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Case of the Month 12/09

This 43 year old male with PMHx of CKD, CVA with residual left sided weakness, DM with peripheral neuropathy, HTN, hyperlipidemia, CHF and PAD presented to the ED complaining of pain to his right foot after twisting the foot while getting out of the car. He was able to ambulate after the injury and in the ED.

Question 1: What's wrong with these pictures? (hint, it's another eponym)

If it helps, compare these pictures to the normal foot x-rays below.

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Answer 1:

There is a fracture-dislocation of the talonavicular and calcaneocuboid joints (circled on images and Netter images below). This is also called a Chopart fracture. This is a somewhat rare injury which is often missed on initial x-rays due to very subtle findings. Clinical findings suggestive of this injury are pain, swelling, inability to bear weight and tenderness over the mid-tarsal joint.

http://www.learningradiology.com/archives06/COW%20221-Choparts%20fracture/chopartsccorrect.html

Question 2: What are the x-ray findings which would increase your suspicion of this injury?

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Answer 2:

Proximal cuneiforms do not line up with the distal edge of the navicular as they should on the AP view. (short arrow on image below)
A calcaneocuboid interspace over 2 mm (long arrow)
Overlap between any bones on the proximal and distal side of the Charcot joint.
A line between the talus and first metatarsal that is not straight on the AP or lateral view (double arrow on lateral x-ray)

Case summary.
This patient's initial x-rays were read as being negative. He returned about a month later complaining of increasing pain and swelling as well as increased difficulty ambulating. He required operative repair (see second image) after the diagnosis of Chopart fracture/dislocation was made on the x-rays below.