Adult foot fractures: A guide
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.
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
Calcaneal fractures
Calcaneal fractures typically occur from severe axial load or fall from a height. Weight bearing is usually limited and secondary to significant pain. Tenderness to palpation over the calcaneus or with squeezing of the heel will produce pain on exam. Initial x-rays should include a lateral and axial view of the calcaneus. Additional imaging, including a CT scan, may be indicated for further evaluation to determine the extent of the fracture or to determine if a fracture is present despite normal x-rays.10
Acute compartment syndrome occurs in 10% of calcaneal fractures and must be considered in patients with calcaneal fractures from severe trauma.18 Tendon injuries of the ankle, hindfoot, and midfoot may present similarly but can be ruled out with clinical exam and appropriate imaging.
Treatment
Avulsion fractures that do not involve more than 25% of the calcaneocuboid joint and nondisplaced calcaneal fractures may be managed conservatively by instructing patients to wear a NWB short leg cast/boot for 4 to 6 weeks.1 Refer for surgical evaluation patients with calcaneal fracture fragments >1 cm, displacement >3 mm, open fractures, joint involvement >25%, and those whose symptoms fail to resolve with conservative management. Stress fractures can be managed conservatively with cessation of aggravating activities and immobilization in a walking boot until symptoms resolve, which typically takes 4 to 6 weeks.1
CORRESPONDENCE
Michael Seth Smith, MD, CAQSM, PharmD, 3450 Hull Road, Gainesville, FL 32611; smithms@ortho.ufl.edu
