot valgus. The American Orthopedic Foot and Ankle Score (AOFAS) of midfoot was 73, and his EQ-5D score showed a high score of 70. While walking, the patient reported minimal pain in the midfoot area. The foot arch was maintained (no collapse), and his gait pattern was normal; however, the previously mentioned swelling of the foot had yet to subside completely. On the 16 of June 2021, the patient visited the clinic for follow-up, and further improvement was reported. His VAS was 0/10, AOFAS was 83, and EQ-5D was very high at 90 (Fig. 4).

Fig. 4

Foot radiographs and clinical images for the third visit to the outpatient clinic: a) foot AP view, b) foot lateral view, c) foot oblique view, d) ankle dorsiflexion, e) ankle plantarflexion, and f) standing posture (anterior and posterior view).

Discussion

The current case report presents a condition of open fracture dislocation of the CC and NC joints. As this condition is rare, the case study design is the most appropriate and feasible design to assist in deciding possible recommendations and management regimes. Our experience with the case presented was successful, which could help in clinical decision-making and possibly future research. One previous case report presented open fracture and dislocation of the CC and NC joints [6]. The second of Wong, Tang, and Tan, an external fixation procedure was initially performed then K-wiring, plating and hamstring allograft for a 26 years old male; the outcome was satisfactory, with no pain or tenderness, but no functional outcome was reported [6]. However, the current case was complicated by infection, which delayed the surgical intervention; however, the pharmaceutical and surgical management provided led to satisfactory results. At only five months post-injury, the VAS was zero, and the functional outcome scores showed highs of 83 AOFAS and 90 EQ-5D indicating satisfactory functional ability.

Although a unified treatment consensus is unavailable, it is generally agreed that early and accurate diagnosis, timely anatomical reduction, and stable fixation are required for the appropriate management of these types of injuries in order to avoid long-term sequelae, consequent functional impairment, and complications such as avascular necrosis, midfoot collapse, or arthritis [5]. More importantly, it is evident from the review of the previous literature that the surgical fixation using K-wiring has good results, but the approach of ORIF is a biomechanically more rigid and robust method of fixation (Table 1). With regards to our patient, he initially underwent closed reduction and was casted and scheduled for emergent ORIF; however, due to the patient's soft tissue condition and infection, ORIF was delayed by about five weeks. Nevertheless, intra-operatively, there was satisfactory joint congruence and stability in the midfoot. Fixation was applied to prevent the occurrence of any future deformity such as pes planus, which occurred with Genena, Abouelela and Fadel's patient, who also developed midfoot arthritis [10]. For the ORIF stage of treatment, we utilized a hybrid technique by using plates and k-wires; this technique is similar to the one used by Kummer, Crevoisier and Eudier [8]. A plate was used in the midfoot to stabilize the NC joint since this is the highest stress area during gait. Therefore, adequate bone congruence and support are of paramount importance. Plates achieve this because they are stiffer, have a higher failure threshold, and have been shown to provide firm fixation without causing further articular damage in comparison to transarticular screws [6], [14]. The rationale behind using a tarsometatarsal (TMT) plate instead of a bridge plate or small locking plate was that a TMT plate would provide a more anatomical fit thereby maximizing joint stability [6], [8]. Additionally, adequate anatomical reduction of the NC joint is vital due to the involvement of the medial column in preserving the foot arch [6]. A k-wire was placed through the CC joint given that it is an inherently stable arthrodial joint due to the strong ligamentous attachments to adjacent bones, with close proximity to the peroneus longus and brevis tendons, rigid fibrous capsule, and saddle-shaped joint surface [5]. In general, it is paramount to regain the anatomical alignment of the axes and column of the midfoot post-dislocation, as any shift will cause considerable change in gait biomechanics, thereby increasing the risk of midfoot arthritis in the future [15]. We believe that the combined use of plates and k-wires will maximize stabilization and lead to favorable functional outcome and quality of life scores.

Table 1

Literature review of the studies exploring fracture dislocation of the calcaneocuboid (CC) and naviculocuneiform (NC) joints.

Study	Case presentation	Management	Outcome
Choudry, Akhtar, and Kumar [3]	One case presented with CC dislocation and NC subluxation associated with anterior calcaneus process fracture.	Closed reduction	No functional outcome recorded
Cheng et al. [5]	One case presented with CC and NC joints dislocation associated with cuboid, medial and intermediate cuneiform fractures.	ORIF with plates and screws	No functional outcome recorded
	One case presented with CC, NC and 1st TMT joints dislocation associated with navicular, medial cuneiform and calcaneal fractures.	ORIF with plates and screws	No functional outcome recorded
Wong, Tang and Tan [6]	One case presented with open dislocation of CC, NC and subtalar joints associated with cuboid and anterior process of the calcaneus fractures.	External fixation initially, then K-wiring, plating and hamstring allograft.	No functional outcome recorded
Dhole et al. [7]	One case presented with fracture-dislocation of CC and NC joints with anterior calcaneus process fracture.	ORIF with K-wires	24 months AOFAS 95
Kummer, Crevoisier, and Eudier [8]	One case presented with CC and NC joints dislocation associated with fractures of the medial cuneiform, anterior calcaneus process and fibula.	- Closed reduction and percutaneous pinning. - After two weeks: ORIF with plate and screws	No functional outcome recorded
Alayed [9]	One case presented with NC joint dislocation and fracture-dislocation of CC associated with calcaneus fracture.	ORIF with K-wire	12 months AOFAS 90
Genena, Abouelela and Fadel [10]	One case presented CC and NC joints dislocation associated with lateral wall calcaneus fracture.	ORIF with K-wire	No functional outcome recorded

Keys: ORIF: open reduction and internal fixation.

The cause of injury in the case presented is very similar to that of Kummer, Crevoisier, and Eudier [8]. We suspect that the patient's foot was in plantar-abduction while the heavy object was passing over the foot. Valgus force travels from the CC joint and pushes the forefoot in varus position through the NC joint. In terms of evaluation, other than using x-rays, more advanced radiography such as CT scans should be utilized as a vital tool for diagnosis and determining a surgical strategy. In particular, it is evident from the review of the previous literature that the most common associated injury reported is a fracture of the anterior process of the calcaneus (Table 1), which can only be detected using CT scans. Therefore, CT scanning should be mandatory for this type of injury. Through CT, it was possible to identify a comminuted fracture in the anterior calcaneus that was not evident initially. Several other case reports have described this associated injury as well, which is possibly due to the compressive force exerted on the CC joint due to hyperabduction of the forefoot [6], [7], [8]. Several treatment strategies have been reported to tackle combined NC and CC fracture-dislocations, including closed reduction (CR) and ORIF using K-wires only or plates and screws or both [3], [5], [6], [7], [8], [9], [10]. The justification for performing an open fixation is that it has been proven to result in better functional outcome scores amongst multiple patients with various midfoot injuries [16]. Several studies have reported an unsuccessful initial closed reduction, most likely due to the fact that combined fracture-dislocations are extremely unstable and the sturdy nature of the foot's anatomy [7], [8], [9], [10].

Multiple clinical assessment tools were used, including the AOFAS, VAS, and EQ-5D questionnaires to evaluate the results of the patient's management holistically. Given that our patient is a manual laborer, it was necessary to assess his health-related quality of life adequately. Therefore, we used a functional outcome score and a quality of life score. The ultimate goal for the patient is to return to work, maintain his job, and resume his normal everyday activities without hindrance. Only two studies have provided a functional outcome score for their patient [7], [9]. The patient of Dhole et al. had an AOFAS score of 95 at 24-months post-operation, and Alayed's patient had a score of 90 at one year post-operation [7], [9]. A study by van der Vliet et al. investigated the functional outcomes and quality of life consequences of patients with midfoot injuries [17]. Although the study only included patients who were treated for Lisfrance and Chopart injuries at a level 1 trauma center, it was revealed that midfoot injuries had been shown to have negative effects on the mid- to long-term quality of life after trauma, and significant probability for long-term impaired functionality, as the median AOFAS score was 64 [17].

The current case report presents an extremely rare injury of open fracture and dislocation of the CC and NC joints, which was only reported once previously as an open injury of this type [6]. Yet, the current case was followed for five months, which could be considered as a limitation. No further follow-up was possible as the patient is an expatriate and traveled to his country and couldn't return due to the COVID-19 pandemic situation. A longer follow-up period would reveal possible arthritis or medial arch collapse, which is recommended as an area for future exploration. However, the current case report provided a longer follow-up of 21 weeks compared to the previously reported case study of 17 weeks by Wong, Tang, and Tan [6]. Additionally, the patient reached a very good status in terms of pain and function, which were objectively proven using VASs, AOFAS, and EQ-5D. Previous report has not used objective measurements [6]. The presented case was complicated by infection, but it was successfully managed and showed that the early detection and management of these rare injuries is crucial.

Conclusion

Fracture dislocation of the CC and NC joints is a highly unusual injury pattern but can lead to serious complications. Proper diagnosis, holistic evaluation, and appropriate management are integral to avoid long-term life-altering consequences. We believe that early ORIF using a combination of stabilizing hardware is a superior technique that will lead to a satisfactory functional outcome and improved quality of life post-injury. Further studies are needed to establish a classification system and understand the potential mechanism of injury.

Source of funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Ethical approval

As this is a case report, no ethical approval is needed.

Consent

Witten informed consent was obtained from the case, and personal data and confidentiality were maintained.

Declaration of competing interest

The authors declare no conflict of interest.