Severe injuries to the foot can result in significant long-term disability. Multiple fractures or dislocations of the feet often initially get overlooked in cases of multiple, severe trauma. Any delay in providing adequate treatment increases the risk of post-traumatic osteoarthritis. Other potential complications include compartment syndromes or vascular injuries.

Mechanism of injury

The mechanism of injury will give important clues to the diagnosis.

Talar injuries

• Falls on to the feet or violent dorsiflexion of the ankle, e.g. against car pedals in a car accident, may cause fractures to the anterior body or articular dome of the talus.
• Displaced fractures and dislocations often result in avascular necrosis.
• Treatment is with adequate analgesia, immobilisation in a backslab plaster of Paris (POP) and referral to the orthopaedic team.
• May require manipulation under anaesthesia and/or open reduction and internal fixation.
• Dislocations of the talus require early reduction under general anaesthetic.

Calcaneal fracture

• Most often follow a fall from height directly on to the heels.
• There may be associated injuries of the Achilles tendon, spine, pelvis, hips and knees.
• May present with swelling, bruising and tenderness over the sides of the calcaneum.
• Fractures are often bilateral. Therefore the other foot should be carefully examined both for comparison and to exclude any injury.
• Specific calcaneal X-rays: breaks in the cortices, trabeculae or signs of compression (reduction in Bohler's angle¹).
• Refer all fractures to the orthopaedic team. Most patients require admission for elevation and analgesia but open reduction and internal fixation may be required.

Upper/midfoot dislocations

• Caused by violent twisting, inverting or everting injuries of the foot.
• Peritalar and subtalar dislocations involve the articulation between the talus and calcaneum. Midtarsal dislocations involve the midtarsal joint (between the calcaneum and talus posteriorly and the navicular and cuboid anteriorly).
• Initial treatment is to provide adequate analgesia and refer to the orthopaedic team.
• Prompt reduction under general anaesthetic is required.
• Isolated dislocation of the talus: rare; requires prompt reduction under general anaesthetic.

Metatarsal fractures and dislocations

• Multiple metatarsal fractures may be caused by heavy objects falling on to the feet or by a vehicle wheel.
• Tarsometatarsal (Lisfranc) dislocation: this can be easily missed on standard foot X-rays. Check that the medial side of the second metatarsal is correctly aligned with the medial side of the middle cuneiform.
• Check and monitor the dorsalis pedis pulse.
• Multiple displaced or dislocated metatarsal fractures require urgent orthopaedic referral.
• Provide adequate analgesia, support in a POP backslab and refer for manipulation under anaesthesia, K-wire fixation or, occasionally, open reduction and internal fixation.

Isolated avulsion fracture of the 5th metatarsal base

• This follows inversion injuries of the ankle. This area should always be checked in patients with ankle injuries and foot X-rays requested if tender.
• Accessory bones or the apophysis (runs parallel to the 5th metatarsal base) may cause confusion when interpreting X-rays.
• Treatment is with analgesia, elevation and support in a padded crepe bandage, or a below-knee POP if symptoms are severe.
• Arrange orthopaedic follow-up.

Jones fracture of the 5th metatarsal

• Transverse fracture of the fifth metatarsal just distal to the intermetatarsal joint.
• Prone to nonunion.
• Treatment is with analgesia, crutches, below-knee POP and orthopaedic follow-up.

Stress fractures of the metatarsals

• Common: often caused by prolonged or unusual exercise ('march fracture'), but may occur without any obvious cause.
• The most common site is the second metatarsal shaft, but the third metatarsal or rarely other metatarsals may be affected.
• May present with swelling over the forefoot and localised tenderness over the metatarsal shaft. Longitudinal compression of the metatarsal shaft (pressing on the metatarsal head below the toe) causes pain along the metatarsal shaft.
• X-rays are usually initially normal. Callus or periosteal reaction seen on X-rays after 2-3 weeks will confirm the diagnosis.
• Treatment is symptomatic with analgesia, elevation, rest and reduced activity as required.
• A padded insole may help. and firm shoes or boots tend to be more comfortable.
• A below-knee POP or 'Aircast' boot may be required if the patient is unable to bear weight.
• Full recovery can be expected within 6-8 weeks.

Document references

1. Wheeless' Textbook of Orthopaedics; Bohler's angle

Internet and further reading

• Wheeless' Textbook of Orthopaedics; Foot Menu

Acknowledgements