Wednesday, June 10, 2009

Sprain of lateral Chopart (calcaneocuboid) joint








Anatomy:

The midtarsal or transverse tarsai joint is comprised of two separate joints: the Talocalcaneonavicular and the Calcaneocuboid. The Calcaneocuboid Joint is formed by the articulation between the calcaneus and the cuboid. 3 primary ligaments support the Calcaneocuboid joint. They are: Dorsal Calcaneocuboid Ligament, Lateral or calcaneocuboid portion of the Bifurcated Ligament & Plantar Calcaneocuboid Ligament, a dense, thick, white structure consisting of two distinct layers.

2 layers of Plantar Calcaneocuboid Ligament are: Deep layer, runs from anterior tubercle of calcaneus to plantar surface of cuboid posterior to groove for peroneus iongus. Also known as the short plantar ligament Superficial layer, arises from calcaneus and inserts into cuboid bone continuing in anterior direction, forming tunnel for peroneus longus (PL) and finally inserting into the 5th, 4th, 3rd, and on occasion 2nd metatarsal heads.

Injury:
Involvement of calcaneo-cuboid joint is a rare entity. This sprain is commonly associated with inversion forces & sprain of LCL of ankle. The selective rupture of the calcaneocuboid ligament is extremely rare and frequently misdiagnosed (1, 2). The calcaneocuboid ligament sprain is confused with Peronius longus tendonitis. Many times the cuboid is subluxed where the pain may come from all the ligaments but more on the planter ligaments of the CC joints. Extreme injuries such as rupture of CC ligaments is although rare yet reported in 5 % cases of supination trauma in the ankle joint and foot (1).

X-ray with varus stress and in certain cases of computer tomography (CT) and magnetic resonance imaging (MRI), beside the routine antero-posterior and lateral views, is emphasized. Comparative X-rays (of normal & involved sides) plays a key role in diagnosis.

Classification of the injury by X-ray with varus stress:
1. Type 1: Calcaneocuboid angle less than 10 degrees without a bony flake.
2. Type 2: Calcaneocuboid angle more than 10 degrees with or without a bony flake.
3. Type 3: Calcaneocuboid angle more than 10 degrees with big bony flake.
4. Type 4: Complex injuries = cuboid compression fracture + ligament rupture.

Principles of management:
According to Lindner & collagues, surgical treatment does not appear to be necessary. 4-week immobilisation by cast is sufficient for elimination of complaints and restoration of adequate functionality. However Andermahr & colleagues recommend:

1. Strapping for 6 weeks in type 1 variety.
2. Shoe cast for 6 weeks in type 2 variety. And if there are persistent symptoms a secondary peroneus brevis tendon graft is done.
3. Type 3 variety should be treated by open reduction and refixation of the ligament.
However there is no mention of treatment about the Complex type 4 injuries by Andermahr.

References:

1. Lindner HO et al; Zentralbl Chir. 1986;111(20):1250-4.
2. Andermahr J et al; Foot Ankle Int. 2000 May;21(5):379-84.
3. Grey’s anatomy


1 comment:

  1. CC joint problems commonly presents as lateral or lateral + hind foot pain.

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