the injured foot

see also:

• orthopaedics in the ED
• the painful foot
• ankle injuries and fractures
• acute foot drop

• foot injuries are common and significant injuries are commonly missed unless actively sort by the treating clinician.
• delayed diagnosis or misdiagnosis of important injuries can contribute to long term morbidity
• this is particularly likely in those who have been injured by large forces such as fall from a height, sports injuries, skiing injuries and motor vehicle accidents.
• common complications include non-union (esp. Jones fracture), avascular necrosis (esp. talar neck), osteoarthritis, osteochondritis (eg. undisplaced talar dome injuries), osteomyelitis (compound injuries or post-ORIF) and mechanical pain syndromes from ligamentous injury.

• Sever's disease - calcaneus
• Köhler's disease - navicular
• Frieberg's disease - metatarsal head (usually 2nd or 3rd)

• Phong Tran's - orthopaedics website - fracture neck of talus
• commonly occurs in car accidents and light aircraft accidents from excessive dorsiflexion with foot on the brake pedal
• also occurs in falls from a height in crouching position
• talar neck fractures are associated with avascular necrosis risk (10% with type I, 50% in type II, 85% in type III)

• no displacement
• Rx padded plaster with toe platform and elevation for 1 week, r/v in fracture clinic for possible non-weight bearing with crutches for 8-12 weeks and reassessment then for union, and avascular necrosis

• subtalar subluxation with proximal part becoming plantar flexed as the distal fragment displaces forwards
• Rx is usually with ORIF, contact ortho.

• tibia driven between the talar fragments
• Rx:
  • refer to ortho ASAP
  • consider attempting closed reduction
  • usually needs ORIF

• rare
• head of talus dislocated from the navicular in association with a type II or type III injury

• shearing injury may force a piece of the talar dome upper articular surface to detach
• small fragments may be excised
• larger fragments may require ORIF
• most will need 6 weeks in BKPOP

• flakes of talar bone are commonly avulsed during ankle injuries from pull of the ankle ligaments or capsular attachments
• these require symptomatic Rx only - eg. 2-4 wks in a walking BK plaster

• may occur during compression injuries such as fall from a height
• generally require CT scan and ortho opinion
• most are managed without surgery but usually require at least 8-10 weeks non-weight bearing and many will have long term pain and restricted function

• Phong Tran's - orthopaedics website - fracture calcaneum
• these usually occur following a fall from a height and must be carefully looked for in anyone with such a history.
• it is commonly bilateral
• Xray findings can be subtle
  • check Bohler's salient angle - should be ~40deg and is less than this in fractures which flatten the heel profile
• when in doubt, consider CT scan
• most patients will require admission

• the mid-tarsal joint lies between the talus and calcaneum posteriorly, and the navicular and cuboid anteriorly
• dislocation of the talonavicular portion of the midtarsal joint may accompany subtalar dislocations which may have partly reduced spontaneously
• dislocation may be associated with fractures, particularly, the navicular
• Rx is usually with closed reduction +/- K wires for 3-4 weeks, or ORIF

• avulsion fractures can usually be Rx with 6 weeks in BKPOP
• displaced fractures of the body should be urgently reduced to reduce risk of oedema and circulatory impairment, then accurately reduced and fixed surgically

• fracture of the base of the 5th MT involving the tarso-metatarsal joint NOT to be confused with a more sinister Jones fracture
• these are common fractures associated with “ankle sprains” from inversion of the ankle as a result of bony avulsion due to stress on peroneus brevis tendon which inserts at this point
• these fractures are easily missed unless looked for.
• in children, take care not to misdiagnose the normal physeal line as being a fracture
  • fractures are usually transverse whilst the apophyseal line (growth plate) is more longitudinal
• whilst many can be managed with crutches and tubigrip, healing may be quicker with a cast

• fracture of the proximal diaphysis of the fifth metatarsal involving the intermetatarsal joint NOT the tarso-metatarsal joint
• this is NOT caused by inversion injuries but commonly occurs in athletes
• commonly results in non-union due to the poor blood supply to this bone and thus can result in chronic pain
• BKPOP for 6-8 weeks will heal 75%
• athletes or those at risk should be referred for possible ORIF

• Phong Tran's - patient information website - LisFranc
• usually follow large forces such as fall from a height, sports injuries or car accidents.
• may occur when a car wheel runs over forefoot with heel on the gutter edge
• Xray usually will show the injury but may require weight bearing views to demonstrate collapse of the normal arch, or CT scan.
• most need surgical repair and there is a high risk of long term sequelae.

• often result from crush injuries
• spiral shaft injuries may result from forced inversion or eversion of the forefoot
• children often fracture the bases or necks of 2nd - 4th MT's and these can usually be managed in BKPOP
• BEWARE LisFranc and Jones fractures (see above)

• Phong Tran's - patient information website - metatarsalgia

• stress fracture - esp. 2nd MT neck or shaft (“march fracture”)
• Morton's neuroma - most commonly occurs in the webspace between the 3rd and 4th toes
• sesamoiditis
• fracture sesamoid of the hallux - sometimes may require operative Rx¹⁾
• MTP joint arthritis - esp. gout, rheumatoid arthritis and psoriatic arthritis
• bursitis
• Freiberg's disease - osteochondritis of a metatarsal head (usually the 2nd or 3rd) in adolescents

• Phong Tran's - patient information website - fracture toe Rx
• most fractures can be managed by buddy taping toe to next toe with gauze between the toes
• significantly angulated or displaced fractures may need closed reduction under a digital block
• compound fractures generally require referral for Mx as usual for compiund fractures:
  • wound irrigation and closure
  • tetanus prophylaxis
  • iv antibiotics