Chapter 43- Fractures of the foot

Question 1

Typical history of calcaneal fracture

Answer 1

-Severe pain, marked swelling and bruising following a fall from a height

Question 2

What other injuries associated with axial loading should be excluded in a suspected calcaneus fracture

Answer 2

-Fracture of the distal tibia, knee, proximal femur or acetabulum, compression fractures of the spine and fractures of the base of skull

Question 3

Classification of fractures of the calcaneus

Answer 3

• Extra-articular fractures: does not involve the subtalar or calcaneo-cuboid joints
• Intra-articular: involve the subtalar or calcaneo-cubioid joints. the sharp inferior edge of the talus is driven down, splitting the calcaneus. the heel is broadened.

Question 4

What should one look for on Xrays for fracture of the calcaneus

Answer 4

• Ask for axial view: look for splits or splaying

- Lat view:upper margin angle should be about 30 degrees (Bohlers angle)

Question 5

Treatment of extra-articular calcaneal fractures

Answer 5

• Many treated conservatively but if widely displaced:
• ORIF
• Encourage early movement
• Crutches, non-weight bearing for 8 weeks, then partial weight bearing for 4 weeks

Question 6

Treatment of intra-articular calcaneal fractures

Answer 6

Refer to specialist for opinion and possibly open reduction

Question 7

Complications of calcaneal fractures

Answer 7

• Painful varus, broad heel
• Slow rehabilitation
• Peroneal tendon impingement and tendinitis
• Anterior ankle impingement
• Subtalar or calcaneo-cuboid arthritis due to intial joint injury

Question 8

Typical history of fracture of the talus

Answer 8

Acute dorsiflexion of the ankle

Question 9

Treatment of undisplaced fracture of the talus

Answer 9

• POP with foot at right angles 8/52

- non weight bearing

Question 10

Treatment of displaced fracture of the talus

Answer 10

-Closed or open reduction- improves union rate and reduces risk of avascular necrosis. Refer to specialist

Question 11

Complications of fracture of the talus

Answer 11

-Avascular necrosis of the proximal body of the talus. this predisposes to an early onset osteoarthritis

Question 12

Dislocation of the talus and subtalus requires emergency reduction to avoid which serious complications

Answer 12

• Ischaemic pressure necrosis of overlying skin
• Avascular necrosis of the talus
• Late pain and stiffness

Question 13

Clues to a lisfranc dislocation on stress Xray

Answer 13

• Widening of the joint space between the 1st and 2nd metatarsal
• Pull-off flake of bone at the base of the 1st metatarsal
• Loss of alignment of the 2nd and 4th metatarsals with cuneiform and cuboid respectively
• Dorsal subluxation of metatarsals with respect to tarsals

Question 14

Treatment of lisfranc dislocation

Answer 14

• Padded bandage may be adequate .

- Emergency reduction (closed or open) with fixation by K-wire or screw/ plate fixation

Question 15

Complications of Lisfranc dislocation

Answer 15

• Forefoot ischaemia

- Osteoarthritis

Question 16

Treatment of metatarsal shaft fractures

Answer 16

• Elevation
• Only if painful- Below knee POP and walking heel
• Reduce a fracture spike or dispaces metatarsal head

Question 17

Treatment of avulsion of the base of the 5th metatarsal

Answer 17

• Padded bandage may be adequate
• Very painful: BK POP with ankle in eversion x 4- 6 weeks
• May progress to non union –> ORIF may be necessary

Question 18

Treatment of stress fracture (often occurring in the neck of metatarsals)

Answer 18

-Restrict activity for 12 weeks or longer

Question 19

Treatment of phalangeal fractures

Answer 19

buddy strapping