Talus fracture

Hindfoot

Talus

Background

• Almost always associated with other injuries

Diagnosis

• CT often required for accurate diagnosis

Management

• Major fracture (talar neck and head)
  • Immediate ortho consultation required (high rate of avascular necrosis)
• Minor fracture
  • Posterior splint, NWB, ortho referral

Calcaneus

Background

• Associated injuries are common
• Types
  • Intra-articular (75%)
    • Sclerotic line may be only evidence of impacted fracture
  • Extra-articular (25%)
    • Anterior process fx is most common

Diagnosis

• Imaging
  • Decreased Boehler's angle (<25') may be only sign of fx (compare w/ opposite side)

Treatment

• Intra-articular fracture
  • Immobilization w/ posterior splint
  • Non-weightbearing
  • Elevation (very important - fx has high rate of severe swelling)
  • Ortho consult
• Extra-articular fracture
  • Immobilization and close ortho f/u

Images

• (A) Normal Boehler's angle and (B) Abnormal Boehler's angle

Midfoot

LisFranc Injury

• See Lisfranc Injury

Navicular/Cuboid/Cuneiform

• All are diagnosed/managed in similar way
  • Imaging: (weight-bearing AP, lateral, oblique)
    • CT sometimes necessary
  • Treatment: Non-weightbearing short leg cast, ortho referral

Forefoot

Fifth Metatarsal

Background

• Os peroneum is an accessory bone (ossicle) located at the lateral side of the tarsal cuboid, proximal to the base of 5th metatarsal, commonly mistaken for fx

3 types of 5th metatarsal fx:

1. Tuberosity (styloid) avulsion fracture:
   1. Most common fx at base of 5th metatarsal
   2. Sx often mild, pts usually present with sprained ankle complaint
   3. Occurs due to forced inversion foot/ankle while in plantar flexion
2. Jones or metaphyseal-diaphyseal junction fracture:
   1. Second most common fx at base of 5th metatarsal
   2. Abrupt onset of lateral foot pain, with no prior h/o pain at that site, suggests acute injury and helps distinguish from stress injury
   3. Occurs due to sudden change in direction w/ heel off the ground
   4. Edema & ecchymosis usually present, may not be able to bear weight
3. Diaphyseal stress fracture:
   1. Occurs through repetitive microtrauma, usually in younger athletes
   2. Important to identify given propensity for delayed union and nonunion
   3. Usually present with h/o months of pain, which is more intense during exercise or weight-bearing
      1. always ask about persistent pain prior to acute event to help distinguish worsening stress fx from acute fx

Diagnosis

Plain radiographs are usually adequate

• Must distinguish Jones fx from diaphyseal stress freacture:
  • Acute fx will have narrow fx line that appears sharp, normal thin cortex adjacent to fx, and normal intramedullary canal
  • Stress fx will demonstrate cortical thickening near fx line, older stress fx will demonstrate widened fx line and intramedullary sclerosis

5th Metatarsal fx types

Management

• Tuberosity (Styloid) Avulsion Fracture
  • Refer to ortho if > 3mm displacement
  • Nondisplaced fx usually require only symptomatic tx, RICE
  • Walking boot (casting rarely necessary) and weight-bearing as tolerated, f/u in 1 week
• Jones Fracture (non-displaced)
  • Posterior splinting, strict NWB, RICE, ortho f/u in 3-5 days
  • 50% of Jones fx treated conservatively may result in nonunion or refracture
  • Conservative tx failure usually due to poor vascular supply of bone and premature return to weight-bearing
• Diaphyseal Stress Fracture
  • Strict NWB short-leg cast, RICE
  • Ortho referral for all stress fxs

Metatarsal

Background

• Must rule-out associated Lisfranc injury

Management

• Posterior splint, NWB, ortho referral in 2-3d

Phalange

• Management: buddy-taping, hard-soled shoe

See Also

• Fractures (Main)
• Foot Diagnoses (Main)

Source

• Tintinalli
• Uptodate
• Ilustration by Dr. Frank Gaillard; CC SA NC BY licence
• http://radiopaedia.org/articles/jones_fracture