by Stefan Wever
- Understand the basic anatomy of the foot.
- Diagnose a foot fracture.
- Manage a foot fracture.
Foot fractures comprises 10% of all fractures and is the most common foot injury seen by general practitioners. The metatarsal and toes are most commonly affected.
The foot consists of 26 bones, which make up the forefoot (metatarsals, phalanges), midfoot (tarsal bones) and hindfoot (talus, calcaneus). Within the foot, the Lisfranc joint connects the forefoot and midfoot and the Chopart joint connects the midfoot and hindfoot.
- History: Patient typically presents with a painful swollen foot following an injury. Typically the patient cannot bear weight on the affected foot.
- Examination: Swollen, possible deformity, ecchymoses (classically with lisfranc injury) present. Palpation reveals bony tenderness over the affected area. Comparison to the uninjured foot elicits abnormalities.
- Additional injuries to take note of: Remember to examine the knee, hip and back for associated injuries with calcaneus fractures sustained by falling from a height. Exclude compartment syndrome of the foot.
- Important to rule out fractures.
- If possible, request weight bearing X-rays when lisfranc injuries are suspected.
Specific fractures Calcaneus
- Often high energy injury (fall from height / motor vehicle accident) with associated injuries.
- Look for associated injuries (spine, hip and knee).
- The midfoot joint is a complex structure that needs extreme stability. Even subtle injuries can lead to long-term problems.
- Injuries can be pure ligamentous or associated with a fracture.
- High energy associated with bony fractures and low energy often with twisting-type sports injuries.
- Often missed, high suspicion if plantar ecchymosis and inability to weight bearing.
Fifth metatarsal base
- Fractures of the base are common.
- Three types exist with type 2 having a increased risk of non union.
- Common injury from direct blow to the foot.
- Most can be treated with buddy strapping only.
- Undisplaced or minimal displaced fractures.
- Hard-soled shoe/ Cast and crutches for 4–6 weeks.
- Elevation, rest, ice, non-steroidal anti-inflammatory drugs.
- Calcaneus fractures need prolonged non-weight bearing up to 3 months.
- Open fractures.
- Lisfranc injury with displacement.
- Displaced calcaneus fractures.
- Some type 2 fifth metatarsal fractures.
- Surgical treatment includes open reduction and internal fixation using wires, screws and plates.
- Foot fractures are common and most can be treated conservatively.
- Lisfranc injuries can occur without an associated fracture.
- Calcaneus fractures can have associated injuries.
- Base of fifth metatarsal fracture is the most common metatarsal fracture.
A 21-year-old rugby player presents after injuring his foot in a scrum. The dorsum of the midfoot is swollen with plantar ecchymosis. He is however able to weight bear on the foot with pain. What is the most likely diagnosis?
- Ankle fracture
- Ankle sprain
- Achilles tendon injury
- Lisfranc injury
- Unlikely to have any injury
Answer: (D) is correct. Plantar ecchymosis is associated with a Lisfranc injury.