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Managing Selected Chronic Conditions in Hospitalized Patients

Common Foot Fractures

This is a corrected version of the article that appeared in print.

Sabrina Silver, DO, CAQSM
Elizabeth Williams, MD
Meghan L. Plunkett, MD

American Family Physician. 2024;109(2):119-129.

Author disclosure: No relevant financial relationships.

Foot fractures account for about one-third of lower extremity fractures in adults. They are typically caused by a crush injury or an axial or twisting force on the foot. Patients usually present with bony point tenderness and swelling of the affected area. Weight-bearing varies based on the extent of the fracture and the patient's pain tolerance. When a foot or toe fracture is suspected, anteroposterior, lateral, and oblique radiography with weight-bearing should be obtained. The Ottawa foot and ankle rules can help determine the need for radiography after an acute ankle inversion injury. Many foot fractures can be managed with a short leg cast or boot or a hard-soled shoe. Weight-bearing and duration of immobilization are based on the stability of the fracture and the patient's pain level. Most toe fractures can be managed nonsurgically with a hard-soled shoe for two to six weeks. Close attention should be paid to the great toe because of its role in weight-bearing, and physicians should follow specific guidelines for orthopedic referral. Meta-tarsal shaft fractures are managed with a boot or hard-soled shoe for three to six weeks. The proximal aspect of the fifth metatarsal has varied rates of healing due to poor blood supply, and management is based on the fracture zone. Lis-franc fractures are often overlooked; radiography with weight-bearing should be obtained, and physicians should look for widening of the tarsometatarsal joint. Other tarsal bone fractures can be managed with a short leg cast or boot for four to six weeks when nonsurgical treatment is indicated. Common foot fracture complications include arthritis, infection, malunion or nonunion, and compartment syndrome.

Foot fractures account for approximately one-third of lower extremity fractures in adults.1–3 Many foot fractures, especially in the forefoot, can be managed nonoperatively. Fractures in the foot may be masked by soft tissue injuries, and a high index of suspicion is required to avoid missing a fracture. This article discusses types of foot fractures, common mechanisms of injury, nonsurgical management, and indications for orthopedic referral. Table 1 summarizes the management of foot fractures.4–13 Foot fractures in children, ankle fractures, bony stress injuries, and guidance for athletes are beyond the scope of this manuscript.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation Evidence rating Comments
Phalangeal fractures of the lesser toes with no rotation and less than 25% joint involvement can be managed nonsurgically.4,5,15 C Clinical reviews and consensus expert opinion
Metatarsal shaft fractures of the second through fourth metatarsals should be reduced when there is more than 3 to 4 mm of displacement or more than 10 degrees of angulation.4,5,21 C Clinical review and consensus expert opinion
Surgical management of a zone 2 or 3 proximal fifth metatarsal fracture should be considered in active patients to decrease the risk of nonunion.8,9,25 B Clinical reviews and one systematic review of patient-oriented outcomes

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 https://www.aafp.org/afpsort.

SABRINA SILVER, DO, CAQSM, is a faculty physician and an assistant professor at the Indiana School of Medicine Indianapolis Family Medicine Residency. At the time this article was written, she was an assistant professor at the Uniformed Services University of the Health Sciences, Bethesda, Md.

ELIZABETH WILLIAMS, MD, is a faculty physician at the Eglin Family Medicine Residency, Eglin Air Force Base, Fla., and an assistant professor in the Department of Family Medicine at the Uniformed Services University of the Health Sciences.

MEGHAN L. PLUNKETT, MD, is a third-year resident in the Eglin Family Medicine Residency, 96th Medical Group.

Address correspondence to Sabrina Silver, DO, CAQSM, 1040 Wishard Blvd., Indianapolis, IN 46202 (silvesab@gmail.com). Reprints are not available from the authors.

Author disclosure: No relevant financial relationships.

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