see also:

• orthopaedics in the ED
• the painful foot
• ankle injuries and fractures
• acute foot drop

• foot injuries are common and significant injuries are commonly missed unless actively sort by the treating clinician.
• delayed diagnosis or misdiagnosis of important injuries can contribute to long term morbidity
• this is particularly likely in those who have been injured by large forces such as fall from a height, sports injuries, skiing injuries and motor vehicle accidents.
• common complications include non-union (esp. Jones fracture), avascular necrosis (esp. talar neck), osteoarthritis, osteochondritis (eg. undisplaced talar dome injuries), osteomyelitis (compound injuries or post-ORIF) and mechanical pain syndromes from ligamentous injury.

• Sever's disease - calcaneus
• Köhler's disease - navicular
• Frieberg's disease - metatarsal head (usually 2nd or 3rd)

• Phong Tran's - orthopaedics website - fracture neck of talus
• commonly occurs in car accidents and light aircraft accidents from excessive dorsiflexion with foot on the brake pedal
• also occurs in falls from a height in crouching position
• talar neck fractures are associated with avascular necrosis risk (10% with type I, 50% in type II, 85% in type III)

• no displacement
• Rx padded plaster with toe platform and elevation for 1 week, r/v in fracture clinic for possible non-weight bearing with crutches for 8-12 weeks and reassessment then for union, and avascular necrosis

• subtalar subluxation with proximal part becoming plantar flexed as the distal fragment displaces forwards
• Rx is usually with ORIF, contact ortho.

• tibia driven between the talar fragments
• Rx:
  • refer to ortho ASAP
  • consider attempting closed reduction
  • usually needs ORIF

• rare
• head of talus dislocated from the navicular in association with a type II or type III injury

• shearing injury may force a piece of the talar dome upper articular surface to detach
• small fragments may be excised
• larger fragments may require ORIF
• most will need 6 weeks in BKPOP

• flakes of talar bone are commonly avulsed during ankle injuries from pull of the ankle ligaments or capsular attachments
• these require symptomatic Rx only - eg. 2-4 wks in a walking BK plaster

• may occur during compression injuries such as fall from a height
• generally require CT scan and ortho opinion
• most are managed without surgery but usually require at least 8-10 weeks non-weight bearing and many will have long term pain and restricted function

• Phong Tran's - orthopaedics website - fracture calcaneum
• these usually occur following a fall from a height and must be carefully looked for in anyone with such a history.
• it is commonly bilateral
• Xray findings can be subtle
  • check Bohler's salient angle - should be ~40deg and is less than this in fractures which flatten the heel profile
• when in doubt, consider CT scan
• most patients will require admission

• the mid-tarsal joint lies between the talus and calcaneum posteriorly, and the navicular and cuboid anteriorly
• dislocation of the talonavicular portion of the midtarsal joint may accompany subtalar dislocations which may have partly reduced spontaneously
• dislocation may be associated with fractures, particularly, the navicular
• Rx is usually with closed reduction +/- K wires for 3-4 weeks, or ORIF

• avulsion fractures can usually be Rx with 6 weeks in BKPOP
• displaced fractures of the body should be urgently reduced to reduce risk of oedema and circulatory impairment, then accurately reduced and fixed surgically

• fracture of the base of the 5th MT involving the tarso-metatarsal joint NOT to be confused with a more sinister Jones fracture
• these are common fractures associated with “ankle sprains” from inversion of the ankle as a result of bony avulsion due to stress on peroneus brevis tendon which inserts at this point
• these fractures are easily missed unless looked for.
• in children, take care not to misdiagnose the normal physeal line as being a fracture
  • fractures are usually transverse whilst the apophyseal line (growth plate) is more longitudinal
• whilst many can be managed with crutches and tubigrip, healing may be quicker with a cast

• fracture of the proximal diaphysis of the fifth metatarsal involving the intermetatarsal joint NOT the tarso-metatarsal joint
• this is NOT caused by inversion injuries but commonly occurs in athletes
• commonly results in non-union due to the poor blood supply to this bone and thus can result in chronic pain
• BKPOP for 6-8 weeks will heal 75%
• athletes or those at risk should be referred for possible ORIF

• Phong Tran's - patient information website - LisFranc
• https://radiopaedia.org/articles/lisfranc-injury
• usually follow large forces such as fall from a height, fall from ladder with foot caught in rungs, sports injuries or car accidents.
• may occur when a car wheel runs over forefoot with heel on the gutter edge
• Lisfranc ligament complex attaches from medial cuneiform to 2nd and 3rd MT bases - injury creates instability and risk of dorsal or lateral dislocation of MTs
• Xray usually will show the injury but may require weight bearing views to demonstrate collapse of the normal arch with widening of the space between medial cuneiform and 2nd MT, or, preferably, CT scan.
• most need surgical repair and there is a high risk of long term sequelae.

• often result from crush injuries
• spiral shaft injuries may result from forced inversion or eversion of the forefoot
• children often fracture the bases or necks of 2nd - 4th MT's and these can usually be managed in BKPOP
• BEWARE LisFranc and Jones fractures (see above)

• Phong Tran's - patient information website - metatarsalgia

• stress fracture - esp. 2nd MT neck or shaft (“march fracture”)
• Morton's neuroma - most commonly occurs in the webspace between the 3rd and 4th toes
• sesamoiditis
• fracture sesamoid of the hallux - sometimes may require operative Rx¹⁾
• MTP joint arthritis - esp. gout, rheumatoid arthritis and psoriatic arthritis
• bursitis
• Freiberg's disease - osteochondritis of a metatarsal head (usually the 2nd or 3rd) in adolescents

• Phong Tran's - patient information website - fracture toe Rx
• most fractures can be managed by buddy taping toe to next toe with gauze between the toes
• significantly angulated or displaced fractures may need closed reduction under a digital block
• compound fractures generally require referral for Mx as usual for compiund fractures:
  • wound irrigation and closure
  • tetanus prophylaxis
  • iv antibiotics