Acute fractures of the foot involve a myriad of unique clinical presentations and, therefore, are subject to specific treatment regimens. In discussing treatment of acute foot fractures, the practitioner must consider surgical and conservative treatment options, choosing that which will yield optimal functional outcome, avoid chronic pain, and minimize degenerative joint disease.
The inherent risks of surgical intervention, including infection, numbness, edema, and risks of anesthesia, must be considered in cases in which surgical intervention is deemed of only marginal benefit. Since conservative treatment is considered inappropriate in the treatment of displaced fractures involving breach of the skin with some degree of soft-tissue damage, that fracture classification will not be considered in the discussion that follows.
Numerous classification systems exist for fractures in the foot and allow the practitioner to appreciate the mechanism of injury, and provide appropriate treatment and prognosis of these fracture patterns. Knowing the mechanism of injury—that is, the motion of the foot combined with positioning at the time of injury—enhances the potential for a satisfactory closed reduction. A well-accepted protocol for treatment of acute foot fractures exists.
A closed fracture of the foot is of low priority in the management of the polytrauma patient and therefore is not addressed until the patient has had a systematic workup. A neurovascular assessment is done initially, including palpation of the dorsalis pedis and posterior tibial artery, as well as assessment of motor and sensory function of the lower extremity. Arterial occlusion and nerve impingement may be secondary to joint dislocation, or displacement of a fracture. Attempts at closed reduction of the osseous impingement by manipulation may be attempted; however, getting radiographs right away may be of benefit in significantly reducing the deformity. If fluoroscopy is available, a proper reduction may be expedited without waiting for plain films. Care should be taken to splint the patient following closed reduction to maintain the correction and prevent recurrence of neurovascular compromise.
Physical examination in acute foot fractures may reveal edema, ecchymosis, gross deformity, inability to function, and pain. Three views of the foot in forefoot trauma and additional views of the ankle in rearfoot and ankle trauma should be obtained initially. Generally this should be done prior to palpation and range of motion examination to avoid fracture displacement, iatrogenic neurovascular compromise, and the unnecessary discomfort of palpating a fracture. All extrinsic tendons should be palpated for deficit. A complete physical examination may be completed following review of initial plain films to determine if additional films are required.
Inversion ankle injuries may be associated with high fibular fractures. Calcaneal fractures resulting from a fall from a height may be associated with a lumbar spine fracture. As a result, initial physical examination should include evaluation of the lumbar spine and the leg to elucidate fibular fracture and syndesmosis injury. Lumbar and sacral spine, ankle, and tibia-fibular plain films should be ordered with initial foot films to rule out fracture. Other studies, including plain films or a computed tomography (CT) scan, may be ordered as needed. Contralateral films may be of great benefit in occult and pediatric fractures.
Elucidation of prior injury, mechanism of current injury, and ability to bear weight on the affected limb, along with any treatment done, may aid in locating a new fracture or lead to suspicion of old fracture when examining plain films.
A methodical approach to radiographic interpretation should be emphasized. Examine soft-tissue contour, joint spaces, and position and outline of each osseous structure. Acute fractures appear as jagged radiolucent lines with or without displacement, rotation, or angular deformity. Occult pathology should be sought out, including presence of cystic change, adjacent osseous or soft-tissue tumor, or disease affecting bone density. Pathological fractures may occur secondary to these findings and may occur without associated trauma or following trivial traumatic episodes.
Once acute fracture has been diagnosed in the neurovascularly stable foot, the surgeon must decide whether to treat with closed versus open reduction. In general, all fractures should be closed and reduced under local or general anesthesia. The patient’s general health and function must be considered at this time. Risks of surgery and of closed reduction under general anesthesia must be weighed against an acceptable fracture displacement in a patient with few recreational or occupational demands. If anatomic reduction can be achieved by closed means, appropriate conservative therapy may be instituted, including weight-bearing or nonweight-bearing on the affected foot, rest, ice, elevation, and use of nonsteroidal anti-inflammatory medication. The decision to place a short leg syntheticast on the lower extremity following diagnosis of an acute foot fracture, which may be closed or reduced appropriately, is determined by the osseous structure involved. If the weight-bearing forces of traction by a myotendinous unit will displace the fracture, casting should be performed.
Talar neck fractures with subtalar joint, ankle joint, and talonavicular joint dislocations must undergo open reduction and internal fixation (ORIF). Reduction of talar neck fractures should be done as soon as possible to decrease the risk of avascular nonunion. Avulsion fractures of the talus are generally excised, if they are large or intra-articular. Small nonarticular avulsion fractures respond well to casting and may reattach, resorb, or form a fibrous union. Fractures of the talar body often involve the posterior, medial, or lateral processes of the talus and may be problematic without ORIF, as these fractures are intra-articular and are frequently associated with subtalar osteoarthritis. If displacement is minimal and the fragment is small, casting in a nonweight-bearing cast is appropriate.3 The practitioner must use careful professional judgment in determining displacement and fragment size when considering ORIF.
Osteochondral fractures of the talar dome associated with ankle sprain are often overlooked.4 Inversion and dorsiflexion of the talus in the ankle mortise may result in fractures of the anterolateral dome, whereas inversion and plantar-flexion motion of the talus result in posterior medial lesions. These fractures were classified by Berndt and Hardy5 as compression fractures, partially detached osteochondral fractures, completely detached fractures, and displaced fractures. Closed reduction and nonweight-bearing are recommended for nondisplaced osteochondral fractures with the exception of detached nondisplaced lateral lesions, which should be excised.
Calcaneal fractures are difficult to manage. The goal of treatment is to attempt to reduce post-traumatic arthritis. The calcaneus, the largest tarsal bone, is composed of a thin shell of cortical bone about a relatively large volume of cancellous bone. Because of the nature of its anatomy, intra-articular fractures of this bone are difficult to reduce. Calcaneal axial views, Isherwood views, and Broden’s projections may be ordered to assess the calcaneus radiographically.6 CT is of great value in assessing fracture planes, displacement, and articular involvement.
Treatment of calcaneal fractures is quite specific for the segment involved. Rowe7 proposed a classification scheme for calcaneal fractures that is best used in conjunction with the Essex-Lopresti classification.8 Both intra- and extra-articular fractures are described. Sanders’ CT classification system9 has prognostic value in determining benefits of ORIF versus arthrodesis. Extra-articular calcaneal fractures are treated based on size, extent of articular involvement, and displacement. In general, fractures of the anterior process, posterior superior calcaneus, sustentaculum tali, calcaneal body, and lateral and medial processes respond well to conservative therapy, if closed reduction is successful.10 Closed reduction of avulsions of the posterior calcaneus by the tendo-Achilles requires ORIF.
Intra-articular fractures of the calcaneus involving the STJ have a poor prognosis. Displaced intra-articular fractures involving the posterior facet of the calcaneus are associated with morbidity. Disruption of the articular surface results in painful STJ degenerative joint disease. Alteration of the width and height of the calcaneus disrupt the normal mechanics of weight-bearing. Traditionally, conservative therapy has been used with poor results. Appropriate preoperative planning and proper open reduction technique can reduce post-traumatic degenerative joint disease, if realignment of articular surfaces, as well as calcaneal height and width, can be restored.
Lisfranc’s joint is the complex articulation between the midfoot and the metatarsals. Fracture or dislocation through this joint has the potential to cause significant disability if treated inappropriately. This clinical entity was classified by Quenu and Kuss and later modified by Hardcastle.11,12 Closed reduction of Lisfranc’s joint has proven unreliable in achieving stable anatomical reduction. Percutaneous pinning or ORIF provide the greatest potential for return to normal function.13
Metatarsal and phalangeal fractures may, in general, be treated by closed means. With the exception of the hallux, the lesser digits do not bear weight in the gait cycle and, therefore, a degree of angular deformity is acceptable. Development of nonunion or malunion may, however, result in pain during ambulation. A malunion may result in development of painful hyperkeratotic lesions and should be addressed surgically as needed.
The metatarsals bear weight from lateral to medial at the level of the metatarsal heads during the gait cycle. Incomplete closed reduction of a metatarsal fracture may result in uneven weight distribution and formation of plantar hyperkeratotic lesions. Following closed reduction, anterior-posterior and axial films may be reviewed to predict nonanatomic position of the metatarsal. The practitioner must weigh the risks of surgical intervention versus the possibility of development of painful hyperkeratotic lesions, or development of DJD at the metatarsal phalangeal joint.
Fractures of the base of the fifth metatarsal are prone to developing delayed union or nonunion as a result of the poor vascularity inherent to the proximal fifth metatarsal.14 If reduction by closed means is acceptable, the surgeon may opt to intervene surgically only if nonunion or delayed union results. Use of a screw axially across the fracture has been proposed to allow compression, in an attempt to avoid nonunion.15 The decision to perform ORIF depends on the surgeon’s experience.
Fracture of the tibial or fibular sesamoid of the first metatarsal phalangeal joint or of any of the variety of nonconstant accessory bones of the foot may be treated primarily or secondarily should symptoms persist. Closed reduction of these fractures is often difficult. Gross displacement of fracture fragments may be encountered. Immobilization and nonweight-bearing may allow minimally displaced fractures to form osseous union, but frequently with development of external bone callus. Symptomatic fibrous nonunion or degenerative joint disease may develop, resulting in chronic pain requiring surgical excision. The surgeon may prefer excision of the acute fracture to avoid such sequelae.
In acute closed foot fractures, concern should be for early return to function, prevention of degenerative joint disease, and avoidance of chronic pain or disability. When considering surgical and conservative treatment options in the surgical candidate, remember that anatomical reduction is the goal of both treatment options.
Brian D. MacDonald, DPM, is in podiatric surgical residency at St. John Hospital, Harrison Township, MI.
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