Image Bank: Foot Fractures

Image and Answer

1st and 2nd phalangeal fractures, note the lucency and cortical disruption

No fracture, this is a growth plate in a child, note the lack of cortication of the fragment and the multiple ossification centers, indicating this is a young foot.

Inverting the image sometimes reveals a subtle fracture, as seen at the base of the 5th metatarsal

+Calcaneal fracture, always track your cortical lines for disruptions

Dedicated calcaneus film, consider this in pt’s w/ falls or significant heel injuries concerning for a fracture. Mild hyperlucency noted (red arrow, likely calcific Achille’s tendon insertion) and hypolucency (blue arrow) concerning for a subtle fracture.

Cuboid fracture, very subtle, easily overlooked

Subtle cuboid fracture vs os naviculare, consider possibility of an avulsion injury 2/2 rupture calcaneocuboid part of the bifurcated ligament should mechanism exist

Cuboid fracture, longitudinal plantar ligament avulsion fx • Tx: NWB splint w/ ortho f/u 2wks for wt-

bearing XRays

Cuboid fracture, note the hypolucent irregularity (green arrows) with cortical distortion (red arrow)• Tx: NWB short leg cast x4-6wks

Navicular pseudofracture…this is actually a normal Xray, the hypolucency is actually just as a result of prominent trabeculae, note the smooth cortical rim

Cuboid Fracture: Use the lateral films to interrogate the plantar aspect of the cuboid, you can easily miss obvious fractures!

Stress Fx/Jones Fx (distal to the insertion of the peroneus brevis and 4th MT groove)

Tx: Strict NWB ortho shoe 4-6wks vs possible ORIF (high risk of non-union, usually only indicated for displaced fx)

Jones Fx (Zone II), no displacement, so likely no surgery

Subtle Stress Fx (Jones Zone iII): Use the lateral films to also interrogate the 5th MT to scan for subtle cortical disruptions (red arrow)

Disrupted Jones III Fx: This will need pinning, not today, but soon…call ortho but send home

Avulsion PseudoJones (Zone II) fracture of the 5th MT

Unstable fracture, will require pinning, strict NWB status until f/u

LisFranc Fracture: Mechanism is twisting on a planted foot, falls, severe plantar flexion. Fracture through the proximal MTs or midfoot disruption causes classic “Terry Thomas” sign highlighted here. Isolated fracture type.

(left) Lis Franc w/ marked MT disruption and homolateral (all 5 MTs) shift

• Homolateral fracture type highly associated with cuboid fractures

(below) Isolated LisFranc w/ subtle cortical disruptions noted

Multiple new (blue arrows) and a healing (red arrow) distal MT fractures in a child…should consider DCFS call if the story is in question

Proximal phalangeal fractures

Tx: Ice, elevation, NWB, f/u ortho for possible pinning given loose fragment

A/P Oblique

Navicular fracture (blue arrows) with cuneiform fracture (red arrows). Navicular fxs have high incidence of avascular necrosis! Need ORIF!!!