Assessment and management of foot injuries and fractures
by Kunal Bhanot

Scenario: called to A&E to assess a 20 year old man who hurt his foot after jumping off a wall. No other injuries.

History
Age
Occupation – useful for deciding treatment
Time/date of injury
Mechanism of injury – direction of torque force to the ankle and the position of the foot - inversion, eversion, impact, fall from height
Immediate problem – pain/swelling, inability to weight bear
Past History

• prior injury to joint causing antecedent laxity and non-acute radiologic
• abnormality.
• chronic medical issues – vasculopathy – may compromise exam results
• use of steroids – considerations for premature osteoporosis
• use of NSAIDs – may mitigate degree of swelling expected

Medication/drugs and allergies/time of last meal

Examination
Attempt to discern fracture versus soft tissue injury.

• Gross deformity, bony tenderness, ecchymosis, discolouration, and inability to weight bear - fracture likely (possibly associated with ligamentous injury)
  
• Ensure examination of ankle, knee, and proximal fibula - concomitant injuries depending on mechanism

Imaging:

• Plain film imaging generally sufficient
• Apply ankle rules
• Dorsal-plantar, lateral, and oblique views.
• May request weight-bearing views if Lisfranc fracture dislocation is suspected

Management:
Immobilization, ice, and foot elevation with analgesia for all patients with significant foot injuries
Initial immobilization with below knee backslab

Toe Fracture (phalangeal)

• Analgesia
• Generally heal well with minimal therapy
• Buddy tape to adjacent unbroken toe
• Great toe fractures may require reduction and rigid immobilization
• Refer to fracture clinic for follow up

Internal metatarsal fracture – 2nd, 3rd, and 4th metatarsals (excluding Lisfranc injury)

• Analgesia
• Non-displaced and displaced fractures heal well
• Weight-bearing as tolerated
• Cast or rigid-bottom orthopaedic shoe, may use elastic support bandages.
• Fracture clinic <1 week

Fifth metatarsal fractures

• Analgesia
• Fracture clinic review 1 week
  
• Distal metatarsal – managed with rigid flat-bottom shoe immobilization
• Proximal avulsion of tuberosity (pseudo-Jones) – compression dressing and weight-bearing as tolerated
• Jones fracture – 1-3 cm distal to tuberosity – immobilize and non-weight-bearing (risk of non-union)
  

Lisfranc ligament injury (often associated with avulsion fractures)
Causes displacement of 2nd/3rd/4th Metatarsals from the 1st metatarsal. Often subtle and easily missed. Large degree of swelling observed.

• Most missed foot fracture. Need weight-bearing views.
• Look for widening between bases of the first and second metatarsals or between the middle and medial cuneiforms.
• Second metatarsal base fracture is suspicious for this injury.
• High-energy injury - look for other injuries
• Needs operative fixation if displaced/unstable
• If in doubt discuss with senior
• Further investigation with MRI/CT scans

Diagram demonstrating different sites of 5th metatarsal fracture

AP x-ray foot demonstrating displaced LisFranc injury

Navicular fracture

• Analgesia
• Non-displaced – immobilization in backslab and non-weightbearing. Review in fracture clinic 1 week.
• Displaced – risk of AVN, apply backslab, further investigation with CT, discuss with senior.

Calcaneal fracture
Analgesia
Often caused by falls from height – high risk for associated injuries – asses ankles, femurs, hips & pelvis and spine
Apply backslab, elevation.
Investigate with CT scan to determine displacement and articular invovlement.
Intra-articular – reduced Böehler’s angle – discuss with senior - possibly for operative fixation.
Extra-articular minimally displaced – Immobilization, non-weightbearing. Review fracture clinic 1 week.
Extra-articular displaced - may require fixation - discuss with senior.

Böehler’s angle – Normal between 20° and 40°

Böehler’s angle less than 20° or 5° than contralateral side indicate fracture