Foot Fractures and Dislocations

oPatientPlus articles are written by UK doctors and are based on research evidence, UK and European Guidelines. They are designed for health professionals to use, so you may find the language more technical than the condition leaflets.

See also separate articles Painful Foot and Heel Pain.

Approximately 10% of all fractures occur in the bones of the foot. These bones include:[1]

  • Hindfoot: the calcaneus and the talus.
  • Midfoot: the navicular, the cuboid and 3 cuneiforms.
  • Forefoot: 5 metatarsals and 14 phalanges.
  • The foot also contains sesamoid bones (bones embedded within a tendon).

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. Stress fractures are common in athletes, and may occur in every bone of the foot and ankle, except the smaller toes.[2]

Initial management includes ice, immobilisation and elevation. Any delay in providing adequate specific treatment increases the risk of post-traumatic osteoarthritis. Other potential complications include non-union, avascular necrosis, compartment syndromes, vascular injuries, post-traumatic ankle deformities and tarsal tunnel syndrome.

  • X-rays:
    • The Ottawa foot rules help to predict significant midfoot fractures. X-rays are required if any of the following are present:
      • Point tenderness over the base of the fifth metatarsal.
      • Point tenderness over the navicular bone.
      • Inability to take 4 steps, both immediately after injury and when seen for assessment.
    • Although developed and validated in adults, the Ottawa foot rules appear to be a reliable tool to exclude fractures in children 5 years of age and older.
  • Bone scans, CT scans, MRI and ultrasound may help to diagnose certain foot fractures that are not seen on plain X-rays.

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  • Falls on to the feet or violent dorsiflexion of the ankle (eg against car pedals in a car accident) may cause fractures to the anterior body or articular dome of the talus.
  • Talar fracture is the second most common fracture of the tarsal bones. There is a high incidence of avascular necrosis and arthritis following displaced fractures.[4]
  • Neck and body fracture:
    • The most common talar fractures and may be associated with subtalar dislocation.
    • Non-displaced fractures are treated with a non-weight-bearing short leg cast.
    • Displaced fractures usually require surgical fixation.
  • Lateral process fracture:
    • Increasingly common because of snowboarding injuries.
    • Treatment includes immobilisation with avoidance of weight bearing.
  • Posterior process (Shepherd's) fracture:
    • Caused by damage to the posterior process of the talus, usually as a result of sudden plantar flexion or repetitive motion, especially dancing or kicking.
    • Clinical examination is usually nonspecific and plain X-rays normal.
    • Treatment includes immobilisation with either partial or full weight bearing.
  • Transchondral/osteochondral talar dome fracture:
    • Rare; often presents as a non-healing ankle sprain. There is tenderness of the talar dome with the foot in dorsiflexion.
    • May be clinically indistinguishable from an ankle sprain and plain X-rays may be normal. A bone scan may be required. Delayed presentation may include crepitus, joint locking and laxity of lateral and anterior ankle ligaments.
    • Initial management involves immobilisation without weight bearing.

Dislocation of the talus[5]

  • Rare; usually results from very high-energy trauma.
  • 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).
  • The dislocation is often open and results in avascular necrosis of the talus and arthritis.
  • Open reduction and internal fixation are required.
  • Most often follow a fall from height directly on to the heels. Fractures are often bilateral.
  • When caused by falls from a height, there is a high rate of associated injuries, eg lumbar compression fractures, forearm fractures, ankle, femur, and elbow fractures. There should also be a high index of suspicion for thoracic aortic rupture and renal vascular pedicle disruption.
  • Calcaneal fractures are divided into intra-articular and extra-articular fractures on the basis of subtalar joint involvement:[6]
    • Intra-articular joint depression fractures:
      • The most common form of calcaneal fracture.
      • Lateral foot X-rays show breaks in the cortices, trabeculae or signs of compression (reduction in Böhler's angle).[7] Böhler's angle is 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; Böhler's angle is normally between 20 and 40°. Angles less than 20°, or more than 5° smaller than that of the uninjured side, indicate a fracture.
      • Open reduction and internal fixation is usually necessary.
    • Extra-articular fractures:
      • Extra-articular fractures account for 30% of all calcaneal fractures in adults.[8]
      • Initial management includes a compression dressing, rest, ice, and elevation, with orthopaedic follow-up.
  • Navicular fractures are rare and most often due to stress fractures in young athletes.[9]
  • They usually heal well with immobilisation and weight bearing as tolerated.
  • Displaced fractures through the navicular body have a high incidence of avascular necrosis and require open reduction and internal fixation.
  • Complete dislocation of the navicular is rare and prompt reduction under general anaesthetic is required. It may require open reduction and arthrodesis of the naviculocuneiform and calcaneocuboid joints.[10]
  • The Lisfranc joint represents the articulation between the midfoot and forefoot and is composed of the 5 tarsometatarsal joints.[11] Traumatic ligament injury and fracture can result in deformity, instability, pain and degenerative joint disease of the Lisfranc joint.[12]
  • Although injuries to the Lisfranc ligament complex have been associated with high-energy trauma, eg motor vehicle collisions and industrial accidents, injuries to the Lisfranc ligament may result from low-energy trauma, including leisure activities or elite athletic activity.[13]
  • Tarsometatarsal dislocation 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. It can result in post-traumatic arthritis and reflex sympathetic dystrophy.
  • Displaced fractures are clinically and radiographically obvious, but non-displaced or minimally displaced fractures may be missed. To facilitate diagnosis, grasp the first and second metatarsals and move them alternately through plantar flexion and dorsiflexion.
  • CT imaging is useful if clinical suspicion is high but plain X-rays appear normal.
  • They require urgent reduction and fixation.

Multiple metatarsal fractures may be caused by direct trauma (eg a heavy object falling on to the foot) or crush injuries (eg a vehicle wheel). Check and monitor the dorsalis pedis pulse. Management includes adequate analgesia, support in a plaster of Paris (POP) backslab, manipulation under anaesthesia, K-wire fixation or, occasionally, open reduction and internal fixation.

First metatarsal fracture

  • The least commonly fractured metatarsal.
  • Minimally displaced or non-displaced fractures: management usually involves immobilisation without weight bearing. Displaced fractures usually require open reduction and internal fixation.

Second, third and fourth metatarsals

  • Fractures are very common.
  • Non-displaced and displaced fractures usually heal well, with weight bearing as tolerated in a cast, rigid orthopaedic shoe or elastic support bandages.
  • Disruptions of the Lisfranc joint must be excluded.

Fifth metatarsal fractures

  • The proximal fifth metatarsal is the most common site of midfoot fractures. Fractures are generally of two types:
    • Jones fracture:
      • Less common; transverse fracture at the base of the fifth metatarsal, just distal to the intermetatarsal joint.
      • Displacement tends to increase with continued weight bearing.
      • Initial therapy includes analgesia and immobilisation without weight bearing.
      • Frequently requires surgical intervention in patients who want to avoid non-weight-bearing cast immobilisation.[14]
      • Prone to non-union, requiring bone grafting and internal fixation.
    • Proximal avulsion fracture:
      • Fractures at the proximal tuberosity are very common and termed pseudo-Jones or tennis fractures. They are usually associated with a lateral ankle strain and often follow 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 fifth metatarsal base) may cause confusion when interpreting X-rays.
      • Treatment includes analgesia, elevation and support in a padded crepe bandage, or a below-knee POP if symptoms are severe.
      • Usually heals well with a compression dressing and weight bearing as tolerated.
  • Midshaft and distal fifth metatarsal fractures are less common.

Stress fractures

  • March fractures are common and often caused by prolonged or unusual exercise, eg jogging.[15]
  • 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 often initially normal and a bone scan may be required for diagnosis. Callus or periosteal reaction is seen on X-rays after 2-3 weeks and will confirm the diagnosis.
  • Treatment is symptomatic with analgesia, elevation, rest and reduced activity as required. A padded insole may help. 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.
  • Stress fractures of the first to fourth metatarsal shafts typically heal well with rest alone.[16] Full recovery can be expected within 6-8 weeks.
  • These are common and usually heal well.
  • Management mainly involves strapping the fractured toe to an adjacent uninjured toe. Union of the fracture occurs in 3-8 weeks but symptoms usually improve much earlier. Significantly displaced fractures, especially of the big toe, may require closed reduction and rigid immobilisation.
  • Irreducible fractures may require open reduction and internal fixation.

Further reading & references

  • Foot Menu, Wheeless' Textbook of Orthopaedics
  1. Panchbhavi VK, Foot Bone Anatomy, Medscape, Jun 2011
  2. Brockwell J, Yeung Y, Griffith JF; Stress fractures of the foot and ankle. Sports Med Arthrosc. 2009 Sep;17(3):149-59.
  3. Silbergleit R, Foot Fracture, Medscape, May 2010
  4. Early JS; Talus fracture management. Foot Ankle Clin. 2008 Dec;13(4):635-57.
  5. McStay CM et al, Foot Dislocation. Medscape, Jul 2010
  6. Badillo K, Pacheco JA, Padua SO, et al; Multidetector CT evaluation of calcaneal fractures. Radiographics. 2011 Jan-Feb;31(1):81-92.
  7. Bohler's angle; Bohler's angle, Wheeless' Textbook of Orthopaedics
  8. Nicklebur S et al, Calcaneus Fractures, Medscape, Sep 2009
  9. Fowler JR, Gaughan JP, Boden BP, et al; The non-surgical and surgical treatment of tarsal navicular stress fractures. Sports Med. 2011 Aug 1;41(8):613-9. doi: 10.2165/11590670-000000000-00000.
  10. Rao H; Complete Open Dislocation of the Navicular-A Case Report. J Foot Ankle Surg. 2011 Dec 6.
  11. Trevino SG, Lisfranc Fracture Dislocation. Medscape, Oct 2009
  12. Chaney DM; The Lisfranc joint. Clin Podiatr Med Surg. 2010 Oct;27(4):547-60. Epub 2010 Jul 22.
  13. DeOrio M, Erickson M, Usuelli FG, et al; Lisfranc injuries in sport. Foot Ankle Clin. 2009 Jun;14(2):169-86.
  14. Fetzer GB, Wright RW; Metatarsal shaft fractures and fractures of the proximal fifth metatarsal. Clin Sports Med. 2006 Jan;25(1):139-50, x.
  15. Perron AD, Metatarsal Stress Fracture, Medscape, Dec 2011
  16. Hatch RL, Alsobrook JA, Clugston JR; Diagnosis and management of metatarsal fractures. Am Fam Physician. 2007 Sep 15;76(6):817-26.

Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.

Original Author:
Dr Colin Tidy
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Peer Reviewer:
Dr John Cox
Document ID:
2159 (v22)
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