Applied Evidence

Adult foot fractures: A guide

J Fam Pract. 2018 November;67(11):E8-E15

Author(s):

This review can help you refine your approach to the diagnosis and management of adult foot fractures, while offering guidance on when to pursue advanced imaging.

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PRACTICE RECOMMENDATIONS

› Manage most fractures of the proximal fifth metatarsal metaphyseal-diaphyseal junction (Jones fracture) conservatively with appropriate treatment and close follow-up; refer for early surgical evaluation only those patients who are highly active and who are interested in a faster return to activity. B

› Use the Ottawa Ankle and Foot Rules to determine whether x-rays are needed in a patient with foot pain and a suspected fracture. A

› Start with weight-bearing x-rays and then consider computed tomography or magnetic resonance imaging for complete evaluation of suspected injury to the Lisfranc joint. C

Strength of recommendation (SOR)

A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series

References

1. Eiff MP, Hatch RL, et al. Fracture Management for Primary Care. 3rd ed. Philadelphia, PA: Elsevier Saunders; 2012.

2. Hatch RL, Rosenbaum Cl. Fracture care by family physicians. A review of 295 cases. J Fam Pract. 1994;38:238-244.

3. Bica D, Sprouse RA, Armen J. Diagnosis and management of common foot fractures. Am Fam Physician. 2016;93:183-191.

4. Hatch RL, Hacking S. Evaluation and management of toe fractures. Am Fam Physician. 2003;68:2413-2418.

5. Snider RK. Essentials of Musculoskeletal Care. 2nd ed. Rosemont, IL: American Orthopedic Surgeons; 2001.

6. Guler F, Baz AB, Turan A, et al. Isolated medial cuneiform fractures: report of two cases and review of the literature. Foot Ankle Spec. 2011;4:306-309.

7. Borrelli J, De S, Van Pelt M. Fracture of the cuboid. J Am Acad Orthop Surg. 2012;20:472.

8. Pinney SJ, Sangeorzan BJ. Fractures of the tarsal bones. Orthop Clin North Am. 2001:32:21-33.

9. Rosenbaum AJ, Uhl R, DiPreta JA. Acute fractures of the tarsal navicular. Orthopedics. 2014;37:541-546.

10. Sanders RW, Clare MP. Calcaneous fractures. In: Rockwood and Green’s Fractures in Adults. 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2010:2064.

11. Singer G, Cichocki M, Schalamon J, et al. A study of metatarsal fractures in children. J Bone Joint Surg Am. 2008;90:772-776.

12. Stiell IG, Greenberg GH, McKnight RD, et al. A study to develop clinical decision rules for the use of radiography in acute ankle injuries. Ann Emerg Med. 1992;21:384-390.

13. Ekinci S, Polat O, Günalp M, et al. The accuracy of ultrasound evaluation in foot and ankle trauma. Am J Emerg Med. 2013;31:1551-1555.

14. Welck MJ, Hayes T, Pastides P, et al. Stress fractures of the foot and ankle. Injury. 2017;48:1722-1726.

15. Hatch RL, Alsobrook JA, Clugston JR. Diagnosis and management of metatarsal fractures. Am Fam Physician. 2007;76:817-826.

16. Schildhauer TA, Coulibaly MO, Hoffman MF. Fractures and dislocations of the midfoot and forefoot. In: Rockwood and Green’s Fractures in Adults. 8th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2015:2690.

17. Mayer SW, Joyner PW, Almekinders LC, et al. Stress fractures of the foot and ankle in athletes. Sports Health. 2014;6:481-491.

18. Kalsi R, Dempsey A, Bunney EB. Compartment syndrome of the foot after calcaneal fracture. J Emerg Med. 2012;43:e101-106.

The evaluation and management of acute musculoskeletal conditions are frequently handled by primary care providers.¹It’s estimated that up to 14% of orthopedic complaints encountered by family physicians involve fractures,² and approximately 15% of these are foot fractures.² Diagnosis requires radiographic evaluation, but ultrasound is proving useful, too. This article reviews the diagnosis and management of adult foot fractures, with an emphasis on when advanced imaging and referral are indicated (TABLE^1,3-10).

$Foot fractures: How to manage, when to refer$

Phalanx fractures: The most common foot fractures

Phalanx fractures typically occur by crush injury, hyperextension, or direct axial force (eg, stubbing the toe).³ Patients with phalanx fractures typically present with pain at or near the site of injury, edema, ecchymosis, and erythema. Throbbing pain is characteristic, and dependent position may worsen the pain.¹ Emergently evaluate any fracture causing tenting of the skin, protrusion from the skin, or neurovascular compromise, and attempt realignment to regain neurovascular function.

$Foot fractures: How to manage, when to refer$

Most patients with phalanx fractures have point tenderness over the site of the fracture; however, this may also occur with contusions. Placing a gentle loading force along the long axis of the bone distal to the injury may help you differentiate between a contusion and a fracture.⁴Pain observed with axial loading of the bone during examination points to a fracture rather than a contusion.

Differential diagnosis

Obtain imaging, including anterior-posterior (AP), lateral, and oblique views at a minimum, for all patients in whom you suspect fractures.⁵ Multiple fractures of the phalanges are common; therefore, always thoroughly examine the phalanges adjacent to the injured one.

Sesamoid bone fractures are uncommon but do occur and are usually due to direct injury from jumping or landing. The most common sesamoid to be injured is the medial sesamoid of the great toe, although the lateral sesamoid can also be injured. Bipartite sesamoids can occur and may confuse the examiner due to their similar appearance on x-rays to a sesamoid fracture.¹These normal variants often appear smooth and are commonly bilateral as opposed to the jagged or abrupt edges of a fracture. Stress fractures occur as well and are typically due to overuse-type injuries.

Other causes of pain similar to that experienced with phalanx fractures include soft tissue injuries to adjacent ligaments, tendons, and muscles. To help discern the cause of pain, evaluate nail beds for subungual hematomas, indicating injury to the nail bed causing bleeding and pressure under the nail. Obvious deformities of the toes or metatarsal-phalangeal joints signal the possibility of a fracture-dislocation. First metatarsophalangeal (MTP) sprain (“turf toe,” a condition common in athletes who hyperextend the toe, such as when pushing off from hard surfaces like turf) and gout can also present with acute pain in the first phalanx.

Treatment

Due to the role of the great toe in weight bearing and balance, great toe fractures are sometimes managed differently than fractures in Toes 2 through 5. Proper alignment and healing from a fracture in the first toe are critical to prevent future pain and other sequelae. Refer for orthopedic evaluation great toe fractures with displacement, angulation, rotational deformity, neurovascular compromise, >25% involvement of the joint space, or obvious dislocation.¹ If referral is not indicated, treat great toe fractures with a short leg walking cast/boot for 2 to 3 weeks followed by buddy taping and use of a hard-soled shoe for 3 to 4 weeks.¹

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