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Emergency And Acute Medicine – Foot Fracture
Basics Description
Foot fractures involve injury to the tarsal bones or metatarsals, including the calcaneus, talus, navicular, cuboid, cuneiforms, and metatarsals.
Etiology
The most common foot fractures involve the metatarsals and phalanges. The calcaneus is the most frequently fractured tarsal bone.
Calcaneus fractures usually result from high-velocity axial compression to the heel; approximately 75% are intra-articular and 50% are associated with other injuries, including spinal fractures, lower extremity trauma, bilateral involvement, or open wounds.
Metatarsal fractures may result from stress, twisting injuries, or direct trauma. The first metatarsal is often injured by direct force. The second and third metatarsals are most commonly affected by stress or twisting injuries. The fifth metatarsal commonly sustains avulsion fractures at the proximal apophysis (dancer’s fracture) or a Jones fracture at the metaphyseal–diaphyseal junction from inversion injury.
Talus fractures are typically caused by dorsiflexion with axial loading. Navicular fractures result from axial compression or stress. Cuboid and cuneiform fractures are rare and usually occur with associated injuries, particularly tarsometatarsal (Lisfranc) injuries. Lisfranc injuries are high-energy injuries caused by axial load on a plantar-flexed foot or forced eversion and are frequently missed on initial evaluation.
Pediatric considerations include a predominance of metatarsal fractures, often from direct trauma, with physeal injury possible. Calcaneal fractures in children are less commonly intra-articular and less often associated with spinal injury.
Diagnosis Signs And Symptoms
History usually reveals trauma; stress fractures may present with progressive pain related to repetitive activity.
Physical examination may show ecchymosis, swelling, deformity, localized tenderness, pain with weight bearing, or joint instability.
Essential Workup
A focused extremity examination is required to assess neurovascular status, skin integrity, swelling, deformity, and function. In suspected calcaneal fractures, evaluation of the spine is essential due to the risk of associated injury. Standard anteroposterior, lateral, and oblique foot radiographs are required.
Diagnosis Tests And Interpretation
Imaging may require special views depending on the suspected injury. Lisfranc injuries may require weight-bearing stress views, MRI for ligamentous assessment, or CT. Talar fractures may require oblique views or CT. Calcaneal fractures require axial views, with a Böhler angle less than 20° suggesting compression fracture, and often CT for further definition. Lumbar spine imaging is recommended in calcaneal fractures. Stress fractures may not be visible on initial radiographs and may require delayed imaging, bone scan, or CT.
Complications to assess include compartment syndrome, nonunion, avascular necrosis (especially with talar neck fractures), and sural nerve injury with calcaneal fractures.
Differential Diagnosis
Ankle sprain, foot contusion, talar dome injury, and Freiberg disease may mimic foot fractures.
Treatment
Prehospital care includes ice application, immobilization, and spinal precautions when calcaneal fracture is suspected.
Initial stabilization prioritizes management of associated injuries.
Emergency department management includes airway, breathing, and circulation assessment, neurovascular evaluation, prompt reduction of dislocations with reassessment, immobilization in a bulky splint, elevation, ice, and crutches. Circumferential casting should be delayed until swelling subsides. Pain control is essential. Compartment syndrome should be suspected with severe pain, swelling, or pain on passive toe movement. Early orthopedic consultation is required for displaced, open, or midfoot fractures.
Medication
Analgesics and sedatives may be used as indicated for pain control and procedural sedation. Antibiotics are indicated for open fractures.
Follow Up Disposition
Admission criteria include open fractures, compartment syndrome, neurovascular compromise, or need for immediate operative fixation.
Discharge criteria include stable patients with isolated, nondisplaced metatarsal fractures who can be managed with immobilization and close orthopedic follow-up.
Clinical Insights And Frequent Errors
Calcaneal fractures should prompt evaluation for spinal injury. Lisfranc injuries are commonly missed and require a high index of suspicion. Persistent pain or swelling despite normal initial imaging warrants reevaluation for occult or stress fractures.
Basics Description
Foot fractures involve injury to the tarsal bones or metatarsals, including the calcaneus, talus, navicular, cuboid, cuneiforms, and metatarsals.
Etiology
The most common foot fractures involve the metatarsals and phalanges. The calcaneus is the most frequently fractured tarsal bone.
Calcaneus fractures usually result from high-velocity axial compression to the heel; approximately 75% are intra-articular and 50% are associated with other injuries, including spinal fractures, lower extremity trauma, bilateral involvement, or open wounds.
Metatarsal fractures may result from stress, twisting injuries, or direct trauma. The first metatarsal is often injured by direct force. The second and third metatarsals are most commonly affected by stress or twisting injuries. The fifth metatarsal commonly sustains avulsion fractures at the proximal apophysis (dancer’s fracture) or a Jones fracture at the metaphyseal–diaphyseal junction from inversion injury.
Talus fractures are typically caused by dorsiflexion with axial loading. Navicular fractures result from axial compression or stress. Cuboid and cuneiform fractures are rare and usually occur with associated injuries, particularly tarsometatarsal (Lisfranc) injuries. Lisfranc injuries are high-energy injuries caused by axial load on a plantar-flexed foot or forced eversion and are frequently missed on initial evaluation.
Pediatric considerations include a predominance of metatarsal fractures, often from direct trauma, with physeal injury possible. Calcaneal fractures in children are less commonly intra-articular and less often associated with spinal injury.
Diagnosis Signs And Symptoms
History usually reveals trauma; stress fractures may present with progressive pain related to repetitive activity.
Physical examination may show ecchymosis, swelling, deformity, localized tenderness, pain with weight bearing, or joint instability.
Essential Workup
A focused extremity examination is required to assess neurovascular status, skin integrity, swelling, deformity, and function. In suspected calcaneal fractures, evaluation of the spine is essential due to the risk of associated injury. Standard anteroposterior, lateral, and oblique foot radiographs are required.
Diagnosis Tests And Interpretation
Imaging may require special views depending on the suspected injury. Lisfranc injuries may require weight-bearing stress views, MRI for ligamentous assessment, or CT. Talar fractures may require oblique views or CT. Calcaneal fractures require axial views, with a Böhler angle less than 20° suggesting compression fracture, and often CT for further definition. Lumbar spine imaging is recommended in calcaneal fractures. Stress fractures may not be visible on initial radiographs and may require delayed imaging, bone scan, or CT.
Complications to assess include compartment syndrome, nonunion, avascular necrosis (especially with talar neck fractures), and sural nerve injury with calcaneal fractures.
Differential Diagnosis
Ankle sprain, foot contusion, talar dome injury, and Freiberg disease may mimic foot fractures.
Treatment
Prehospital care includes ice application, immobilization, and spinal precautions when calcaneal fracture is suspected.
Initial stabilization prioritizes management of associated injuries.
Emergency department management includes airway, breathing, and circulation assessment, neurovascular evaluation, prompt reduction of dislocations with reassessment, immobilization in a bulky splint, elevation, ice, and crutches. Circumferential casting should be delayed until swelling subsides. Pain control is essential. Compartment syndrome should be suspected with severe pain, swelling, or pain on passive toe movement. Early orthopedic consultation is required for displaced, open, or midfoot fractures.
Medication
Analgesics and sedatives may be used as indicated for pain control and procedural sedation. Antibiotics are indicated for open fractures.
Follow Up Disposition
Admission criteria include open fractures, compartment syndrome, neurovascular compromise, or need for immediate operative fixation.
Discharge criteria include stable patients with isolated, nondisplaced metatarsal fractures who can be managed with immobilization and close orthopedic follow-up.
Clinical Insights And Frequent Errors
Calcaneal fractures should prompt evaluation for spinal injury. Lisfranc injuries are commonly missed and require a high index of suspicion. Persistent pain or swelling despite normal initial imaging warrants reevaluation for occult or stress fractures.
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