AUTHOR AND EDITOR INFORMATION

Section 1 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

INTRODUCTION

Section 2 of 11  

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• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Background

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.

Age

In contrast to adults, children have relatively stronger ligaments than bone or cartilage. As a result, fractures are more common than sprains in children. However, a child's forefoot is flexible and resilient to injury. When metatarsal or phalangeal fractures do occur, they may be difficult to recognize because of multiple growth centers. In such cases, comparison views of the uninjured foot often are helpful.

CLINICAL

Section 3 of 11  

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• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

History

• Mechanism of injury
• Time between injury and presentation
• Prior injuries

Physical

• Inspect injured foot for swelling, bruises, deformity, and open wounds.
• Uncover uninjured foot for side-by-side comparison.
• Palpate for pulses, capillary refill, tenderness, instability, and crepitus.
• Test range of motion and joint function. Normal ranges of motion of the foot relative to the ankle are 45° plantarflexion, 20° dorsiflexion, 30° inversion, 20° eversion, 20° internal rotation, and 10° external rotation. Comparisons with the uninjured foot are helpful.
• Explore all open wounds.
• Conduct and document a careful neurologic exam of foot, including both motor and sensory functions.

Causes

Trauma - Direct, indirect, or overuse

DIFFERENTIALS

Section 4 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

WORKUP

Section 5 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

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.
  • 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
• Other imaging modalities: Bone scanning, CT scanning, MRI, and ultrasonography may help diagnose certain foot fractures that are occult on plain film radiography (Johnson, 2006). Although recent anecdotal reports suggest that ultrasonography may someday have a role in routine assessment of acute foot fractures (Banal, 2006), second-line imaging studies generally need not be performed while the patient is in the ED and are usually ordered only after consultation with a foot surgeon.

TREATMENT

Section 6 of 11  

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• Differentials
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• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Prehospital Care

Stabilize and elevate foot.

Emergency Department Care

• Ice, immobilize, and elevate 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 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.
• 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 7).
• 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, recent data suggest that elastic support bandages are equivalent or superior to casts for such metatarsal fractures (Zenios, 2005). 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 (Fetzer, 2006). Fractures are of 2 general types, the Jones fracture and the pseudo-Jones or tennis fracture. Midshaft (see Image 8) and distal fifth metatarsal fractures (see Image 9) are less common.
• Proximal avulsion fracture: Fractures at the proximal tuberosity are very common and termed pseudo-Jones or tennis fractures (see Image 1). 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 2). 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.
• 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 Image 3, Image 6). 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 (Saab, 2005).
  • 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 (Haapamaki, 2004).
• Talar fracture: Talar fracture is the second most common fracture of the tarsal bone. 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. 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. Displaced fractures through the navicular body have a high incidence of avascular necrosis and require open reduction and internal fixation (see Images 11-12).
• 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.
  • These fractures usually result from falls from a height. They have a high rate of associated injuries. Calcaneal fractures are part of the "lover's triad," with lumbar compression fractures and forearm fractures. Ankle, femur, and elbow fractures are also common. 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:
  • • Intraarticular 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 7-8). 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 (Knight, 2006). Obtain an urgent orthopedic consultation for calcaneal fractures, since open reduction and internal fixation is usually necessary.
    • Extraarticular fracture: Treat these calcaneal fractures with a bulky compression dressing, rest, ice, and elevation. Arrange orthopedic follow-up care.

Consultations

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.

MEDICATION

Section 7 of 11  

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Analgesics (narcotics, NSAIDs) are generally the only medications needed to treat foot fractures. Administer antibiotics and tetanus prophylaxis to patients with open fractures.

Drug Category: Nonsteroidal anti-inflammatory agents (NSAIDs)

These agents are used most commonly for relief of mild to moderately severe pain. Effects of NSAIDs in treatment of pain tend to be patient specific, yet ibuprofen is usually DOC for initial therapy. Other NSAIDS also may be used.

Drug Category: Narcotic combination analgesics

Pain control is essential to quality patient care. It ensures patient comfort, promotes pulmonary toilet, and aids physical therapy regimens. Many analgesics have sedating properties that benefit patients who have sustained fractures. Hydrocodone and oxycodone preparations are generally more effective and better tolerated than other narcotic-acetaminophen combinations such as those containing codeine.

Drug Category: Antibiotics

Prophylaxis is given to patients with open fractures.

Drug Name	Clindamycin (Cleocin)
Description	Lincosamide is useful as treatment against serious skin and soft-tissue infections caused by most staphylococcal strains. Also effective against aerobic and anaerobic streptococci, except enterococci. Clindamycin is used for prophylaxis in penicillin-allergic patients. Useful as treatment against streptococci and most staphylococcal strains.
Adult Dose	600 mg PO/IV q6-8h for 5-7d
Pediatric Dose	20-40 mg/kg IM/IV tid/qid for 5-7 d
Contraindications	Documented hypersensitivity; regional enteritis; ulcerative colitis; hepatic impairment; antibiotic-associated colitis
Interactions	Increases duration of neuromuscular blockade induced by tubocurarine and pancuronium; erythromycin may antagonize effects; antidiarrheals may delay absorption
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Adjust dose in severe hepatic dysfunction; no adjustment necessary in renal insufficiency; associated with severe and possibly fatal colitis

Drug Name	Gentamicin (Gentacidin, Garamycin)
Description	Aminoglycoside antibiotic used for gram-negative bacterial coverage. Commonly used in combination with both an agent against gram-positive organisms and one that covers anaerobes. Used in conjunction with ampicillin or vancomycin for prophylaxis in patients with open fractures.
Adult Dose	1.5 mg/kg/dose IV q8-24h; not to exceed 80 mg; dosing interval based on renal function
Pediatric Dose	2 mg/kg/dose IV q8h; dosing interval based on renal function
Contraindications	Documented hypersensitivity; non–dialysis-dependent renal insufficiency
Interactions	Other aminoglycosides, cephalosporins, penicillins, and amphotericin B may increase nephrotoxicity; enhances effects of neuromuscular blocking agents, thus prolonged respiratory depression may occur; loop diuretics may increase auditory toxicity of aminoglycosides—irreversible hearing loss of varying degrees may occur (monitor regularly)
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Narrow therapeutic index (not intended for long-term therapy); caution in renal failure (not on dialysis), myasthenia gravis, hypocalcemia, and conditions that depress neuromuscular transmission; adjust dose in renal impairment

Drug Category: Tetanus toxoid

This agent is used for tetanus immunization. Booster injection is recommended in previously immunized individuals to prevent this potentially lethal syndrome.

FOLLOW-UP

Section 8 of 11  

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• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Complications

• 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 (Prayson, 2006). Suspicion of compartment syndrome warrants emergent orthopedic consultation; treatment is fasciotomy when the diagnosis is confirmed.
• Long-term complications
• • Arthritis
  • Infection
  • Nonunion or instability
  • Gait disturbances

Prognosis

• Generally excellent with appropriate treatment

Patient Education

• Proper instruction in crutch-walking is required for those unable to bear weight.
• For excellent patient education resources including crutch walking instructions, visit eMedicine's Breaks, Fractures, and Dislocations Center. Also, see eMedicine's patient education article Broken Foot.

MISCELLANEOUS

Section 9 of 11  

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• Introduction
• Clinical
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• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Medical/Legal Pitfalls

• Failure to note fractures because radiographs not obtained or misread
• Failure to consult or refer to an orthopedic surgeon when necessary

MULTIMEDIA

Section 10 of 11  

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• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Media file 1:  Fractures, foot. Proximal fifth metatarsal avulsion fracture (also termed pseudo-Jones, tennis, or dancer fracture).
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Media file 2:  Fractures, foot. Jones fracture of the fifth metatarsal.
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Media type:  X-RAY

Media file 3:  Fractures, foot. Lisfranc fracture-dislocation.
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Media type:  X-RAY

Media file 4:  Fractures, foot. Calcaneal fracture with intraarticular involvement and joint depression.
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Media file 5:  Fractures, foot. Calcaneal fracture with intraarticular involvement and joint depression with Böehler angle imposed. Reduced angle of 16° is pathologic.
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Media type:  X-RAY

Media file 6:  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.
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Media type:  X-RAY

Media file 7:  Fractures, foot. CT scan showing fracture of first cuneiform and proximal first metatarsal.
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Media type:  CT

Media file 8:  Fractures, foot. Spiral fracture of the shaft of the fifth metatarsal. This fracture was treated conservatively with immobilization.
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Media type:  X-RAY

Media file 9:  Fractures, foot. Minimally displaced fracture of the distal fifth metatarsal. This fracture was treated conservatively with immobilization in a rigid flat bottom shoe.
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Media type:  X-RAY

Media file 10:  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.
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Media type:  X-RAY

Media file 11:  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.
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Media type:  X-RAY

Media file 12:  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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Media type:  X-RAY

REFERENCES

Section 11 of 11

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

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• Vuori JP, Aro HT. Lisfranc joint injuries: trauma mechanisms and associated injuries. J Trauma. Jul 1993;35(1):40-5. [Medline].
• Wang CL, Shieh JY, Wang TG. Sonographic detection of occult fractures in the foot and ankle. J Clin Ultrasound. Oct 1999;27(8):421-5. [Medline].
• Wedmore IS, Charette J. Emergency department evaluation and treatment of ankle and foot injuries. Emerg Med Clin North Am. Feb 2000;18(1):85-113, vi. [Medline].
• 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].

Article Last Updated: Aug 29, 2006