Diagnosis and Management of Common Foot Fractures

 


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Am Fam Physician. 2016 Feb 1;93(3):183-191.

Author disclosure: No relevant financial affiliations.

Foot fractures are among the most common foot injuries evaluated by primary care physicians. They most often involve the metatarsals and toes. Patients typically present with varying signs and symptoms, the most common being pain and trouble with ambulation. Diagnosis requires radiographic evaluation, although emerging evidence demonstrates that ultrasonography may be just as accurate. Management is determined by the location of the fracture and its effect on balance and weight bearing. 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 four to six 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 two weeks, with progressive mobility as tolerated after initial immobilization. A Jones fracture has a higher risk of nonunion and requires at least six to eight 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 two to three weeks, then a rigid-sole shoe for an additional three to four weeks. Lesser toe fractures can be treated with buddy taping and a rigid-sole shoe for four to six weeks.

Primary care physicians are often the first clinicians patients see for foot injuries, and fractures are among the most common foot injuries they evaluate.1 This article will highlight some common foot fractures that can be managed by primary care physicians.

Foot fractures range widely in severity, prognosis, and treatment. Healing rates also vary considerably depending on the age of the patient and comorbidities. Thus, this article provides general healing ranges for each fracture.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

The use of musculoskeletal ultrasonography may be considered to diagnose subtle metatarsal fractures.

C

9, 10

Nondisplaced or minimally displaced (less than 3 mm) fractures of the second to fifth metatarsal shafts with less than 10° of angulation can be treated conservatively with a short leg walking boot, cast shoe, or elastic bandage, with progressive weight bearing as tolerated.

C

24, 6

The Ottawa Ankle and Foot Rules should be used to help determine whether radiography is needed when evaluating patients with suspected fractures of the proximal fifth metatarsal.

A

14, 16

Early surgical management of a Jones fracture allows for an earlier return to activity than nonsurgical management and should be strongly considered for athletes or other highly active persons.

B

2, 6, 13, 2022

Nondisplaced or minimally displaced (less than 2 mm) fractures of the lesser toes with less than 25% joint involvement and no angulation or rotation can be managed conservatively with buddy taping or a rigid-sole shoe.

C

6, 24, 25


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

The use of musculoskeletal ultrasonography may be considered to diagnose subtle metatarsal fractures.

C

9, 10

Nondisplaced or minimally displaced (less than 3 mm) fractures of the second to fifth metatarsal shafts with less than 10° of angulation can be treated conservatively with a short leg walking boot, cast shoe, or elastic bandage, with progressive weight bearing as tolerated.

C

24, 6

The Ottawa Ankle and Foot Rules should be used to help determine whether radiography is needed when evaluating patients with suspected fractures of the proximal fifth metatarsal.

A

14, 16

Early surgical management of a Jones fracture allows for an earlier return to activity than nonsurgical management and should be strongly considered for athletes or other highly active persons.

B

2, 6, 13, 2022

Nondisplaced or minimally displaced (less than 2 mm) fractures of the lesser toes with less than 25% joint involvement and no angulation or rotation can be managed conservatively with buddy taping or a rigid-sole shoe.

C

6, 24, 25


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

The fractures reviewed in this article are summarized in Table 1. These include metatarsal fractures, which account for 35% of foot fractures.2,3 About 80% of metatarsal fractures are nondisplaced or minimally

The Authors

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DAVID BICA, DO, CAQSM, is a clinical assistant professor in the Department of Family Medicine at Brown University Alpert Medical School, Pawtucket, R.I....

RYAN A. SPROUSE, MD, CAQSM, is an assistant professor in the Department of Family Medicine at West Virginia University School of Medicine–Eastern Division, Harpers Ferry. At the time the article was written, Dr. Sprouse was a primary care sports medicine fellow at East Carolina University Brody School of Medicine, Greenville, N.C.

JOSEPH ARMEN, DO, CAQSM, is a clinical assistant professor in the Department of Family Medicine at East Carolina University Brody School of Medicine.

Address correspondence to David Bica, DO, Brown University, 1351 S. County Trail, Building 1, Suite 100, East Greenwich, RI 02818 (e-mail: david_bica@brown.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

REFERENCES

show all references

1. Hatch RL, Rosenbaum CI. Fracture care by family physicians. A review of 295 cases. J Fam Pract. 1994;38(3):238–244....

2. Boutefnouchet T, Budair B, Backshayesh P, Ali SA. Metatarsal fractures: a review and current concepts. Trauma. 2014;16(3):147–163.

3. Hatch RL, Alsobrook JA, Clugston JR. Diagnosis and management of metatarsal fractures. Am Fam Physician. 2007;76(6):817–826.

4. Cakir H, Van Vliet-Koppert ST, Van Lieshout EM, De Vries MR, Van Der Elst M, Schepers T. Demographics and outcome of metatarsal fractures. Arch Orthop Trauma Surg. 2011;131(2):241–245.

5. Singer G, Cichocki M, Schalamon J, Eberl R, Höllwarth ME. A study of metatarsal fractures in children. J Bone Joint Surg Am. 2008;90(4):772–776.

6. Eiff MP, Hatch R, Calmbach WL. Fracture Management for Primary Care. 2nd ed. Philadelphia, Pa.: Saunders; 2003: 306–330.

7. Pao DG, Keats TE, Dussault RG. Avulsion fracture of the base of the fifth metatarsal not seen on conventional radiography of the foot: the need for an additional projection. AJR Am J Roentgenol. 2000;175(2):549–552.

8. Sarwar A, Wu JS, Kung J, et al. Graphic representation of clinical symptoms: a tool for improving detection of subtle fractures on foot radiographs. AJR Am J Roentgenol. 2014;203(4):W429–W433.

9. Canagasabey MD, Callaghan MJ, Carley S. The sonographic Ottawa Foot and Ankle Rules study (the SOFAR study). Emerg Med J. 2011;28(10):838–840.

10. Ekinci S, Polat O, Günalp M, Demirkan A, Koca A. The accuracy of ultrasound evaluation in foot and ankle trauma. Am J Emerg Med. 2013;31(11):1551–1555.

11. Boyd AS, Benjamin HJ, Asplund C. Splints and casts: indications and methods. Am Fam Physician. 2009;80(5):491–499.

12. Zenios M, Kim WY, Sampath J, Muddu BN. Functional treatment of acute metatarsal fractures: a prospective randomised comparison of management in a cast versus elasticated support bandage. Injury. 2005;36(7):832–835.

13. Thevendran G, Deol RS, Calder JD. Fifth metatarsal fractures in the athlete: evidence for management. Foot Ankle Clin. 2013;18(2):237–254.

14. Stiell IG, Greenberg GH, McKnight RD, et al. Decision rules for the use of radiography in acute ankle injuries. Refinement and prospective validation. JAMA. 1993;269(9):1127–1132.

15. Ivins D. Acute ankle sprain: an update. Am Fam Physician. 2006;74(10):1714–1720.

16. Plint AC, Bulloch B, Osmond MH, et al. Validation of the Ottawa Ankle Rules in children with ankle injuries. Acad Emerg Med. 1999;6(10):1005–1009.

17. Mehlhorn AT, Zwingmann J, Hirschmüller A, Südkamp NP, Schmal H. Radiographic classification for fractures of the fifth metatarsal base. Skeletal Radiol. 2014;43(4):467–474.

18. Wiener BD, Linder JF, Giattini JF. Treatment of fractures of the fifth metatarsal: a prospective study. Foot Ankle Int. 1997;18(5):267–269.

19. Shahid MK, Punwar S, Boulind C, Bannister G. Aircast walking boot and below-knee walking cast for avulsion fractures of the base of the fifth metatarsal: a comparative cohort study. Foot Ankle Int. 2013;34(1):75–79.

20. Smith TO, Clark A, Hing CB. Interventions for treating proximal fifth metatarsal fractures in adults: a meta-analysis of the current evidence-base. Foot Ankle Surg. 2011;17(4):300–307.

21. Mologne TS, Lundeen JM, Clapper MF, O'Brien TJ. Early screw fixation versus casting in the treatment of acute Jones fractures. Am J Sports Med. 2005;33(7):970–975.

22. Quill GE Jr. Fractures of the proximal fifth metatarsal. Orthop Clin North Am. 1995;26(2):353–361.

23. Mittlmeier T, Haar P. Sesamoid and toe fractures. Injury. 2004;35(suppl 2):SB87–SB97.

24. Schnaue-Constantouris EM, Birrer RB, Grisafi PJ, Dellacorte MP. Digital foot trauma: emergency diagnosis and treatment. J Emerg Med. 2002;22(2):163–170.

25. Van Vliet-Koppert ST, Cakir H, Van Lieshout EM, De Vries MR, Van Der Elst M, Schepers T. Demographics and functional outcome of toe fractures. J Foot Ankle Surg. 2011;50(3):307–310.



 

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