Foot Fracture 

Updated: Sep 23, 2018
Author: Robert Silbergleit, MD; Chief Editor: Trevor John Mills, MD, MPH 

Overview

Practice Essentials

Approximately 10% of all fractures occur in the 26 bones of the foot. These bones comprise 2 bones in the hindfoot (calcaneus, talus),[1, 2] 5 bones in the midfoot (navicular, cuboid, 3 cuneiforms), and 19 bones in the forefoot (5 metatarsals,[3, 4, 5] 14 phalanges). In addition, the foot contains sesamoid bones, most commonly the os trigonum, os tibiale externum, os peroneum, and os vesalianum pedis. Their smooth sclerotic bony margins and relatively consistent locations help distinguish them from fractures. Hindfoot connects to the midfoot at the Chopart joint; forefoot connects to the midfoot at the Lisfranc joint.[6, 7, 8]

Foot fractures are among the most common foot injuries evaluated by primary care physicians, most often involving the metatarsals and toes.[9, 10, 11] Diagnosis requires radiographic evaluation, but ultrasonography has also proven to be highly accurate. If any of the following are present, a radiograph is required: point tenderness over the base of fifth metatarsal; point tenderness over the navicular bone;iInability to take 4 steps, both immediately after injury and in the ED.[12]

Management is determined by the location of the fracture and its effect on balance and weight bearing.[13]

Treatment approaches include the following[13] :

  • Metatarsal shaft fractures are initially treated with a posterior splint and avoidance of weight-bearing activities; subsequent treatment consists of a short leg walking cast or boot for 4-6 weeks.
  • Proximal fifth metatarsal fractures have different treatments depending on the location of the fracture. A fifth metatarsal tuberosity avulsion fracture can be treated acutely with a compressive dressing, then the patient can be transitioned to a short leg walking boot for 2 weeks, with progressive mobility as tolerated after initial immobilization.
  • A Jones fracture has a higher risk of nonunion and requires at least 6-8 weeks in a short leg non-weight-bearing cast; healing time can be as long as 10 to 12 weeks.
  • Great toe fractures are treated with a short leg walking boot or cast with toe plate for 2-3 weeks, then a rigid-sole shoe for an additional 3-4 weeks. Lesser toe fractures can be treated with buddy taping and a rigid-sole shoe for 4-6 weeks.
  • Lisfranc injuries can be categorized as stable or unstable. Stable Lisfranc injuries can be immobilized in the ED and patients discharged home, but unstable injuries require an orthopedic referral for consideration of surgical fixation.

Below is an example of a common fracture.

Fractures, foot. Proximal fifth metatarsal avulsio Fractures, foot. Proximal fifth metatarsal avulsion fracture (also termed pseudo-Jones, tennis, or dancer fracture).

For patient education resources including crutch walking instructions, see the Breaks, Fractures, and Dislocations Center, as well as Broken Foot.

Epidemiology

In contrast to adults, children have relatively stronger ligaments than bone or cartilage. As a result, fractures are more common than sprains in children. However, a child's forefoot is flexible and resilient to injury. When metatarsal or phalangeal fractures do occur, they may be difficult to recognize because of multiple growth centers. In such cases, comparison views of the uninjured foot often are helpful. Persistent foot pain in children should raise the physician's concern for potentially important fractures, even in the absence of plain radiographic signs.[14]

In pediatric patients, foot tractures account for approximately 5-13% of all fractures. Toe fractures in children represent the most common foot fractures in the pediatric age group, accounting for as many as 18% of foot fractures. Phalangeal fractures represent 3-7% of all physeal fractures and are usually Salter-Harris type I or type II injuries.  Pediatric phalanx fractures are more common in boys than girls and are most commonly closed injuries.[15]

 

Presentation

History

History of foot fracture includes the following:

  • Mechanism of injury

  • Time between injury and presentation

  • Prior injuries

Physical

Physical examination for foot fracture includes the following:

  • Inspect injured foot for swelling, bruises, deformity, and open wounds.

  • Uncover uninjured foot for side-by-side comparison.

  • Palpate for pulses, capillary refill, tenderness, instability, and crepitus.

  • Test range of motion and joint function. Normal ranges of motion of the foot relative to the ankle are 45 degrees plantarflexion, 20 degrees dorsiflexion, 30 degrees inversion, 20 degrees eversion, 20 degrees internal rotation, and 10 degrees external rotation. Comparisons with the uninjured foot are helpful.

  • Explore all open wounds.

  • Conduct and document a careful neurologic exam of foot, including both motor and sensory functions.

 

DDx

Differential Diagnoses

 

Workup

Imaging Studies

Plain-film radiography

Ottawa foot rules are a tool that predicts significant midfoot fractures. They are guidelines used to determine whether radiographs are necessary.[12] If any of the following are present, a radiograph is required: point tenderness over the base of fifth metatarsal; point tenderness over the navicular bone;iInability to take 4 steps, both immediately after injury and in the ED.

Although developed and validated in adults, the Ottawa foot rule also appears to be a reliable tool to exclude fractures in children 5 years of age and older.[16] When performed, a systematic approach to reading foot radiographs is important and reduces the risk of missing important injuries.[17]

In a study by Pires et al, the Ottawa ankle rules showed a high reliability for determination of when to take radiographs in patients with foot or ankle sprains. Weight-bearing inability was found to be the most important isolated item to predict the presence of a fracture (69.4% sensitivity, 61.6% specificity, 63.1% accuracy, 21.9% positive predictive value, and 93% negative predictive value). Orthopedic surgeon subjective analysis had a 55.6% sensitivity, 90.1% specificity, 46.5% positive predictive value, and 92.9% negative predictive value. The general orthopedic surgeon opinion accuracy was 85.4%. The Ottawa ankle rules presented 97.2% sensitivity, 7.8% specificity, 13.9% positive predictive value, 95% negative predictive value, and 19.9% accuracy.[18]

Other imaging modalities

Bone scanning, CT scanning, MRI, and ultrasonography may help diagnose certain foot fractures that are occult on plain film radiography.[19, 20] Although recent anecdotal reports and small diagnostic trials suggest that ultrasonography may someday have a role in routine assessment of acute foot fractures,[21, 22] second-line imaging studies generally do not need to be performed while the patient is in the ED and are usually ordered only after consultation with a foot surgeon.

Bedside ultrasonography in addition to Ottawa Foot and Ankle Rules (OFAR) in acutely injured patients was found to reduce the number of ordered x-rays and length of stay in ED in patients 18 years and older. The sensitivity of US in detecting foot and ankle fractures was 100%, and the specificity of OFAR increased from 50% to 100% with the addition of US. The negative predictive value and positive predictive value were both 100%.[23]

 

Treatment

Emergency Department Care

Immediate care includes icing, immobilizing, and elevating the foot and providing analgesia to all patients with significant foot fractures.[24]

Patients with forefoot fractures frequently also have associated soft tissue damage, which may necessitate external fixation.[10]

Options for initial immobilization include the following:

  • Posterior or stirrup splints

  • Reinforced bulky dressing, also termed Jones splint, which consists of a web roll and an elastic compression bandage

  • Rigid, flat-bottom orthopedic shoe also termed postop or Reece shoe

  • Definitive immobilization often requires application of a cylindrical cast, applied during the acute phase (and often bivalved to accommodate further swelling) or after a few days when edema has begun to decrease.

Toe fracture

Toe fractures are common and generally heal well with little or no therapy. Buddy tape the broken toe to an adjacent, uninjured toe (with padding in between the toes to prevent skin maceration) and apply a rigid flat-bottom orthopedic shoe. While union of fracture segments occurs in 3-8 weeks, symptoms usually improve much earlier. Significantly displaced fractures, especially of the first toe, may be treated more aggressively with closed reduction and rigid immobilization. Irreducible fractures sometimes require open reduction and internal fixation.[25]

First metatarsal fracture

The first metatarsal is the least commonly fractured metatarsal.[10] The first metatarsal head bears twice the weight of other metatarsal heads. Treat minimally displaced or nondisplaced fractures with immobilization without weight bearing. Displaced fractures usually require open reduction and internal fixation (see image below).

Fractures, foot. CT scan showing fracture of first Fractures, foot. CT scan showing fracture of first cuneiform and proximal first metatarsal.

Internal metatarsal fracture

Fractures of internal (second, third, fourth) metatarsals are very common. Nondisplaced and displaced fractures usually heal well, with weight bearing as tolerated, in a cast or rigid flat-bottom orthopedic shoe. In fact, data suggest that elastic support bandages are equivalent or superior to casts for such metatarsal fractures.[26] Exclude disruptions of the Lisfranc (tarsometatarsal) joint by maintaining a high level of suspicion.

March fracture is a stress fracture of the second and/or third metatarsal that commonly occurs in joggers. Radiographs are often negative, and sometimes a bone scan helps determine this diagnosis. Treatment is cessation of aggravating activity for 4-6 weeks.

Fifth metatarsal fracture

The proximal fifth metatarsal is the most common site of midfoot fractures.[3, 9] Fractures are of 2 general types, the Jones fracture and the pseudo-Jones or tennis fracture. Midshaft (see first image below) and distal fifth metatarsal fractures (see second image below) are less common; these are shown in the images below.

Fractures, foot. Spiral fracture of the shaft of t Fractures, foot. Spiral fracture of the shaft of the fifth metatarsal. This fracture was treated conservatively with immobilization.
Fractures, foot. Minimally displaced fracture of t Fractures, foot. Minimally displaced fracture of the distal fifth metatarsal. This fracture was treated conservatively with immobilization in a rigid flat bottom shoe.

 

Proximal avulsion fracture

Fractures at the proximal tuberosity are very common and termed pseudo-Jones or tennis fractures (see image below). This avulsion injury usually is associated with a lateral ankle strain and occurs at the attachment of the peroneus brevis tendon. It heals well with a compression dressing and weight bearing as tolerated.

Fractures, foot. Proximal fifth metatarsal avulsio Fractures, foot. Proximal fifth metatarsal avulsion fracture (also termed pseudo-Jones, tennis, or dancer fracture).

Jones fracture

This less common but more problematic fracture occurs transversely at the base of the fifth metatarsal, 1.5-3 cm distal to the proximal tuberosity (see image below). Displacement of this fracture tends to increase with continued weight bearing. Forefoot adduction has been found to be a risk factor for Jones fracture, with the presence of metatarsus adductus being associated with a 2.4 times greater risk of Jones fracture, according to one study.[27]  Patients with this fracture often (35-50%) develop persistent nonunions requiring bone grafting and internal fixation.[4] Initial therapy must include immobilization without weight bearing.[28] One study suggested that the short controlled ankle movement (CAM) walker boot more effectively offloads the fifth metatarsal during common gait activities than a postoperative sandal or a standard athletic shoe after treatment of Jones fractures and other base of fifth metatarsal fractures.[29]

Fractures, foot. Jones fracture of the fifth metat Fractures, foot. Jones fracture of the fifth metatarsal.

Fracture at Lisfranc (tarsometatarsal) joint

The Lisfranc joint is found at the base of second metatarsal and is formed by a 6-bone arch that includes the first, second, and third cuneiforms and first, second, and third metatarsals. Fracture-dislocations at this joint are rare, yet are still the most commonly misdiagnosed foot injuries (see images below). It has been estimated that 20% of Lisfranc fracture-dislocations are misdiagnosed.[8] A Lisfranc fracture-dislocation involves injury to the bony and soft tissue structures of the tarsometatarsal joint, and patients typically present to the ED with pain particularly with weight bearing; with swelling; and after a characteristic mechanism of injury such as high-velocity trauma. Stable injuries can be immobilized in the ED and patients discharged home, but unstable injuries require an orthopedic referral for consideration of surgical fixation.[30] They can result in posttraumatic arthritis and reflex sympathetic dystrophy. Displaced fractures are clinically and radiographically obvious, yet nondisplaced or minimally displaced fractures may be subtle.[6]

Fractures, foot. Lisfranc fracture-dislocation. Fractures, foot. Lisfranc fracture-dislocation.
Fractures, foot. Subtle fracture of the first cune Fractures, foot. Subtle fracture of the first cuneiform at the Lisfranc joint. Another fracture at the base of the first metatarsal is not seen here but was found on subsequent computed tomography.

To facilitate diagnosis, grasp first and second metatarsals and move them alternately through plantarflexion and dorsiflexion.

Radiographic diagnosis is made by detecting widening (diastasis) of 2-5 mm between the bases of the first and second metatarsals or between the middle and medial cuneiforms. Fracture at the base of the second metatarsal strongly suggests the diagnosis. If standard radiographs appear normal despite clinical suspicion, radiographs of the injured foot bearing weight may reveal the fracture. These fractures require immediate orthopedic consultation for reduction and fixation. CT imaging is useful if clinical suspicion is high despite nondiagnostic plain radiography.[31]

Talar fracture

Talar fracture is the second most common fracture of the tarsal bones. Blood supply is somewhat tenuous, resulting in a high incidence of avascular necrosis following displaced fractures. According to Dale et al, talar fracture patterns cannot be characterized by radiography alone, and CT is critical for detecting and characterizing talar fractures.[32]

Neck and body fracture are the most common talar fractures and may be associated with subtalar dislocation.[33] Displaced fractures usually require surgical fixation. Nondisplaced fractures are treated with non–weight-bearing short leg cast for 6-10 weeks.

Lateral process fracture was previously rare, yet now is more common because of snowboarding injuries. Treatment should include immobilization with strict avoidance of weight bearing.

Posterior process (Shepherd) fracture is aused by damage to the posterior process of the talus, this fracture's usual mechanism is sudden plantarflexion or repetitive motion, especially in athletes who dance or kick. Diagnosis usually is not confirmed in the ED, because clinical examination is typically nonspecific and plain film radiography normal. Suspicion warrants referral to an orthopedist. Treatment includes immobilization with either partial or full weight bearing. Note that this fracture often is confused with an accessory bone that occurs at this location, the os trigonum.

Transchondral/osteochondral talar dome fracture is a rare injury that often presents as a nonhealing ankle sprain and is caused by small cartilaginous avulsions or body chips in tibial articulation. Tenderness of the talar dome can be appreciated with the foot in dorsiflexion. Radiographs may be normal, and injuries cannot be distinguished clinically from ankle sprains. Delayed presentation may show crepitus, joint locking, and laxity of lateral and anterior ankle ligaments. Suspicion warrants referral to an orthopedist for bone scan or other definitive imaging. Initial therapy for this injury is immobilization without weight bearing.

Navicular fractures are rare and most often represent stress fractures in young athletes. They usually heal well with immobilization and weight bearing as tolerated.[34] Displaced fractures through the navicular body have a high incidence of avascular necrosis and require open reduction and internal fixation (see images below).

Comminuted navicular fracture in a young drunk dri Comminuted navicular fracture in a young drunk driver involved in a motor vehicle crash. The patient sustained no other injuries and was discharged in a plaster splint with strict nonweightbearing. The patient subsequently had a computerized tomography (CT) scan and underwent open reduction and internal fixation 9 days after the injury. A standard anteroposterior (AP) view is shown here.
An added oblique view of this same patient with a An added oblique view of this same patient with a navicular fracture was performed in the ED to help verify the absence of other significant fractures. Obtaining views that are not part of the routine foot series can be helpful and should be added when needed.

Calcaneal fracture

Calcaneal fractures usually occur in patients aged 30-50 years, with a peak incidence at 45 years. They occur in males 5 times more often than in females. They are most commonly caused by motor vehicle crashes or falls from a height.[35, 36, 37, 38]

When caused by falls from a height, these fractures have a high rate of associated injuries. Identification of a calcaneal fracture should prompt a search for other related findings. Calcaneal fractures are part of the "lover's triad" (named for the constellation of injuries that may occur when jumping out of a second-story bedroom window), with lumbar compression fractures and forearm fractures. Ankle, femur, and elbow fractures are also common.[39] A high index of suspicion for thoracic aortic rupture and renal vascular pedicle disruption must be maintained when calcaneal fractures are seen.

Intra-articular joint depression fracture  is the most common form of calcaneal fracture. Lateral foot radiograph reveals a reduction in the Böehler's angle, the posterior angle formed by intersection of a line from the posterior to the middle facet and a line from the anterior to the middle facet (see images below). Böehler's angle is normally between 20 and 40°. Angles less than 20°, or more than 5° smaller than that of uninjured side, indicate a fracture. Although often useful, the sensitivity of Böehler's angle has been shown to be less than that of physician gestalt in interpreting calcaneal films.[40] Obtain an urgent orthopedic consultation for calcaneal fractures, since open reduction and internal fixation is usually necessary.

Fractures, foot. CT scan showing fracture of first Fractures, foot. CT scan showing fracture of first cuneiform and proximal first metatarsal.
Fractures, foot. Spiral fracture of the shaft of t Fractures, foot. Spiral fracture of the shaft of the fifth metatarsal. This fracture was treated conservatively with immobilization.

Extra-articular calcaneal fractures should be treated with a bulky compression dressing, rest, ice, and elevation. Arrange orthopedic follow-up care.

Open calcaneus fractures are severe, high-energy injuries that have the potential for considerable morbidity, especially considering the high rate of concomitant orthopedic and whole body system injuries. Patients with type III open injuries are at increased risk of amputation. Management of these injuries include intravenous antibiotics, tetanus prophylaxis, and urgent debridement and irrigation.[41]

Consultations

Nonemergent referral or urgent consultation with an orthopedic surgeon (or podiatrist if appropriate) is often necessary; which is appropriate depends on the type of fracture.

Complications

Compartment syndrome is the most dangerous acute complication of foot fractures. This syndrome is associated primarily with midfoot fractures sustained as the result of a crush mechanism. Clinical signs include marked swelling (early) and neurovascular compromise (late). Recent data emphasize that compartment syndrome is a subjective clinical diagnosis. Measurement of compartment pressures may provide useful supplemental information, but pressure thresholds defining compartment syndrome in lower extremity fractures are elusive,[42] and the osseofascial spaces of the foot are not distinct or isolated.[43] Suspicion of compartment syndrome warrants emergent orthopedic consultation; treatment is fasciotomy when the diagnosis is confirmed.

Long-term complications of foot fracture include the following:

  • Arthritis
  • Infection
  • Nonunion or instability
  • Gait disturbances
 

Guidelines

Guidelines Summary

The American College of Radiology Appropriateness Criteria for acute trauma to the foot include the following[44] :

  • If a patient with acute foot trauma does not meet the inclusion criteria to be evaluated by the Ottawa Rules (such as a diabetic with peripheral neuropathy involving the foot), then imaging should be obtained. The first imaging study in this scenario should be a 3-view radiographic series of the foot.
  • If there is clinical concern for a midfoot injury (such as a Lisfranc injury), then imaging should be performed. The first imaging study in this situation is usually a 3-view radiographic series of the foot with weight bearing on at least the AP view, if possible. If there is continued clinical concern for a Lisfranc injury in the setting of a normal radiograph, then advanced imaging (MRI or CT) should be considered and performed on a case-by-case basis. Likewise, when there is clinical concern for an acute tendon rupture, further imaging with MRI or US would be confirmatory.
  • If there is clinical suspicion for plantar plate injury after MTP joint injury, radiography is the initial imaging modality. Weight-bearing AP, lateral, and sesamoid axial views may detect proximal migration of one or both hallux sesamoids with great toe injuries. US and MRI can directly evaluate the soft-tissue structures of the capsuloligamentous complex, specifically the plantar plate.
  • In the setting of penetrating trauma to the foot with a possible foreign body, radiography (if the foreign body is radiopaque) or US (with nonradiopaque foreign bodies) should be used to determine if a foreign body is indeed present.
 

Medication

Medication Summary

Analgesics (narcotics, NSAIDs) are generally the only medications needed to treat foot fractures. Administer antibiotics and tetanus prophylaxis to patients with open fractures.

Nonsteroidal Anti-inflammatory Agents (NSAIDS)

Class Summary

These agents are used most commonly for relief of mild to moderately severe pain. Effects of NSAIDs in treatment of pain tend to be patient specific, yet ibuprofen is usually DOC for initial therapy. Other NSAIDS also may be used.

Ibuprofen (Ibuprin, Advil, Motrin)

Usually DOC for treatment of mild to moderately severe pain, if no contraindications. Inhibits inflammatory reactions and pain, probably by decreasing activity of enzyme cyclooxygenase, which inhibits prostaglandin synthesis.

Narcotic Combination Analgesics

Class Summary

Pain control is essential to quality patient care. It ensures patient comfort, promotes pulmonary toilet, and aids physical therapy regimens. Many analgesics have sedating properties that benefit patients who have sustained fractures. Hydrocodone and oxycodone preparations are generally more effective and better tolerated than other narcotic-acetaminophen combinations such as those containing codeine.

Hydrocodone bitartrate and acetaminophen (Vicodin ES)

Drug combination indicated for relief of moderately severe to severe pain.

Antibiotics

Class Summary

Prophylaxis is given to patients with open fractures.

Penicillin G (Pfizerpen)

Interferes with synthesis of cell wall mucopeptide during active replication, resulting in bactericidal activity against susceptible microorganisms.

Clindamycin (Cleocin)

Lincosamide is useful as treatment against serious skin and soft-tissue infections caused by most staphylococcal strains. Also effective against aerobic and anaerobic streptococci, except enterococci. Clindamycin is used for prophylaxis in penicillin-allergic patients. Useful as treatment against streptococci and most staphylococcal strains.

Gentamicin (Gentacidin, Garamycin)

Aminoglycoside antibiotic used for gram-negative bacterial coverage. Commonly used in combination with both an agent against gram-positive organisms and one that covers anaerobes. Used in conjunction with ampicillin or vancomycin for prophylaxis in patients with open fractures.

Tetanus Toxoid

Class Summary

This agent is used for tetanus immunization. Booster injection is recommended in previously immunized individuals to prevent this potentially lethal syndrome.

Tetanus toxoid adsorbed or fluid

Induces active immunity against tetanus in selected patients. Tetanus and diphtheria toxoids are the immunizing DOC for most adults and children older than 7 y. Necessary to administer booster doses to maintain tetanus immunity throughout life. Pregnant patients should receive only tetanus toxoid, not a diphtheria antigen-containing product. In children and adults, may administer into deltoid or midlateral thigh muscles. In infants, preferred site of administration is midthigh laterally.

 

Questions & Answers

Overview

What are foot fractures?

What is the prevalence of foot fractures?

Presentation

Which clinical history findings are characteristic of foot fractures?

What is included in the physical exam to evaluate foot fractures?

DDX

What are the differential diagnoses for Foot Fracture?

Workup

What is the role of radiography in the workup of foot fractures?

What is the role of imaging studies in the workup of foot fractures?

Treatment

How are foot fractures of the first metatarsal treated?

What are talar foot fractures and how are they treated?

How are foot fractures treated in the emergency department (ED)?

How are foot fractures of the toe treated?

How are foot fractures of the internal metatarsals treated?

How are foot fractures of the fifth metatarsal treated?

How are proximal avulsion foot fractures treated?

What are Jones food fractures and how are they treated?

How are foot fractures of the Lisfranc (tarsometatarsal) joint diagnosed and treated?

What are calcaneal foot fractures and how are they treated?

Which specialist consultations are beneficial to patients with foot fractures?

What are the possible complications of foot fractures?

What are long-term complications of foot fractures?

Guidelines

What are the ACR appropriate criteria for imaging of foot fractures?

Medications

Which medications are used in the treatment of foot fractures?

Which medications in the drug class Tetanus Toxoid are used in the treatment of Foot Fracture?

Which medications in the drug class Antibiotics are used in the treatment of Foot Fracture?

Which medications in the drug class Narcotic Combination Analgesics are used in the treatment of Foot Fracture?

Which medications in the drug class Nonsteroidal Anti-inflammatory Agents (NSAIDS) are used in the treatment of Foot Fracture?