Foot Fracture Treatment & Management

Immediate care includes icing, immobilizing, and elevating the foot and providing analgesia to all patients with significant foot fractures. ^[24]

Patients with forefoot fractures frequently also have associated soft tissue damage, which may necessitate external fixation. ^[10]

Options for initial immobilization include the following:

• 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. ^[25]

First metatarsal fracture

The first metatarsal is the least commonly fractured metatarsal. ^[10] 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).

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. ^[26] 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. ^{[3, 9]} 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.

 

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.

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. Forefoot adduction has been found to be a risk factor for Jones fracture, with the presence of metatarsus adductus being associated with a 2.4 times greater risk of Jones fracture, according to one study. ^[27]  Patients with this fracture often (35-50%) develop persistent nonunions requiring bone grafting and internal fixation. ^[4] Initial therapy must include immobilization without weight bearing. ^[28] One study suggested that the short controlled ankle movement (CAM) walker boot more effectively offloads the fifth metatarsal during common gait activities than a postoperative sandal or a standard athletic shoe after treatment of Jones fractures and other base of fifth metatarsal fractures. ^[29]

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). It has been estimated that 20% of Lisfranc fracture-dislocations are misdiagnosed. ^[8] A Lisfranc fracture-dislocation involves injury to the bony and soft tissue structures of the tarsometatarsal joint, and patients typically present to the ED with pain particularly with weight bearing; with swelling; and after a characteristic mechanism of injury such as high-velocity trauma. Stable injuries can be immobilized in the ED and patients discharged home, but unstable injuries require an orthopedic referral for consideration of surgical fixation. ^[30] 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. ^[6]

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. ^[31]

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. According to Dale et al, talar fracture patterns cannot be characterized by radiography alone, and CT is critical for detecting and characterizing talar fractures. ^[32]

Neck and body fracture are the most common talar fractures and may be associated with subtalar dislocation. ^[33] Displaced fractures usually require surgical fixation. Nondisplaced fractures are treated with non–weight-bearing short leg cast for 6-10 weeks.

Lateral process fracture 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 is aused 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 is a rare injury that 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 fractures are rare and most often represent stress fractures in young athletes. They usually heal well with immobilization and weight bearing as tolerated. ^[34] Displaced fractures through the navicular body have a high incidence of avascular necrosis and require open reduction and internal fixation (see images below).

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. ^{[35, 36, 37, 38]}

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. ^[39] A high index of suspicion for thoracic aortic rupture and renal vascular pedicle disruption must be maintained when calcaneal fractures are seen.

Intra-articular joint depression fracture  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. ^[40] Obtain an urgent orthopedic consultation for calcaneal fractures, since open reduction and internal fixation is usually necessary.

Extra-articular calcaneal fractures should be treated with a bulky compression dressing, rest, ice, and elevation. Arrange orthopedic follow-up care.

Open calcaneus fractures are severe, high-energy injuries that have the potential for considerable morbidity, especially considering the high rate of concomitant orthopedic and whole body system injuries. Patients with type III open injuries are at increased risk of amputation. Management of these injuries include intravenous antibiotics, tetanus prophylaxis, and urgent debridement and irrigation. ^[41]

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.

Compartment syndrome is the most dangerous acute complication of foot fractures. This syndrome is associated primarily with midfoot fractures sustained as the result of a crush mechanism. Clinical signs include marked swelling (early) and neurovascular compromise (late). Recent data emphasize that compartment syndrome is a subjective clinical diagnosis. Measurement of compartment pressures may provide useful supplemental information, but pressure thresholds defining compartment syndrome in lower extremity fractures are elusive, ^[42] and the osseofascial spaces of the foot are not distinct or isolated. ^[43] Suspicion of compartment syndrome warrants emergent orthopedic consultation; treatment is fasciotomy when the diagnosis is confirmed.

Long-term complications of foot fracture include the following:

• Arthritis
• Infection
• Nonunion or instability
• Gait disturbances