June 17, 2019

Episode 165.0 – Foot Fractures

14 minutes

A look at foot fractures – which can be splinted and which may need the OR.

Hosts:

Audrey Bree Tse, MD

Brian Gilberti, MD

https://media.blubrry.com/coreem/content.blubrry.com/coreem/Foot_Fractures.mp3

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Tags: Orthopedics

Show Notes

Episode Produced by Audrey Bree Tse, MD

Background:

Why do we care about Jones fractures?

Propensity for poor healing due to watershed area of blood supply

Fifth metatarsal fractures account for 68% of metatarsal fractures in adults

Proximal 5th metatarsal fractures are divided into 3 zones (93% zone 1, 4% zone 2, 3% zone 3)

Zone 1 (pseudo-Jones):

Tuberosity avulsion fracture

Typically avulsion type injuries due to acute episode of forefoot supination with plantar flexion

Typical fracture pattern is transverse to slightly oblique

Zone 2 (Jones fracture):

Fracture at the metaphyseal-diaphyseal junction of the fifth metatarsal

Typically acute episode of large adduction force applied to forefoot with the ankle plantar flexed

Zone 3:

Proximal diaphyseal stress fracture

Typically results from a fatigue or stress mechanism

Clinical Presentation:

History of acute or repetitive trauma to forefoot

Fracture type / pattern closely related to injury location

Foot often swollen, ecchymotic, very tender to fifth metatarsal +/- crepitus, inability to hear weight

Diagnosis:

Clinical exam:

Evaluate skin integrity

Check neurovascular status

Evaluate toes/ feet/ ankles/ tib fib/ knees/ hips, involved tendon function, associated adjacent structures (Achilles, ankle ROM/ function, etc)

3 XR views: lateral, anteroposterior, 45* oblique

Acute stress fractures are typically not detected on the standard 3 views; therefore, repeat XRs 10-14d after onset of sx (may see radiolucent reabsorption gap around fracture)

For more complex mid foot trauma, consider CT to r/o Lisfranc

Treatment:

Consider classification of fracture, patient demographics & activity level when deciding on treatment

Tertiary care centers that have access to Orthopedics/Podiatry services

Consider consultation for “true” Jones fractures, as some cases may be operatively managed acutely and/or for expedited follow-up to be arranged

If working in community/rural locations: other than patients that present with “open” injuries, concerns for compartment syndrome (almost never), and “high-end”/professional athletes, there are generally no other circumstances that would require expedited transfer to a tertiary care center for immediate further evaluation.

Less favorable outcomes associated with certain patient factors: female gender, DM, obesity

Surgical:

Different modalities of surgery:

Intramedullary screw

Bone graft

Closed reduction and fixation with K-wire

ORIF (all +/- need for bone graft)

Surgery likely recommended for displacement >10 degrees of plantar angulation or 3-4 mm of translation in any plane

Indications for OR:

Neck and shaft fractures with >10 degrees plantar angulation or 3mm of displacement in any plane with insufficient closed reduction

Avulsion fractures (zone one) with >3 mm of displacement or comminuted

Zone two fractures: displaced zone two fractures require operative management. For acute non displaced Jones fractures, consider early intramedullary screw fixation in athletes (studies have shown return to sport ~ 8 weeks, weight bearing within 1-2 weeks)

Zone three fractures (diaphyseal stress fractures) in athletes

Nonoperative:

All non displaced fifth metatarsal fractures can be treated non operatively

Non displaced zone 1 fractures: protected weight bearing/ symptomatic care in short leg walking cast, air-boot, posterior splint, or compression wrap/ rigid shoe until discomfort subsides

Zone 2 and 3 fractures are more complex because they often result in prolonged healing time and potential for delayed/ nonunion

Acute zone 2 fractures: nonweightbearing in short leg cast for 6-8 weeks

Acute zone 3 fractures: nonweightbearing in short leg cast for up to 20 weeks

With respect to athletes: repeat fracture after surgical treatment of Jones fracture can occur after healing and screw removal; thus it is recommended that the screw be left in until the end of the athlete’s career

References:

Bowes J, Buckley R. Fifth metatarsal fractures and current treatment. World J Orthop. 2016;7(12):793–800. Published 2016 Dec 18. doi:10.5312/wjo.v7.i12.793

Petrisor BA, Ekrol I, Court-Brown C. The epidemiology of metatarsal fractures. Foot Ankle Int. 2006 Mar; 27(3): 172-4.

Rammelt S, Heineck J, Zwipp H. Metatarsal fractures. Injury. 2004;35 Suppl 2:SB77–SB86.

Tham W, Sng S, Lum YM, Chee YH. A Look Back in Time: Sir Robert Jones, ‘Father of Modern Orthopaedics’. Malays Orthop J. 2014;8(3):37–41. doi:10.5704/MOJ.1411.009

Thomas JL, Davis BC. Three-wire fixation technique for displaced fifth metatarsal base fractures. J Foot Ankle Surg. 2011;50:776–779.

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LISFRANC SHOW NOTES:

Intro:

Can’t miss diagnoses: needs stat ortho

20% miss rate

Can be dislocation, fracture, fracture dislocation, or ligamentous injury

Jacques Lisfranc in Napoleonic Wars: performed transmetatarsal amputation for midfoot gangrene

Anatomy:

Lisfranc ligament: 3 ligaments that run from the base of the second metatarsal to the medial cuneiform bone. Helps attach the forefoot to the midfoot bones

If ligament complex gets disrupted, can end up with chronic deformity and disability

Injury definitions:

Dislocation: widening between base of 1st and 2nd metatarsal, or between cuneiforms

Fracture dislocation: associated fracture, most commonly at the base of the proximal second metatarsal

Physical Exam:

Pain and swelling in midfoot

Pain elicited with passive abduction and pronation of the midfoot while holding heel steady

Plantar ecchymosis

r/o compartment syndrome

Feel for DP pulse!

Diagnosis:

XRs: AP, lateral, oblique, stress views with weight bearing