Information
Editors
Fractures of the Foot
Toe fracture
- The treatment consists of wearing a stout shoe for 1-4 weeks with the injured toe strapped to an adjacent toe.
- The patient should be allocated sick leave for 1-4 weeks, depending on his/her occupation.
- If the displacement of the fracture exceeds the diameter of the bone itself, or if a joint is dislocated, the fracture must be reduced under block anaesthesia followed by immobilisation as outlined above.
- Fractures of the proximal phalanx of the great toe as well as those involving a proximal interphalangeal (PIP) joint or the first metatarsophalangeal (MTP) joint require careful, often surgical, reduction.
Metatarsal fracture
- Single fractures are treated with a supporting bandage combined with protective weight bearing, as tolerated, for a few weeks.
- The treatment of non-displaced fractures of multiple metatarsal bones consists of a plaster cast for 3-4 weeks. However, if the fracture is displaced or angulated, open reduction and fixation with Kirschner wires is required followed by a plaster cast for 4-6 weeks.
- A fracture of the fifth metatarsal base (avulsion of the short peroneal muscle tendon) heals well with an application of adhesive strapping or a plaster cast for 4-6 weeks combined with protective weight bearing (avoidance of excessive strain on the ball of the foot). If the fracture is situated in the proximal metaphysis (Jones fracture) and is acute and has only minor dislocation, it may be treated as above. If the fracture involves a diastasis of more than 2-3 mm or there are findings suggestive of a stress fracture Stress Fractures, surgical treatment is indicated, particularly in persons who move actively.
Fracture of a tarsometatarsal joint (Lisfranc's joint)
- The diagnosis is often missed. Always suspect when the foot is exceptionally painful and swollen.
- Various injury mechanisms: stepping in a hole while walking, pressing brake pedal in a collision accident, other player stepping on the foot while playing football, fall accident
- When imaging midfoot injuries with conventional radiography, three projections are required: anteroposterior (AP), oblique and lateral. In modern clinical practice, a CT scan is always warranted when a significant midfoot injury is suspected.
- The primary site of injury is the base of the 2nd metatarsal bone (2nd tarsometatarsal joint) that often dislocates dorsally and laterally. The base is lifted upwards leading to an avulsion fracture, and the gap between the 1st and 2nd metatarsal is widened.
- The treatment often consists of surgical repair. Immobilisation in a plaster cast combined with protected weight bearing is indicated for 6 weeks.
- Painful for an extended period, 10-16 weeks.
Dislocation of the transverse tarsal joint (Chopart's joint)
- Should always be suspected when the foot is unusually painful and swollen.
- May reduce spontaneously in which case x-ray findings are minimal.
- Suggestive radiological findings include bone fractions, resulting from avulsion or compression, on the lateral or medial aspects of the joint (picture ). Computed tomography scanning is now a routine investigation.
- The treatment often consists of surgical fixation followed by a plaster cast for 6-8 weeks.
- In practice, all fractures of the navicular bone need to be assessed by a specialist. The fracture requires careful reduction, and the risk of avascular necrosis must be borne in mind.
Talus (ankle bone)
- An orthopaedic consultation and computerised tomography scanning are always warranted in fractures of the talus.
- Early reduction and screw fixation is required, especially in fracture-dislocations but also in all displaced fractures of the neck and body of the talus, even where the displacement is minimal.
- A large proportion of the talus surface area consists of articular surface, and hence the blood supply to the bone is only modest. Bone union is therefore slow to take place, and the risk of avascular necrosis is significant in the body of the talus.
- The time needed for immobilisation and partial weight bearing are dependent on the type of fracture; usually 8-16 weeks. Clinical follow-up should be extended to last up to 6-12 months, and the patient must be informed about the possible complications.
Calcaneus (heel bone)
- Often caused by a fall from a height in working-age men.
- Increasingly also avulsion fractures by the achilles tendon (due to minor slipping etc.) as well as osteoporotic low-energy fractures in the elderly.
- The possibility of associated injuries in legs and lumbar spine must not be overlooked.
- There is often extensive swelling and blistering of the hindfoot.
- If, based on plain x-rays, an intra-articular fracture (= fracture reaches talocalcaneal joint) or a dislocated fracture is suspected, the patient should be referred for computerised tomography scanning and to assessment by a specialist.
- Especially avulsion fractures in the upper part of the posterior calcaneus involve an imminent threat of skin necrosis, and therefore the patient should be referred to specialist care without delay.
- Conservative treatment and surgical follow-up care should both be functional, i.e. the ankle is mobilised immediately but only partial weight bearing is allowed for at least 6-12 weeks.
- Treatment by a plaster cast is often warranted, especially in patients with diabetes and patients not able to fully co-operate with treatment.
- Skin necrosis develops rapidly in avulsion fractures related to the achilles tendon, and consequently surgical treatment should take place without delay.
- Indications for surgery: intra-articular fracture or clear step-off, comminution at the joint surface or changed posture of the foot (valgus position, the heel bone "escapes" from under the foot towards lateral direction).
- The total healing time will in practice be at least six months, and it will not be possible to assess the final result until after 1-2 years.