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Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e

Chapter 277: Foot Injuries Sarah Andrus Gaines; Daniel A. Handel

INTRODUCTION

Foot injuries occur most commonly in work and athletic environments.1 Work-related foot injuries can be

associated with substantial medical costs and lost wages.2 Sport-related foot and ankle injuries require care

so the athlete can return to the demands of the sport as quickly as possible.3 Motor vehicle crash patients

with a foot or ankle injury typically have a higher injury severity score than those without such injuries.4

ANATOMY

The foot is divided into three sections: the hindfoot, the midfoot, and the forefoot. The Chopart jointseparates the hindfoot from the midfoot. The Lisfranc joint divides the midfoot and the forefoot. Thehindfoot is comprised of the talus and the calcaneus. The midfoot encompasses the medial, middle, andlateral cuneiforms; the navicular; and the cuboid. The tarsus refers to the bones of the hind and midfoot. Theforefoot includes the metatarsals and the proximal, middle, and distal phalanges (Figure 277-1). Ligamentsand muscles enable foot movements of eversion, inversion, adduction, and abduction.

FIGURE 277-1.

A. Diagram of normal bony anatomy of the foot. B. Radiograph of normal bony alignment of the foot. [Panel Bimage used with permission of Robert DeMayo, MD.]

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Vascular supply of the foot originates from branches of the popliteal artery: the anterior tibial artery, with itsbranch the dorsalis pedis supplying the dorsal aspect of the foot; and the posterior tibial and peronealarteries supplying the sole (Figure 277-2).

FIGURE 277-2.

A. Arteries of the dorsum of the foot. B. Vessels and nerves of the sole of the foot. a. = artery; aa. = arteries;Abd. hall. = abductor hallucis; Ant. lat. = anterior lateral; Ant. med. = anterior medial; br. = branch; brev. =brevis; dig. = digitorum; Flex. = flexor; Lat. = lateral; Med. plant. = medial plantar; n. = nerve; nn. = nerves;Post. = posterior; Quad. = quadratus; Superf. = superficial; trans. = transverse.

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The sural, saphenous, peroneal, and lateral plantar nerves innervate the foot for both motor and sensoryfunction and originate in branches from the sciatic and femoral nerves.

CLINICAL FEATURES

HISTORY

Ask about the mechanism of injury and direction of force. Obtain key information, including ability to bearweight a�er the injury, prior injury or surgery to the area, and any other potential injuries. Because it requiresgreat force to fracture the foot, other injuries can coexist, and foot pain can distract from other seriousinjuries.

PHYSICAL EXAMINATION

The foot examination does not necessarily begin with the foot, but with the entire lower extremity on thea�ected side. Examine the hip, knee, and ankle. Evaluate neurovascular integrity. Vascular compromise ofthe foot is identified with diminished pulses, a cool extremity, and mottled skin. Once the generalexamination is completed and the focused foot examination begins, start with the general appearance of thefoot and compare it with the uninjured side. Look for obvious closed or open deformities. Ask the patient toidentify painful areas. Palpate the foot for abnormal findings or tenderness. Pay particular attention to thebase of the fi�h metatarsal and the dorsal aspect of the base of the second metatarsal. Range the joint bothpassively and actively through all typical motions of the foot. Evaluate gait when possible.

HINDFOOT INJURIES

CALCANEUS INJURIES

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Clinical Features

The calcaneus is the most commonly fractured tarsal bone, whereas the talus is infrequently fractured.5

Fractures in the hindfoot typically require a large force, like an axial load to the heel, to occur. Because of thisforce, associated injuries are common.

Calcaneal fractures are subdivided into intra-articular and extra-articular fractures, with intra-articularfractures being the more common of the two. A displaced intra-articular fracture is common and poses itsown challenges for long-term care. Some surgeons advocate for open reduction and internal fixation; others

prefer nonoperative closed reduction; and still others prefer primary arthrodesis.6

Diagnosis

Plain radiographs, specifically the lateral view, are needed for fracture diagnosis. The Boehler angle ismeasured using the lateral view and represents the intersection of two lines: (1) the line drawn from thehighest part of the anterior process of the calcaneus and the highest point of the posterior articular surface ofthis bone, and (2) the line between the highest point of the posterior articular surface of the calcaneus andthe most superior part of the calcaneal tuberosity. The normal angle measures between 25 and 40 degrees.When the angle is <25 degrees, suspect a fracture (Figure 277-3). Because this angle varies widely betweenindividuals, a comparison view is helpful if the diagnosis is in question. Although plain radiographs arehelpful when the fracture is visible, a CT can provide detail and help clarify the management plan.

FIGURE 277-3.

A. Calcaneal fracture with abnormal Boehler angle. B. Normal radiograph with normal Boehler angle. [Imageused with permission of Robert DeMayo, MD.]

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Treatment and Follow-Up

For intra-articular fractures, obtain orthopedic consultation to determine the management plan. Fornondisplaced fractures, treat an intra-articular fracture with immobilization, a well-padded posterior splint,strict elevation, non–weight-bearing status, and appropriate analgesia. Elevate the leg above the heart tominimize edema and the risk of compartment syndrome (see the chapter titled "Compartment Syndrome").Displaced fractures may require surgical repair. Care for an extra-articular fracture is elevation,immobilization, analgesia, and orthopedic follow-up. Some of these will require outpatient surgical

intervention, with less invasive, percutaneous approaches being adopted in more recent years.7

TALUS INJURIES

Clinical Features

Fractures of the talus usually require a significant mechanism such as extreme dorsiflexion or a fall from agreat height. "Major" talus fractures are those involving the head, neck, or body of the talus (Figure 277-4)and can result in avascular necrosis. "Minor" talus fractures are those that do not cross the central part of thetalus (Figure 277-5). A lateral process talar fracture is sometimes called "snowboarder's ankle," and iscommonly mistaken for a lateral ankle sprain.

FIGURE 277-4.

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Major talus fractures. [Reproduced with permission from Simon RR, Sherman SC (eds): EmergencyOrthopedics, 6th ed. New York: McGraw-Hill, 2011; Fig. 23-13, p. 525.]

FIGURE 277-5.

Minor talus fractures. [Reproduced with permission from Simon RR, Sherman SC (eds): EmergencyOrthopedics, 6th ed. New York: McGraw-Hill, 2011; Fig. 23-14, p. 527.]

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Diagnosis, Treatment, and Follow-Up

Diagnosis begins with plain radiography, but CT provides better visualization of the talus. Minor talusfractures can be treated on an outpatient basis with a posterior splint, non–weight-bearing status, analgesia,and orthopedic referral. Major talar fractures ideally require orthopedic consultation in the ED.

Dislocations of the talus, when the tibiotalar joint remains intact, are either peritalar or subtalar. Thetalocalcaneal and talonavicular joints are disrupted by a rotational-inversion force. Dislocations are rare butare orthopedic emergencies. Immediate orthopedic consultation and reduction are necessary to preventneurovascular compromise to the foot.

MIDFOOT INJURIES

LISFRANC INJURIES

Clinical Features

The midfoot is divided into two columns, with the medial column containing the navicular, cuneiforms, andthe first three tarsometatarsal joints; the lateral column contains the cuboid and fourth and fi�htarsometatarsal joints (Figure 277-1). The midfoot is a vital bridge between the hindfoot and the forefoot.Injuries to the midfoot have the potential to dramatically a�ect an individual's daily function, including theability to stand and walk. Untreated midfoot injuries in diabetics can lead to the development of Charcot's

foot (collapse of the mid-foot arch) and lifelong complications with ambulating.8

The cornerstone of mechanism, diagnosis, and treatment of Lisfranc injuries lies in the anatomy of thesecond metatarsal and the Lisfranc ligament, which runs between the lateral base of the medial cuneiformand the medial base of the second metatarsal. Its strength exceeds that of the plantar ligament construct by

severalfold.9 Lisfranc injuries range from sprains to fracture-dislocations, with concurrent fractures of thehind and forefoot being relatively common, especially fractures of the second metatarsal. The usual

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mechanism of injury for sprains is a low-velocity indirect force, whereas plantar-flexion with an axial load(such as strenuous jumping over an obstacle) is seen in more significant injuries. Sports injuries (specifically

football) and motor vehicle crashes are common situations for these injuries.10,11

Diagnosis

Pain elicited by torsion of the midfoot raises suspicion for a Lisfranc injury. Also, injuries about thetarsometatarsal joint, with pain on passive dorsi- or plantarflexion of the foot, should result in a specificevaluation of the midfoot for a Lisfranc injury. Radiographic studies should include at minimum bilateralweight-bearing anteroposterior (when tolerable), lateral, and 30-degree oblique views of the foot. Bonydisplacement of 1 mm or greater between the bases of the first and second metatarsals is considered

unstable. CT imaging is the ideal imaging study for this injury.12 It provides better delineation of bonystructures and diagnoses occult fractures or subluxations that can be missed on plain radiographs (Figure277-6).

FIGURE 277-6.

A. Radiograph of Lisfranc injury. B. CT of Lisfranc injury. Note the metatarsal bones are fractured (arrow) anddisplaced from the tarsus. [Image used with permission of Robert DeMayo, MD.]

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Lisfranc injuries have multiple classification systems.10 The Nunley classification groups low-energyligamentous injuries by diastasis and preservation or loss of arch height: type I are nondisplaced, type IIinvolve diastasis between the first and second metatarsal heads, and type III involve diastasis with loss of

arch height.11

Treatment and Follow-Up

Treatment of a nondisplaced injury (<1 mm between the bases of the first and second metatarsals) is with anon–weight-bearing splint, rest, ice, and elevation. Orthopedic reevaluation is usually scheduled within 2weeks when repeat imaging will likely be obtained and a cast will likely remain on for an additional 4 weeks.At 6 weeks, gradual progressive weight bearing can be attempted.

Displaced Lisfranc injuries are unsTable and require orthopedic consultant in the ED and anatomic

reduction.13 Whether the reduction is open or closed depends on the degree of the injury and is determinedby the orthopedic consultant. Surgical options are variable and range from open reduction and internal

fixation to primary arthrodesis.14 Compartment syndrome is an acute complication of significant Lisfrancinjuries (see the chapter titled "Compartment Syndrome").

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NAVICULAR INJURIES

Navicular fractures are typically caused by a direct blow or axial loading. Avulsion injuries can also occur witha pulling or rotational force. On physical examination, tenderness and ecchymosis are found about thenavicular. Imaging includes bilateral weight-bearing anteroposterior, lateral, and oblique radiographs. CT isbest for evaluating the talonavicular joint surfaces. The goals of treatment are maintenance of anatomy andrestoration of articular congruity. Nondisplaced fractures should be treated in a non–weight-bearing shortleg cast for 6 to 8 weeks, with orthopedic reevaluation in approximately 2 weeks. Orthopedic consultation inthe ED is usually required for displaced, and therefore unstable, fractures, to determine the management

plan. Given that the central part of the navicular bone is avascular,15 complications include avascularnecrosis, nonunion, and instability, all of which can lead to a flatfoot deformity.

CUBOID INJURIES

The cuboid articulates with the calcaneus and the fourth and fi�h metatarsals. Plantarflexion and abductionis the most common mechanism of injury. Imaging includes bilateral weight-bearing anteroposterior, lateral,and oblique radiographs. CT may be helpful. Nondisplaced fractures are treated with a short leg cast andinitial non–weight-bearing status. Comminuted injuries are treated with surgery. Complications include footinstability and joint arthrosis.

CUNEIFORM INJURIES

The cuneiforms all articulate with the navicular. Isolated cuneiform injuries are very rare, but especially witha high-energy mechanism of injury, cuneiform fractures can coexist with other fractures of the foot. Imagingstudies are the same as for the other bones of the midfoot. Treatment depends on which bone is injured:medial cuneiform injuries are typically treated with surgery, whereas closed reduction usually su�ices for themiddle and lateral cuneiform bones.

FOREFOOT INJURIES

Forefoot injuries cover a broad range from those requiring minimal intervention to those requiring operativerepair. Fractures range from the minimally displaced to open, comminuted fractures.

FIFTH METATARSAL INJURIES

Clinical Features

Fractures of the proximal fi�h metatarsal occur in three forms and can be identified using the joint betweenthe proximal fourth and fi�h metatarsal as a guide: (1) tuberosity or styloid fractures, which are proximal tothe joint; (2) Jones fractures, which are also known as metaphyseal-diaphyseal junction fractures; and (3)diaphyseal stress fractures.

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Diagnosis

Plain radiographs are usually adequate. CT scans should be considered for more detailed imaging in the

high-performance athlete17 (Figure 277-7).

FIGURE 277-7.

A. Anteroposterior radiograph of Jones fracture (arrow). B. Lateral radiographs of Jones fracture (arrow).[Image used with permission of Robert DeMayo, MD.]

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Treatment and Follow-Up

Patients with nondisplaced Jones fractures should be non–weight bearing in a cast for 6 to 8 weeks.Complications of a Jones fracture treated nonoperatively include bony nonunion, which may later require

intramedullary screw fixation. Shock wave therapy has also been reported for treatment of nonunion.17

Some orthopedic surgeons are advocating for early surgical correction, especially in athletes, so posterior

splinting and outpatient referral to an orthopedic surgeon are appropriate initial treatment.18 Nondisplacedavulsion fractures of the tuberosity, also known as a pseudo-Jones fracture, can be treated with a walkingcast and pain control with weight bearing as tolerated.

METATARSAL INJURIES

Proximal fractures of the first through fourth metatarsals are typically caused by a crush injury or direct blow.Take care to exclude an associated Lisfranc injury. An isolated proximal metatarsal fracture can be treatedwith a posterior splint and non–weight-bearing status. Orthopedic follow-up within 2 to 3 days is needed forthe likely placement of a more definitive cast.

Nondisplaced isolated fractures of the sha� of a metatarsal, usually caused by an acute direct blow ortwisting force, can typically be seen on oblique or lateral foot films. These can typically be treated with aposterior splint or orthopedic shoe or walking boot (see chapter titled "Initial Evaluation and Management ofOrthopedic Injuries"). Repeat imaging can be performed 1 week a�er injury and then again at 6 weeks.

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Fractures with displacement of 3 to 4 mm or angulation >10 degrees usually require surgical reduction13

(Figure 277-8).

FIGURE 277-8.

A. Anteroposterior radiograph of multiple metatarsal sha� fractures. B. Lateral radiograph of multiplemetatarsal sha� fractures. [Image used with permission of Robert DeMayo, MD.]

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STRESS INJURIES

Chronic direct forces cause stress fractures. Stress fractures typically occur in the setting of increasing activityor chronic overuse and are sometimes called "march fractures." Stress fractures are rarely visible on plainradiographs; MRI can be used when pain is persistent. A clinical diagnosis typically su�ices. Cessation of the

causative activity usually results in good outcomes for recovery.18

METATARSOPHALANGEAL INJURIES

Metatarsophalangeal joint injuries are caused by multiple mechanisms and occur in various forms, includingsprains, subluxations, and dislocations. Turf toe is a form of a sprain that results when there is acute orchronic hyperdorsiflexion of the first metatarsophalangeal joint while the foot remains in plantarflexion.History usually yields the diagnosis. When radiographs are obtained, a capsular avulsion, the hallmark of thisinjury, is seen. On physical examination, passive ranging results in a pathologically increased range ofmotion. Treatment is rest, ice, and elevation. Upon returning to sports, a reinforced shoe can be helpful and

protective from further injury.19 MRI is useful and can diagnose subtle associated injuries.20

Dislocations of the metatarsophalangeal joint, usually dorsal, can also occur. A high-energy mechanism is theusual cause, and this injury o�en accompanies other foot injuries. Treatment ranges from closed reduction tooperative repair, depending on the severity of injury.

PHALANGE INJURIES

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Fractures of the phalanges are the most common fractures of the forefoot, with a stubbing mechanism of the

hallucal proximal phalanx being the most common injury.19 Radiographs are obtained if there is extensiveinjury, suspicion of foreign body or open fracture, or if the great toe is injured. Radiographs are notnecessarily obtained for the distal phalanges of the other toes if the only injury is a closed isolated injury ofthe distal phalanx. Crush mechanisms can lead to distal phalanx fractures. Treatment is with buddy taping tothe adjacent toe or application of tape about the forefoot for greater stability (taking care to avoid unduepressure from the tape) and a hard-soled shoe.

For general guidance regarding the care of patients with acute bony foot injuries, see Table 277-1.

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TABLE 277-1

Summary of Emergent Care of Bony Foot Injuries

Fracture

or Injury

Type

ED

ImagingED Care*

Orthopedic

Referral

(immediate:

within 24 h;

early: within 2

wk)

Home

Care/Weight-

Bearing

Status

Advice on

Long-Term

Care and

Management

Special

Considerations

Calcaneal,

intra- and

extra-

articular

Plain films,

Boehler

angle; CT

for subtle

findings

Posterior

splint

Intra-

articular:

immediate;

extra-

articular: early

NWBS; RICE Possible

surgery

Talus

fracture

CT Posterior

splint

Major:

immediate;

minor: early

NWBS; RICE Possible

surgery

Risk of

avascular

necrosis

Lisfranc CT Splint Displaced:

ortho consult

in ED;

nondisplaced:

early

NWBS; RICE Possible

surgery

Risk of

compartment

syndrome;

arthritis

Navicular

fracture

Plain films

or CT

Splint Nondisplaced:

early;

displaced:

immediate

NWBS; RICE Possible

surgery

Risk of

avascular

necrosis;

nonunion

Cuboid

fracture

Plain films

or CT

Splint Early NWBS; RICE Comminuted:

possible

surgery

Cuneiform

fracture

Plain films

or CT

Splint Early NWBS; RICE Medial:

possible

surgery

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*All patients with fractures should receive adequate analgesia, and splints should be well padded.

Abbreviations: NWBS = non–weight-bearing status; ortho = orthopedist; RICE = rest, ice, compression, elevation; Td =

Tetanus booster.

Fracture

or Injury

Type

ED

ImagingED Care*

Orthopedic

Referral

(immediate:

within 24 h;

early: within 2

wk)

Home

Care/Weight-

Bearing

Status

Advice on

Long-Term

Care and

Management

Special

Considerations

Jones Plain films;

CT for

athletes

Splint Early NWBS; RICE Athletes:

possible

surgery

Metatarsal

fracture

Plain films Posterior

splint

Within a week

for a cast

NWBS; RICE Surgery not

likely

Stress

fracture

Clinical Cessation of

causative

activity

Phalange

fracture

Plain films Buddy

taping

Hard-soled

shoe and

weight

bearing as

tolerated

Open

fractures

of any

kind

Consider

antibiotics,

Td

Pain

control

Ortho consult

in ED

TENDON INJURIES

Lacerations to the foot may result in injury to the extensor hallucis longus tendon, with inability to dorsiflexthe great toe, or tibialis anterior tendon, with loss of dorsiflexion of the foot. Consult with the orthopedist.

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1. 

2. 

3. 

4. 

5. 

6. 

Treatment is primary repair if the tendon edges are opposable; otherwise, tendon reconstruction is

necessary.21

Lacerations of the flexor hallucis longus are typically repaired. Lacerations to the flexor tendons of the othertoes are generally le� unrepaired, as there is little if any functional impact.

Dislocation of the posterior tibial tendon is uncommon and is o�en misdiagnosed as ankle sprain.Mechanism of injury is forced dorsiflexion of the foot and ankle eversion when the posterior tibial tendon is

contracted, as may occur in snowboarding or ice skating.22 Treatment is surgical repair.

Achilles tendon injuries are discussed in the chapters titled "Leg Injuries" and "So� Tissue Problems of theFoot." Repair of lacerations of the foot is discussed in the chapter titled "Lacerations of the Leg and Foot."

Acknowledgments: The authors would like to thank Drs. John A. Michael, Ian G. Stiell, and Peter Ramsey fortheir contributions to previous editions of this chapter. We would also like to thank Drs. Esther Choo andRobert DeMayo for the radiographic images.

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