Basics
Description
Injury to tarsal bones or metatarsals including calcaneus, talus, navicular, cuboid, cuneiform, and metatarsals
Etiology
- Most common foot injuries are of the metatarsals and phalanges.
- The calcaneus is the most commonly fractured of the tarsal bones.
- Calcaneus fractures: Compression injury from sudden high-velocity impact to heel:
- 75% are intra-articular; 50% have associated injuries:
- 10% spine fractures
- 25% with associated lower extremity trauma
- 9% bilateral, 5% open
- Metatarsal fractures: Divided into stress fractures, twisting injuries, or direct trauma:
- 1st metatarsal: Direct applied force
- 2nd and 3rd metatarsals are most often involved in stress fractures and twisting injuries.
- 5th metatarsal: Avulsion fracture (dancers fracture) of proximal apophysis is the most common injury.
- Jones fracture: Transverse fracture of the metaphyseal-diaphyseal junction of 5th metatarsal; results from twisting while foot inverted.
- Talus: Caused by dorsiflexion with axial load, common snowboarder's injury
- Navicular: Results from axial compression or stress fractures
- Cuboid and cuneiform fractures are rare and occur in conjunction with other injuries, often with tarsal-metatarsal injuries.
- Tarsal-metatarsal injuries (Lisfranc injuries) are high-energy injuries:
- Axial load on plantar-flexed foot, or hindfoot fixed with forced foot eversion
- Unstable forefoot on hindfoot
- 20% go undiagnosed on initial visit.
- 3 types: Convergent, divergent, and incongruent
- Metatarsal fractures account for 90% of foot fractures in children, usually from direct trauma:
- Lesser metatarsal fractures (2-4) most common followed by base of 5th then base of 1st metatarsal.
- Physeal injury may occur with proximal 1st metatarsal fractures.
- Other common injuries include phalangeal fractures (17%) and navicular fractures (5%).
- Fractures of talus or calcaneus occur with distal tibia or fibula fractures (8%).
- Calcaneus fractures are less likely intra-articular. Less common to have associated spine fractures.
Diagnosis
Signs and Symptoms
History
- History of preceding trauma most common
- Stress fractures may present with increasing pain in the setting of repetitive activities.
Physical Exam
- Ecchymosis, pain, swelling, or deformity of foot
- Pain with weight bearing
- Joint instability
Essential Workup
- Physical exam of extremity is necessary to assess neurovascular status, skin integrity, gross swelling, deformity, or loss of function.
- Exam of spine is also essential in suspected calcaneus fractures, as there is a 10% incidence of coexistent injury.
- Anteroposterior/lateral and oblique views are necessary for all foot fractures.
- Complications:
- Compartment syndrome most commonly presents as severe pain in a swollen foot:
- Pressures >35 mm Hg require opening of all major foot compartments.
- May have hypesthesia of plantar foot
- Weak toe flexion
- Late findings include claw toe deformity.
- Nonunion and avascular necrosis are common complications with talar neck fractures owing to distal blood supply.
- Calcaneus fractures may be accompanied by sural nerve injury; test sensation along lateral aspect of foot.
Diagnosis Tests & Interpretation
Imaging
Special views may be needed for some fractures:
- Lisfranc fractures may require stress views with weight bearing. They may require MRI to evaluate ligamentous stability. May require CT for evaluation of small fractures if clinically suspicious
- Fleck sign: Pathognomonic-avulsion of ligament from 2 MT base or medial cuneiform
- Talar fractures may require a 45 ° internal oblique view. May require CT.
- Midfoot fractures may require an external oblique foot view.
- Calcaneus fractures require an axial view and may require CT:
- Bohlers angle <20 ° suggests a compression fracture of calcaneus.
- Lumbosacral spine films are necessary in all patients with calcaneus fractures.
- Stress fractures may require 2 wk to appear on plain films; bone scan or CT may be used to elucidate suspected fractures.
Differential Diagnosis
- Anterior effects of calcaneus and talar dome fractures can be misdiagnosed as ankle sprains.
- Foot contusions
- Freiberg disease: Osteochondrosis of 2nd metatarsal head may be mistaken for stress fracture.
Treatment
Pre-Hospital
- Ice bag should be placed on affected foot and foot and ankle immobilized.
- All patients suspected of calcaneus fracture should have spinal immobilization; often, mechanism is fall from height >6 ft.
Initial Stabilization/Therapy
Manage coexisting trauma as indicated.
Ed Treatment/Procedures
- Airway, breathing, and circulation management
- Assess for neurovascular compromise distal to fracture site.
- Dislocations must be reduced as quickly as possible with assessment of neurovascular status before and after procedure:
- Procedural sedation usually required
- Immobilize, ice, and elevate in a bulky splint:
- Application of circumferential cast should be delayed until swelling subsides.
- Crutches
- Pain management:
- If large amount of swelling and pain with toe movement, suspect compartment syndrome.
- Ultrasound-guided regional anesthesia may be used for reduction
- Orthopedic consult indicated early for displaced fractures:
- Many injuries require repair within 6 hr of injury to prevent delay of open reduction with internal fixation for 6-10 days owing to swelling.
Medication
- Cefazolin: 1 g IV/IM (peds: 25 mg/kg IV/IM)
- Diprivan: 40 mg IV q10s until sedation
- Etomidate: 0.1-0.2 mg/kg IV
- Fentanyl: 50-250 μg IV titrated (peds: 2 μg/kg IV)
- Hydromorphone 0.5-2 mg IV q2h (peds: 0.15 mg/kg IV q4-6h)
- Ibuprofen: 800 mg PO (peds: 10 mg/kg PO)
- Meperidine: 25-100 mg IV/IM titrated (peds: 1-1.75 mg/kg IV/IM)
- Methohexital: 1-1.5 mg/kg IV
- Morphine: 2-10 mg IV/IM titrated (peds: 0.1 mg/kg IV)
Follow-Up
Disposition
Admission Criteria
- Open fracture
- Evidence of compartment syndrome or neurovascular injury
- Open reduction internal fixation required immediately
Discharge Criteria
Most patients with metatarsal fractures can be discharged with orthopedic follow-up.
Issues for Referral
All open fractures, as well as all midfoot/Lisfranc injuries and displaced fractures that are not successfully reduced, should be seen in ED by an orthopedic specialist.
Additional Reading
- Banarjee R, Nickishch F, Easley ME, et al. Foot fractures. In: Browner, ed. Skeletal Trauma, 4th ed., Vol. 2. Philadelphia, PA: Saunders; 2008, Chapter 61.
- Green NE, Swiontkowski M. Skeletal Trauma in Children: Foot Fractures, 4th ed. Philadelphia, PA: Saunders; 2008, Chapter 16.
- Harrast MA, Colonno D. Stress fractures in runners. Clin Sports Med. 2010;29(3):399-416.
- Ishikawa SN. Fractures and dislocations of the foot. In: Canale ST & Beaty JH; eds. Campbells Operative Orthopedics. 12th ed. Mosby St. Louis, MO; 2012, Chapter 88.
- Khan W, Oragui E, Akagha E. Common fractures and injuries of the ankle and foot: Functional anatomy, imaging, classification and management. J Perioper Pract. 2010;20(7):249-258.
Codes
ICD9
- 825.20 Closed fracture of unspecified bone(s) of foot [except toes]
- 825.25 Closed fracture of metatarsal bone(s)
- 825.29 Other closed fracture of tarsal and metatarsal bones
- 825.30 Open fracture of unspecified bone(s) of foot [except toes]
- 825.0 Fracture of calcaneus, closed
- 825.1 Fracture of calcaneus, open
- 825.21 Closed fracture of astragalus
- 825.22 Closed fracture of navicular [scaphoid], foot
- 825.23 Closed fracture of cuboid
- 825.24 Closed fracture of cuneiform, foot
- 825.2 Fracture of other tarsal and metatarsal bones, closed
- 825.31 Open fracture of astragalus
- 825.32 Open fracture of navicular [scaphoid], foot
- 825.33 Open fracture of cuboid
- 825.34 Open fracture of cuneiform, foot
- 825.35 Open fracture of metatarsal bone(s)
- 825.39 Other open fracture of tarsal and metatarsal bones
- 825.3 Fracture of other tarsal and metatarsal bones, open
- 825 Fracture of one or more tarsal and metatarsal bones
ICD10
- S92.209A Fracture of unsp tarsal bone(s) of unsp foot, init
- S92.309A Fracture of unsp metatarsal bone(s), unsp foot, init
- S92.909A Unsp fracture of unsp foot, init encntr for closed fracture
- S92.909B Unsp fracture of unsp foot, init encntr for open fracture
- S92.009A Unsp fracture of unsp calcaneus, init for clos fx
- S92.009B Unsp fracture of unsp calcaneus, init for opn fx
- S92.109A Unsp fracture of unsp talus, init encntr for closed fracture
- S92.109B Unsp fracture of unsp talus, init encntr for open fracture
- S92.209B Fx unsp tarsal bone(s) of unsp foot, init for opn fx
- S92.216A Nondisp fx of cuboid bone of unsp foot, init for clos fx
- S92.216B Nondisp fx of cuboid bone of unsp foot, init for opn fx
- S92.236A Nondisp fx of intermediate cuneiform of unsp foot, init
- S92.236B Nondisp fx of intermed cuneiform of unsp ft, init for opn fx
- S92.246A Nondisp fx of medial cuneiform of unsp foot, init
- S92.246B Nondisp fx of medial cuneiform of unsp foot, init for opn fx
- S92.256A Nondisp fx of navicular of unsp foot, init for clos fx
- S92.256B Nondisp fx of navicular of unsp foot, init for opn fx
- S92.309B Fx unsp metatarsal bone(s), unsp foot, init for opn fx
SNOMED
- 342070009 Closed fracture of foot (disorder)
- 263245004 Fracture of tarsal bone (disorder)
- 263251009 metatarsal bone fracture (disorder)
- 367527001 Open fracture of foot (disorder)
- 15574005 fracture of foot (disorder)
- 263246003 Fracture of talus (disorder)
- 263247007 fracture of calcaneus (disorder)
- 263248002 Fracture of navicular (disorder)
- 263249005 Fracture of cuboid (disorder)
- 281536003 Fracture of cuneiform (disorder)