Thursday, March 30, 2023

Foot Fracture

Practice Essentials

Approximately 10% of all fractures occur in the 26 bones of the foot. These bones comprise 2 bones in the hindfoot (calcaneus, talus),
5 bones in the midfoot (navicular, cuboid, 3 cuneiforms), and 19 bones in the forefoot (5 metatarsals,
14 phalanges). In addition, the foot contains sesamoid bones, most commonly the os trigonum, os tibiale externum, os peroneum, and os vesalianum pedis. Their smooth sclerotic bony margins and relatively consistent locations help distinguish them from fractures. Hindfoot connects to the midfoot at the Chopart joint; forefoot connects to the midfoot at the Lisfranc joint.

Foot fractures are among the most common foot injuries evaluated by primary care physicians, most often involving the metatarsals and toes.
Diagnosis requires radiographic evaluation, but ultrasonography has also proven to be highly accurate. 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;iInability to take 4 steps, both immediately after injury and in the ED.

Management is determined by the location of the fracture and its effect on balance and weight bearing.

Treatment approaches include the following

Metatarsal shaft fractures are initially treated with a posterior splint and avoidance of weight-bearing activities; subsequent treatment consists of a short leg walking cast or boot for 4-6 weeks.

Proximal fifth metatarsal fractures have different treatments depending on the location of the fracture. A fifth metatarsal tuberosity avulsion fracture can be treated acutely with a compressive dressing, then the patient can be transitioned to a short leg walking boot for 2 weeks, with progressive mobility as tolerated after initial immobilization.

A Jones fracture has a higher risk of nonunion and requires at least 6-8 weeks in a short leg non-weight-bearing cast; healing time can be as long as 10 to 12 weeks.

Great toe fractures are treated with a short leg walking boot or cast with toe plate for 2-3 weeks, then a rigid-sole shoe for an additional 3-4 weeks. Lesser toe fractures can be treated with buddy taping and a rigid-sole shoe for 4-6 weeks.

Lisfranc injuries can be categorized as stable or unstable. Stable Lisfranc injuries can be immobilized in the ED and patients discharged home, but unstable injuries require an orthopedic referral for consideration of surgical fixation.

Below is an example of a common fracture.

Fractures, foot. Proximal fifth metatarsal avulsio

Fractures, foot. Proximal fifth metatarsal avulsion fracture (also termed pseudo-Jones, tennis, or dancer fracture).

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For patient education resources including crutch walking instructions, see the Breaks, Fractures, and Dislocations Center, as well as Broken Foot.

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