Foot Fracture Workup

  • Author: Robert Silbergleit, MD; Chief Editor: Rick Kulkarni, MD   more...
 
Updated: Apr 16, 2012
 

Imaging Studies

  • Plain-film radiography
    • Ottawa foot rules are a tool that predicts significant midfoot fractures. They are guidelines used to determine whether radiographs are necessary.[2]
    • If any of the following are present, a radiograph is required.
      • Point tenderness over the base of fifth metatarsal
      • Point tenderness over the navicular bone
      • Inability to take 4 steps, both immediately after injury and in the ED
    • Although developed and validated in adults, the Ottawa foot rule also appears to be a reliable tool to exclude fractures in children 5 years of age and older.[3]
    • When performed, a systematic approach to reading foot radiographs is important and reduces the risk of missing important injuries.[4]
  • Other imaging modalities: Bone scanning, CT scanning, MRI, and ultrasonography may help diagnose certain foot fractures that are occult on plain film radiography.[5, 6] Although recent anecdotal reports and small diagnostic trials suggest that ultrasonography may someday have a role in routine assessment of acute foot fractures,[7, 8] second-line imaging studies generally do not need to be performed while the patient is in the ED and are usually ordered only after consultation with a foot surgeon.
Proceed to Treatment & Management
 
 
Contributor Information and Disclosures
Author

Robert Silbergleit, MD  Associate Professor, Department of Emergency Medicine, University of Michigan Medical School

Robert Silbergleit, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American Association for the Advancement of Science, American Heart Association, American Stroke Association, National Association of EMS Physicians, Sigma Xi, Society for Academic Emergency Medicine, and Society for Neuroscience

Disclosure: Nothing to disclose.

Specialty Editor Board

Francis Counselman, MD, FACEP  Chair, Professor, Department of Emergency Medicine, Eastern Virginia Medical School

Francis Counselman, MD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, Association of Academic Chairs of Emergency Medicine (AACEM), Norfolk Academy of Medicine, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Tom Scaletta, MD  Chair, Department of Emergency Medicine, Edward Hospital; Past-President, American Academy of Emergency Medicine

Tom Scaletta, MD is a member of the following medical societies: American Academy of Emergency Medicine

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD  Attending Physician, Department of Emergency Medicine, Cambridge Health Alliance, Division of Emergency Medicine, Harvard Medical School

Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: WebMD Salary Employment

References

  1. Sethuraman U, Grover SK, Kannikeswaran N. Tarsometatarsal injury in a child. Pediatr Emerg Care. Sep 2009;25(9):594-6. [Medline].

  2. Perry JJ, Stiell IG. Impact of clinical decision rules on clinical care of traumatic injuries to the foot and ankle, knee, cervical spine, and head. Injury. Dec 2006;37(12):1157-65. [Medline].

  3. Dowling S, Spooner CH, Liang Y, Dryden DM, Friesen C, Klassen TP, et al. Accuracy of Ottawa Ankle Rules to exclude fractures of the ankle and midfoot in children: a meta-analysis. Acad Emerg Med. Apr 2009;16(4):277-87. [Medline].

  4. Pearse EO, Klass B, Bendall SP. The 'ABC' of examining foot radiographs. Ann R Coll Surg Engl. Nov 2005;87(6):449-51. [Medline].

  5. Johnson PT, Fayad LM, Fishman EK. Sixteen-slice CT with volumetric analysis of foot fractures. Emerg Radiol. May 2006;12(4):171-6. [Medline].

  6. Ting AY, Morrison WB, Kavanagh EC. MR imaging of midfoot injury. Magn Reson Imaging Clin N Am. Feb 2008;16(1):105-15, vi. [Medline].

  7. Banal F, Etchepare F, Rouhier B. Ultrasound ability in early diagnosis of stress fracture of metatarsal bone. Ann Rheum Dis. Jul 2006;65(7):977-8. [Medline].

  8. Canagasabey MD, Callaghan MJ, Carley S. The sonographic Ottawa Foot and Ankle Rules study (the SOFAR study). Emerg Med J. Oct 2011;28(10):838-40. [Medline].

  9. Schnaue-Constantouris EM, Birrer RB, Grisafi PJ. Digital foot trauma: emergency diagnosis and treatment. J Emerg Med. Feb 2002;22(2):163-70. [Medline].

  10. Zenios M, Kim WY, Sampath J. Functional treatment of acute metatarsal fractures: a prospective randomised comparison of management in a cast versus elasticated support bandage. Injury. Jul 2005;36(7):832-5. [Medline].

  11. Fetzer GB, Wright RW. Metatarsal shaft fractures and fractures of the proximal fifth metatarsal. Clin Sports Med. Jan 2006;25(1):139-50, x. [Medline].

  12. Zwitser EW, Breederveld RS. Fractures of the fifth metatarsal; diagnosis and treatment. Injury. Jun 2010;41(6):555-62. [Medline].

  13. Saab M. Lisfranc fracture--dislocation: an easily overlooked injury in the emergency department. Eur J Emerg Med. Jun 2005;12(3):143-6. [Medline].

  14. Haapamaki VV, Kiuru MJ, Koskinen SK. Ankle and foot injuries: analysis of MDCT findings. AJR Am J Roentgenol. Sep 2004;183(3):615-22. [Medline].

  15. Rammelt S, Zwipp H. Talar neck and body fractures. Injury. Feb 2009;40(2):120-35. [Medline].

  16. DiGiovanni CW. Fractures of the navicular. Foot Ankle Clin. Mar 2004;9(1):25-63. [Medline].

  17. Benson E, Conroy C, Hoyt DB, Eastman AB, Pacyna S, Smith J, et al. Calcaneal fractures in occupants involved in severe frontal motor vehicle crashes. Accid Anal Prev. Jul 2007;39(4):794-9. [Medline].

  18. Hahn MP, Richter D, Ostermann PA. [Injury pattern after fall from great height. An analysis of 101 cases]. Unfallchirurg. Dec 1995;98(12):609-13. [Medline].

  19. Knight JR, Gross EA, Bradley GH, Bay C, LoVecchio F. Boehler's angle and the critical angle of Gissane are of limited use in diagnosing calcaneus fractures in the ED. Am J Emerg Med. Jul 2006;24(4):423-7. [Medline].

  20. Prayson MJ, Chen JL, Hampers D. Baseline compartment pressure measurements in isolated lower extremity fractures without clinical compartment syndrome. J Trauma. May 2006;60(5):1037-40. [Medline].

  21. Richter J, Schulze W, Klaas A, Clasbrummel B, Muhr G. Compartment syndrome of the foot: an experimental approach to pressure measurement and release. Arch Orthop Trauma Surg. Feb 2008;128(2):199-204. [Medline].

  22. Mounts J, Clingenpeel J, McGuire E, Byers E, Kireeva Y. Most frequently missed fractures in the emergency department. Clin Pediatr (Phila). Mar 2011;50(3):183-6. [Medline].

  23. van Rijn J, Dorleijn DM, Boetes B, Wiersma-Tuinstra S, Moonen S. Missing the Lisfranc fracture: a case report and review of the literature. J Foot Ankle Surg. Mar-Apr 2012;51(2):270-4. [Medline].

 
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Fractures, foot. Proximal fifth metatarsal avulsion fracture (also termed pseudo-Jones, tennis, or dancer fracture).
Fractures, foot. Jones fracture of the fifth metatarsal.
Fractures, foot. Lisfranc fracture-dislocation.
Fractures, foot. Calcaneal fracture with intraarticular involvement and joint depression.
Fractures, foot. Calcaneal fracture with intraarticular involvement and joint depression with Böehler angle imposed. Reduced angle of 16 degrees is pathologic.
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.
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.
Fractures, foot. Minimally displaced fracture of the distal fifth metatarsal. This fracture was treated conservatively with immobilization in a rigid flat bottom shoe.
Fractures, foot. Two fractures of the proximal phalanx of the great toe. The fracture at the base is obvious, but the fracture at the head is more subtle. Make certain to examine every bone on the radiograph to avoid being distracted by obvious finding.
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.
 
 
 
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