Episode 165.0 – Foot Fractures

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 Download Leave a Comment 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. ______________________ 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 Watch out for “fleck sign” Consider CT if pt cannot bear weight, or even if XR negative and high suspicion Treatment: Ortho consult! ______________________ THANKS TO DANNY PURCELL, MD and MAY LI, MD Read More