METATARSAL / CALCANEAL INJURIES Flashcards
DOCUMENTATION
Look for plantar bruising
Ottawa Ankle Rules:
Pain over posterior aspect of distal 6 cm of lateral or medial Malleoli
Unable to wt. bear 4 steps immediately and in ED (Limping okay)
Ottawa Foot Rules:
Pain over navicular or base of 5th metatarsal
Unable to wt. bear 4 steps immediately and in ED (Limping okay)
“Cup” the heel for tenderness
Head of 2nd metatarsal
Move 1st and 2nd toe in opposite directions
Mid Foot Squeeze
DDx:
Base 5th Metatarsal Fracture
Jones Fracture (Proximal 5th Metatarsal)
Metatarsal Shaft Fracture
Metatarsal Stress Fracture
Lisfranc’s (tarsometatarsal) fracture-dislocation
Calcaneal Fracture
XRAY:
3 View Xray of Foot
AP View: B52
Bones - start proximally, go medial to lateral
Base of 5th Metatarsal
Base of 2nd Metatarsal - medial aspect of 2nd, and alignment with cuneiform, <1mm space)
Oblique View:
Medial border of 4th MT and medial border of cuboid should alight
Anterior process of calcaneus
Lateral View:
Alignment of metatarsals and cuneiforms
Calcaneus: Measure Boehler’s Angle
Normal angle 20-40
Boehler’s angle < 20 ~ Calcaneal Fracture
Weight Bearing View:
Lisfranc’s
Harris View
Lumbar XRAY
Calcaneal Fracture
MECHANISM
High Impact injury fall from height
PHYSICAL EXAM
Cup the heel for tenderness
Check lower back
XRAY:
Calcalneal View
Boehler’s Angle
Draw one line from the posterior tuberosity to the apex of the posterior facet
Draw a second line from the apex of the posterior facet to the apex of the anterior process.
Normal angle 20-40
Boehler’s angle < 20 ~ Calcaneal Fracture
Lumbar XRAY
If calcaneal fracture on xray, get a CT scan
MANAGEMENT: Nondisplaced
Posterior slab with Bulk Dressing
Non weight bearing
Ortho follow up ~ 1 week
MANAGEMENT: Displaced, intra-articular, tongue-type calcaneus
Posterior slab with Bulk Dressing
Emergency ortho Referal
COMPLICATIONS:
Compartment Syndrome
Skin Necrosis
PEARLS:
Document compartment and skin status
Document time of orthopedic consult
Jones Fracture
MECHANISM:
Often seen in athletes with repetitive start / stops of the side of the foot
XRAY
Fracture at the junction of the proximal and middle thirds of the 5th metatarsal
Transverse - may see periosteal reaction
MANAGEMENT
Posterior slab
Non weight bearing
Ortho Follow Up 1 Week
COMPLICATIONS
High risk of non-union
Base of 5th Metatarsal / Dancer’s Fracture
MECHANISM
Ankle Inversion
CLINICAL FEATURES
Tenderness of the base of the 5th Metatarsal
XRAY FINDINGS
Avulsion at insertion of peroneus brevis or lateral plantar aponeurosis
MANAGEMENT
If displaced, almost all heal well
Low profile are foam walker PRN
Weight bear as tolerated
Ortho follow up in 1-2 weeks
LISFRANC’S (TARSOMETATARSAL) FRACTURE-DISLOCATION
MECHANISM
High Energy Blunt Trauma (MVC)
Axial and Rotational Force (Foot Planted in a Hole and rotated)
CLINICAL FEATURES
Pain over midfoot
Inability to weight bear or stand on tip toes
Plantar arch ecchymosis
XRAY FINDINGS
AP:
fleck sign (bone fragment between the cuneiform and 2nd metatarsal)
>2-mm widening between the medial cuneiform and second metatarsal
>1-mm widening between the first and second metatarsals or medial and middle cuneiforms
Lateral:
Dorsal subluxation of the metatarsals at the tarsometatarsal joint
Talometatarsal angle >15°
Reduced distance between the medial cuneiform and fifth metatarsal
Weight Bearing View:
widening of joint space between 1st and 2nd metatarsal
MANAGEMENT
Reduce the metatarsal head
Short leg, posterior splint
Non weight bearing
Ortho follow up 1-2 weeks
Compartment syndrome, significant dislocation - urgent ortho consult
COMPLICATIONS
Compartment syndrome
Unreduced -> soft tissue damage and skin necrosis
Metatarsal Shaft Fracture
MECHANISM
Rolling the foot
XRAY
Spiral fracture of the metatarsal shaft
MANAGEMENT
Low profile foam walker
OR
Posterior Slab
Follow-up with ortho in a week
Metatarsal Stress Fracture
MECHANISM
Increased activity ex/ marching
XRAY
May show subtle transverse fracture
Mild periosteal reaction
OR
Normal
MANAGEMENT
Weight bear as tolerated
Foam walker PRN
Ortho follow up in 1-2 weeks
