Foot Fracture Treatment & Management

Stabilize and elevate the foot.

• Ice, immobilize, and elevate the foot and provide analgesia to all patients with significant foot fractures.
• Options for initial immobilization

  • Posterior or stirrup splints
  • Reinforced bulky dressing, also termed Jones splint, which consists of a web roll and an elastic compression bandage
  • Rigid, flat-bottom orthopedic shoe also termed postop or Reece shoe
  • Definitive immobilization often requires application of a cylindrical cast, applied during the acute phase (and often bivalved to accommodate further swelling) or after a few days when edema has begun to decrease.
• Toe fracture: Toe fractures are common and generally heal well with little or no therapy. Buddy tape the broken toe to an adjacent, uninjured toe (with padding in between the toes to prevent skin maceration) and apply a rigid flat-bottom orthopedic shoe. While union of fracture segments occurs in 3-8 weeks, symptoms usually improve much earlier. Significantly displaced fractures, especially of the first toe, may be treated more aggressively with closed reduction and rigid immobilization. Irreducible fractures sometimes require open reduction and internal fixation.^[8]
• First metatarsal fracture: This is the least commonly fractured metatarsal. The first metatarsal head bears twice the weight of other metatarsal heads. Treat minimally displaced or nondisplaced fractures with immobilization without weight bearing. Displaced fractures usually require open reduction and internal fixation (see image below). Fractures, foot. CT scan showing fracture of first cuneiform and proximal first metatarsal.
• Internal metatarsal fracture

  • Fractures of internal (second, third, fourth) metatarsals are very common. Nondisplaced and displaced fractures usually heal well, with weight bearing as tolerated, in a cast or rigid flat-bottom orthopedic shoe. In fact, data suggest that elastic support bandages are equivalent or superior to casts for such metatarsal fractures.^[9] Exclude disruptions of the Lisfranc (tarsometatarsal) joint by maintaining a high level of suspicion.
  • March fracture is a stress fracture of the second and/or third metatarsal that commonly occurs in joggers. Radiographs are often negative, and sometimes a bone scan helps determine this diagnosis. Treatment is cessation of aggravating activity for 4-6 weeks.
• Fifth metatarsal fracture: The proximal fifth metatarsal is the most common site of midfoot fractures.^[10] Fractures are of 2 general types, the Jones fracture and the pseudo-Jones or tennis fracture. Midshaft (see first image below) and distal fifth metatarsal fractures (see second image below) are less common; these are shown in the images below. Fractures, foot. Spiral fracture of the shaft of the fifth metatarsal. This fracture was treated conservatively with immobilization. Fractures, foot. Minimally displaced fracture of the distal fifth metatarsal. This fracture was treated conservatively with immobilization in a rigid flat bottom shoe.

  • Proximal avulsion fracture: Fractures at the proximal tuberosity are very common and termed pseudo-Jones or tennis fractures (see image below). This avulsion injury usually is associated with a lateral ankle strain and occurs at the attachment of the peroneus brevis tendon. It heals well with a compression dressing and weight bearing as tolerated. Fractures, foot. Proximal fifth metatarsal avulsion fracture (also termed pseudo-Jones, tennis, or dancer fracture).
  • Jones fracture: This less common but more problematic fracture occurs transversely at the base of the fifth metatarsal, 1.5-3 cm distal to the proximal tuberosity (see image below). Displacement of this fracture tends to increase with continued weight bearing. Patients with this fracture often (35-50%) develop persistent nonunions requiring bone grafting and internal fixation. Initial therapy must include immobilization without weight bearing. Fractures, foot. Jones fracture of the fifth metatarsal.
• Fracture at Lisfranc (tarsometatarsal) joint

  • The Lisfranc joint is found at the base of second metatarsal and is formed by a 6-bone arch that includes the first, second, and third cuneiforms and first, second, and third metatarsals. Fracture-dislocations at this joint are rare, yet are still the most commonly misdiagnosed foot injuries (see images below). They can result in posttraumatic arthritis and reflex sympathetic dystrophy. Displaced fractures are clinically and radiographically obvious, yet nondisplaced or minimally displaced fractures may be subtle.^[11] Fractures, foot. Lisfranc fracture-dislocation. Fractures, foot. Subtle fracture of the first cuneiform at the Lisfranc joint. Another fracture at the base of the first metatarsal is not seen here but was found on subsequent computed tomography.
  • To facilitate diagnosis, grasp first and second metatarsals and move them alternately through plantarflexion and dorsiflexion.
  • Radiographic diagnosis is made by detecting widening (diastasis) of 2-5 mm between the bases of the first and second metatarsals or between the middle and medial cuneiforms. Fracture at the base of the second metatarsal strongly suggests the diagnosis. If standard radiographs appear normal despite clinical suspicion, radiographs of the injured foot bearing weight may reveal the fracture. These fractures require immediate orthopedic consultation for reduction and fixation. CT imaging is useful if clinical suspicion is high despite nondiagnostic plain radiography.^[12]
• Talar fracture: Talar fracture is the second most common fracture of the tarsal bones. Blood supply is somewhat tenuous, resulting in a high incidence of avascular necrosis following displaced fractures.

  • Neck and body fracture: These are the most common talar fractures and may be associated with subtalar dislocation.^[13] Displaced fractures usually require surgical fixation. Nondisplaced fractures are treated with non–weight-bearing short leg cast for 6-10 weeks.
  • Lateral process fracture: This type was previously rare, yet now is more common because of snowboarding injuries. Treatment should include immobilization with strict avoidance of weight bearing.
  • Posterior process (Shepherd) fracture: Caused by damage to the posterior process of the talus, this fracture's usual mechanism is sudden plantarflexion or repetitive motion, especially in athletes who dance or kick. Diagnosis usually is not confirmed in the ED, because clinical examination is typically nonspecific and plain film radiography normal. Suspicion warrants referral to an orthopedist. Treatment includes immobilization with either partial or full weight bearing. Note that this fracture often is confused with an accessory bone that occurs at this location, the os trigonum.
  • Transchondral/osteochondral talar dome fracture: This rare injury often presents as a nonhealing ankle sprain and is caused by small cartilaginous avulsions or body chips in tibial articulation. Tenderness of the talar dome can be appreciated with the foot in dorsiflexion. Radiographs may be normal, and injuries cannot be distinguished clinically from ankle sprains. Delayed presentation may show crepitus, joint locking, and laxity of lateral and anterior ankle ligaments. Suspicion warrants referral to an orthopedist for bone scan or other definitive imaging. Initial therapy for this injury is immobilization without weight bearing.
• Navicular fracture: Navicular fractures are rare and most often represent stress fractures in young athletes. They usually heal well with immobilization and weight bearing as tolerated.^[14] Displaced fractures through the navicular body have a high incidence of avascular necrosis and require open reduction and internal fixation (see images below). Comminuted navicular fracture in a young drunk driver involved in a motor vehicle crash. The patient sustained no other injuries and was discharged in a plaster splint with strict nonweightbearing. The patient subsequently had a computerized tomography (CT) scan and underwent open reduction and internal fixation 9 days after the injury. A standard anteroposterior (AP) view is shown here. An added oblique view of this same patient with a navicular fracture was performed in the ED to help verify the absence of other significant fractures. Obtaining views that are not part of the routine foot series can be helpful and should be added when needed.
• Calcaneal fracture

  • Calcaneal fractures usually occur in patients aged 30-50 years, with a peak incidence at 45 years. They occur in males 5 times more often than in females. They are most commonly caused by motor vehicle crashes or falls from a height.^[15]
  • When caused by falls from a height, these fractures have a high rate of associated injuries. Identification of a calcaneal fracture should prompt a search for other related findings. Calcaneal fractures are part of the "lover's triad" (named for the constellation of injuries that may occur when jumping out of a second-story bedroom window), with lumbar compression fractures and forearm fractures. Ankle, femur, and elbow fractures are also common.^[16] A high index of suspicion for thoracic aortic rupture and renal vascular pedicle disruption must be maintained when calcaneal fractures are seen. The 2 main types of calcaneal fractures are as follows:
  • Intra-articular joint depression fracture: This is the most common form of calcaneal fracture. Lateral foot radiograph reveals a reduction in the Böehler's angle, the posterior angle formed by intersection of a line from the posterior to the middle facet and a line from the anterior to the middle facet (see images below). Böehler's angle is normally between 20 and 40°. Angles less than 20°, or more than 5° smaller than that of uninjured side, indicate a fracture. Although often useful, the sensitivity of Böehler's angle has been shown to be less than that of physician gestalt in interpreting calcaneal films.^[17] Obtain an urgent orthopedic consultation for calcaneal fractures, since open reduction and internal fixation is usually necessary. Fractures, foot. CT scan showing fracture of first cuneiform and proximal first metatarsal. Fractures, foot. Spiral fracture of the shaft of the fifth metatarsal. This fracture was treated conservatively with immobilization.
  • Extra-articular fracture: Treat these calcaneal fractures with a bulky compression dressing, rest, ice, and elevation. Arrange orthopedic follow-up care.

Nonemergent referral or urgent consultation with an orthopedic surgeon (or podiatrist if appropriate) is often necessary; which is appropriate depends on the type of fracture.