Applied Evidence

Adult foot fractures: A guide

J Fam Pract. 2018 November;67(11):E8-E15

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References

1. Eiff MP, Hatch RL, et al. Fracture Management for Primary Care. 3rd ed. Philadelphia, PA: Elsevier Saunders; 2012.

2. Hatch RL, Rosenbaum Cl. Fracture care by family physicians. A review of 295 cases. J Fam Pract. 1994;38:238-244.

3. Bica D, Sprouse RA, Armen J. Diagnosis and management of common foot fractures. Am Fam Physician. 2016;93:183-191.

4. Hatch RL, Hacking S. Evaluation and management of toe fractures. Am Fam Physician. 2003;68:2413-2418.

5. Snider RK. Essentials of Musculoskeletal Care. 2nd ed. Rosemont, IL: American Orthopedic Surgeons; 2001.

6. Guler F, Baz AB, Turan A, et al. Isolated medial cuneiform fractures: report of two cases and review of the literature. Foot Ankle Spec. 2011;4:306-309.

7. Borrelli J, De S, Van Pelt M. Fracture of the cuboid. J Am Acad Orthop Surg. 2012;20:472.

8. Pinney SJ, Sangeorzan BJ. Fractures of the tarsal bones. Orthop Clin North Am. 2001:32:21-33.

9. Rosenbaum AJ, Uhl R, DiPreta JA. Acute fractures of the tarsal navicular. Orthopedics. 2014;37:541-546.

10. Sanders RW, Clare MP. Calcaneous fractures. In: Rockwood and Green’s Fractures in Adults. 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2010:2064.

11. Singer G, Cichocki M, Schalamon J, et al. A study of metatarsal fractures in children. J Bone Joint Surg Am. 2008;90:772-776.

12. Stiell IG, Greenberg GH, McKnight RD, et al. A study to develop clinical decision rules for the use of radiography in acute ankle injuries. Ann Emerg Med. 1992;21:384-390.

13. Ekinci S, Polat O, Günalp M, et al. The accuracy of ultrasound evaluation in foot and ankle trauma. Am J Emerg Med. 2013;31:1551-1555.

14. Welck MJ, Hayes T, Pastides P, et al. Stress fractures of the foot and ankle. Injury. 2017;48:1722-1726.

15. Hatch RL, Alsobrook JA, Clugston JR. Diagnosis and management of metatarsal fractures. Am Fam Physician. 2007;76:817-826.

16. Schildhauer TA, Coulibaly MO, Hoffman MF. Fractures and dislocations of the midfoot and forefoot. In: Rockwood and Green’s Fractures in Adults. 8th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2015:2690.

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With regard to the lesser toes, refer patients with fracture-dislocations, displaced intra-articular fractures, and fractures that do not reduce easily. Nondisplaced fractures of the lesser toes do not require surgical referral.¹ These can be treated with splinting (buddy taping) and use of rigid-sole shoes for 4 to 6 weeks. Treatment duration depends largely on patient compliance; generally, continue treatment until point tenderness resolves.¹

Treatment of sesamoid fractures consists of resting the affected foot with a walking boot, hard-soled shoe, or “donut” pad under the sesamoid bone to help distribute weight on the foot when standing. Length of treatment is approximately 6 to 8 weeks for most fractures.¹ Consider surgical referral if nonoperative management is unsuccessful.

Metatarsal fractures: Look for malalignment

Metatarsal fractures account for 5% of all foot fractures encountered in primary care.² These fractures typically occur as a result of falls, direct trauma, or rotational injuries (eg, ankle and foot sprains).¹ In athletes, the most common cause of these fractures is high rotational force. Patients typically present with pain over the injury site, swelling, bruising, and pain with weight bearing.

Ultrasound can be used to visualize fractures of the long bones and to identify displacement, angulation, and step-offs.

As part of your exam, look for malalignment, rotational deformities, and evidence of open fracture. Palpation at the site of the fracture may increase the pain; however, as is true with phalanx fractures, contusions may also cause significant tenderness upon palpation. Also assess range of motion—with special attention to signs of malrotation—and evaluate the adjacent metatarsals, as multiple bones, ligaments, or both are often involved.¹

Fifth metatarsal fractures are the most common in adults, likely because of decreased cortical thickness as compared with the other metatarsals.^3,11 In addition, multiple soft tissue attachments connect at the proximal aspect of the fifth metatarsal. Classification of these types of metatarsal fractures is based on anatomic location.³ Jones fractures are one type of fracture at the proximal aspect of the fifth metatarsal that occur at the metaphyseal-diaphyseal junction specifically (FIGURE 1). Because this area receives its blood supply from small terminal vessels, fractures here have a high risk of non-union and, thus, should be top of mind in any patient with tenderness at the base of the fifth metatarsal.

$Proximal fifth metatarsal Jones fracture$

Continue to: MRI/ultrasound in addition to plain films?

Adult foot fractures: A guide

References

Metatarsal fractures: Look for malalignment

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