Practice Essentials
Approximately 10% of all fractures occur in the 26 bones of the foot. The foot contains two bones in the hindfoot (calcaneus and talus), [1] five in the midfoot (navicular, cuboid, and three cuneiforms), and 19 in the forefoot (five metatarsals [2, 3, 4] and 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. The hindfoot connects to the midfoot at the Chopart joint; the forefoot connects to the midfoot at the Lisfranc joint. [5, 6, 7]
Foot fractures are among the most common foot injuries evaluated by primary care physicians, most often involving the metatarsals and toes. [8, 9, 10] The diagnosis typically is made on the basis of radiographic evaluation, but ultrasonography (US) has also proved to be highly accurate. [11, 12] A radiograph is required if any of the following are present [13] :
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Point tenderness over the base of fifth metatarsal
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Point tenderness over the navicular bone
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Inability to take four steps, both immediately after injury and in the emergency department (ED)
Management is determined by the location of the fracture and its effect on balance and weightbearing. [14]
Treatment approaches include the following [14] :
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Metatarsal shaft fracture - These fractures are initially treated with a posterior splint and avoidance of weightbearing activities; subsequent treatment consists of a short leg walking cast or boot for 4-6 weeks
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Proximal fifth metatarsal fracture - These 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, and the patient can then be transitioned to a short leg walking boot for 2 weeks, with progressive mobility as tolerated after initial immobilization
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Jones fracture - These fractures have a higher risk of nonunion and require at least 6-8 weeks in a short leg nonweightbearing cast; healing time can be as long as 10-12 weeks
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Toe fracture - 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
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Lisfranc injuries - These 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
Epidemiology
Compared with adults, children have ligaments that are relatively strong in relation to their 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 the rpesence of multiple growth centers. In such cases, comparison views of the uninjured foot are often helpful. Persistent foot pain in children should raise the physician's concern for potentially important fractures, even in the absence of plain radiographic signs. [15]
In pediatric patients, foot tractures account for approximately 5-13% of all fractures. Toe fractures in children represent the most common foot fractures in the pediatric age group, accounting for as many as 18% of foot fractures. Phalangeal fractures represent 3-7% of all physeal fractures and are usually Salter-Harris type I or type II injuries. Pediatric phalanx fractures are more common in boys than in girls and are most commonly closed injuries. [16]
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Proximal fifth metatarsal avulsion fracture (also termed pseudo-Jones, tennis, or dancer fracture).
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Jones fracture of fifth metatarsal.
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Lisfranc fracture-dislocation.
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Calcaneal fracture with intra-articular involvement and joint depression.
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Calcaneal fracture with intra-articular involvement and joint depression with Böhler angle imposed. Reduced Böhler angle of 16 degrees is pathologic.
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Subtle fracture of first cuneiform at Lisfranc joint. Another fracture at base of first metatarsal is not seen here but was found on subsequent CT.
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CT scan shows fracture of first cuneiform and proximal first metatarsal.
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Spiral fracture of shaft of the fifth metatarsal. This fracture was treated conservatively with immobilization.
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Minimally displaced fracture of distal fifth metatarsal. This fracture was treated conservatively with immobilization in rigid flat-bottom shoe.
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Two fractures of proximal phalanx of great toe. Fracture at base is obvious, but fracture at head is more subtle. Every bone on radiograph must be examined to avoid being distracted by obvious finding.
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Comminuted navicular fracture in young drunk driver involved in motor vehicle crash. Patient sustained no other injuries and was discharged in plaster splint with strict nonweightbearing. Patient subsequently had a CT scan and underwent open reduction and internal fixation 9 days after injury. Standard anteroposterior (AP) view is shown.
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Added oblique view of same patient with navicular fracture was obtained in ED to help verify the absence of other significant fractures. Obtaining views that are not part of routine foot series can be helpful and should be added when needed.
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