Painful foot or ankle? Don't overlook these 5 injuries
A missed diagnosis of one of these conditions risks delay in referral for orthopedic evaluation and surgical management—possibly leading to complications.
PRACTICE RECOMMENDATIONS
› Suspect higher-grade syndesmotic disruption (which typically requires surgical intervention) in patients whose ankle pain persists after 3 weeks of immobilization or who have a tibial or fibular diastasis on a plain film. C
› Order weight-bearing x-rays to make an accurate diagnosis of Lisfranc injury. Refer for potential surgical intervention if diastasis is evident at the base between the first and second metatarsals. C
› Distinguish between proximal diaphysial (Jones) fracture of the fifth metatarsal, diaphysial stress fracture, and avulsion fracture—essential because avulsion fracture can be treated nonoperatively but the other 2 require surgical intervention. 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
Examination. On exam, there might be swelling and ecchymosis over the lateral foot, with sharp tenderness to palpation at the base of the fifth metatarsal.
Imaging. Most fractures are revealed on standing AP, oblique, and lateral x-rays. Plain films are often falsely negative early in stress fracture; MRI is the gold standard of diagnosis.27,30
Management. Preferred treatment for a nondisplaced tuberosity avulsion fracture is typically 2-pronged: compressive dressings or casting for pain control and weight-bearing and range-of-motion exercises as tolerated.1 Follow-up every 2 to 3 weeks is recommended to ensure appropriate healing—ie, pain nearly resolved by 3 weeks post-injury and radiographic union evident at 8 weeks. If displacement is > 3 mm, > 60% of the metatarsal–cuboid joint surface is affected, or there is a 1 to 2 mm step-off on the cuboid articular surface, consider referral to an orthopedist.1,29
Jones fractures can be managed initially with posterior splinting, non-weight-bearing, and close follow-up. When radiographic healing has not been achieved by 6 to 8 weeks, non-weight-bearing status can be extended by another 4 weeks. When displacement is > 2 mm, or there is no healing after 12 weeks of immobilization and delayed union on x-rays, referral for surgical management is indicated.1 In select cases, when earlier return to activity is desired, referral for early surgical fixation is appropriate.27
Surgical referral is indicated in all cases of diaphysial stress fracture because of the high rate of nonunion and refracture. Conservative management, based on the orthopedic surgeon’s assessment, might be an option in a minority of patients.29
CORRESPONDENCE
Aileen Roman, MD, Boston University Medical School, Department of Family Medicine, 11 Melnea Cass Boulevard, Boston MA, 02119; aileen.roman@bmc.org
