JUNIORBONES
Orthopaedics and trauma for junior orthopaedic trainees and medical students
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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
Picture
Diagram demonstrating different sites of 5th metatarsal fracture
Lisfranc injury
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.


Bohlers angle
Böehler’s angle – Normal between 20° and 40°
calcaneum fracture
Böehler’s angle less than 20° or 5° than contralateral side indicate fracture
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