Foot Fractures

There are 28 bones in the foot. These bones support our weight and allow us to walk and run. Certain activities or injuries can cause a fracture, or break, in one or more of these bones. Pain, swelling, redness and even bruising are signs of a possible fracture. Fractures of the foot can be diagnosed by x-rays or other studies. A foot and ankle surgeon can determine the best treatment course. Rest, icing and immobilization are often the treatments; however, surgery is sometimes necessary to repair the fracture.

Lisfranc Injuries

What Is the Lisfranc Joint?

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The Lisfranc joint is the point at which the metatarsal bones (long bones that lead up to the toes) and the tarsal bones (bones in the arch) connect. The Lisfranc ligament is a tough band of tissue that joins two of these bones. This is important for maintaining proper alignment and strength of the joint.

How Do Lisfranc Injuries Occur?

Injuries to the Lisfranc joint most commonly occur in automobile accident victims, military personnel, runners, horseback riders, football players and participants of other contact sports, or something as simple as missing a step on a staircase. Lisfranc injuries occur as a result of direct or indirect forces to the foot. A direct force often involves something heavy falling on the foot. Indirect force commonly involves twisting the foot.

Types of Lisfranc Injuries

There are three types of Lisfranc injuries, which sometimes occur together:

  • The Lisfranc ligament and other ligaments on the bottom of the midfoot are stronger than those on the top of the midfoot. Therefore, when they are weakened through a sprain (a stretching of the ligament), patients experience instability of the joint in the middle of the foot.
  • A break in a bone in the Lisfranc joint can be either an avulsion fracture (a small piece of bone is pulled off) or a break through the bone or bones of the midfoot.
  • The bones of the Lisfranc joint may be forced from their normal positions.

Symptoms

Symptoms of a Lisfranc injury may include:

  • Swelling of the foot
  • Pain throughout the midfoot when standing or when pressure is applied
  • Inability to bear weight (in severe injuries)
  • Bruising or blistering on the arch are important signs of a Lisfranc injury. Bruising may also occur on the top of the foot.
  • Abnormal widening of the foot.

Diagnosis

Lisfranc injuries are sometimes mistaken for ankle sprains, making the diagnostic process very important. To arrive at a diagnosis, the foot and ankle surgeon will ask questions about how the injury occurred and will examine the foot to determine the severity of the injury. X-rays and other imaging studies may be necessary to fully evaluate the extent of the injury. The surgeon may also perform an additional examination while the patient is under anesthesia to further evaluate a fracture or weakening of the joint and surrounding bones.

Nonsurgical Treatment

Anyone who has symptoms of a Lisfranc injury should see a foot and ankle surgeon right away. If unable to do so immediately, it is important to stay off the injured foot, keep it elevated (at or slightly above hip level) and apply a bag of ice wrapped in a thin towel to the area every 20 minutes of each waking hour. These steps will help keep the swelling and pain under control.

Treatment by the foot and ankle surgeon may include one or more of the following, depending on the type and severity of the Lisfranc injury:

  • Sometimes the foot is placed in a cast to keep it immobile, and crutches are used to avoid putting weight on the injured foot.
  • Oral medications. Nonsteroidal anti-inflammatory medications (NSAIDs), such as ibuprofen, help reduce pain and inflammation.
  • Ice and elevation. Swelling is reduced by icing the affected area and keeping the foot elevated, as described above.
  • Physical therapy. After the swelling and pain have subsided, physical therapy may be prescribed.

When Is Surgery Needed?

Certain types of Lisfranc injuries require surgery. The foot and ankle surgeon will determine the type of procedure that is best suited to the individual patient. Some injuries of this type may require emergency surgery.

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AP and Lateral views of a Lisfranc fracture dislocation

Complications of Lisfranc Injuries

Complications can and often arise following Lisfranc injuries. A possible early complication following the injury is compartment syndrome, in which pressure builds up within the tissues of the foot, requiring immediate surgery to prevent tissue damage. A buildup of pressure could damage the nerves, blood vessels and muscles in the foot. Arthritis and problems with foot alignment are very likely to develop. In most cases, arthritis develops several months after a Lisfranc injury, requiring additional treatment.

Fractures of the Fifth Metatarsal

What Is a Fifth Metatarsal Fracture?

Fractures (breaks) are common in the fifth metatarsal—the long bone on the outside of the foot that connects to the little toe. Two types of fractures that often occur in the fifth metatarsal are:

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  • Avulsion fracture. In an avulsion fracture, a small piece of bone is pulled off the main portion of the bone by a tendon or ligament. This type of fracture is the result of an injury in which the ankle rolls. Avulsion fractures are often overlooked when they occur with an ankle sprain.
  • Jones fracture. Jones fractures occur in a small area of the fifth metatarsal that receives less blood and is therefore more prone to difficulties in healing. A Jones fracture can be either a stress fracture (a tiny hairline break that occurs over time) or an acute (sudden) break. Jones fractures are caused by overuse, repetitive stress or trauma. They are less common and more difficult to treat than avulsion fractures. Other types of fractures can occur in the fifth metatarsal. Examples include midshaft fractures, which usually result from trauma or twisting, and fractures of the metatarsal head and neck.

Symptoms

Avulsion and Jones fractures have the same signs and symptoms. These include:

  • Pain, swelling and tenderness on the outside of the foot
  • Difficulty walking
  • Bruising

Diagnosis

Anyone who has symptoms of a fifth metatarsal fracture should see a foot and ankle surgeon as soon as possible for proper diagnosis and treatment. To arrive at a diagnosis, the surgeon will ask how the injury occurred or when the pain started. The foot will be examined, with the doctor gently pressing on different areas of the foot to determine where there is pain. The surgeon will also order x-rays. Because a Jones fracture sometimes does not show up on initial x-rays, additional imaging studies may be needed.

Nonsurgical Treatment

Until you are able to see a foot and ankle surgeon, the RICE method of care should be performed:

  • Rest: Stay off the injured foot. Walking may cause further injury.
  • Ice: Apply an ice pack to the injured area, placing a thin towel between the ice and the skin. Use ice for 20 minutes and then wait at least 40 minutes before icing again.
  • Compression: An elastic wrap should be used to control swelling.
  • Elevation: The foot should be raised slightly above the level of your heart to reduce swelling.

The foot and ankle surgeon may use one of these nonsurgical options for treatment of a fifth metatarsal fracture:

  • Depending on the severity of the injury, the foot is kept immobile with a cast, cast boot or stiff-soled shoe. Crutches may also be needed to avoid placing weight on the injured foot.
  • Bone stimulation. A pain-free external device is used to speed the healing of some fractures. Bone stimulation, most commonly used for Jones fractures, may be used as part of the treatment or following an inadequate response to immobilization.

When Is Surgery Needed?

If the injury involves a displaced bone, multiple breaks or has failed to adequately heal, surgery may be required. The foot and ankle surgeon will determine the type of procedure that is best suited to the individual patient.

Toe and Metatarsal Fractures (Broken Toes)

The structure of the foot is complex, consisting of bones, muscles, tendons and other soft tissues. Of the 28 bones in the foot, 19 are toe bones (phalanges) and metatarsal bones (the long bones in the midfoot). Fractures of the toe and metatarsal bones are common and require evaluation by a specialist. A foot and ankle surgeon should be seen for proper diagnosis and treatment, even if initial treatment has been received in an emergency room.

What Is a Fracture?

A fracture is a break in the bone. Fractures can be divided into two categories: traumatic fractures and stress fractures.

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Traumatic fractures (also called acute fractures) are caused by a direct blow or impact, such as seriously stubbing your toe. Traumatic fractures can be displaced or nondisplaced. If the fracture is displaced, the bone is broken in such a way that it has changed in position (malpositioned).

Signs and symptoms of a traumatic fracture include:

  • You may hear a sound at the time of the break.
  • Pinpoint pain (pain at the place of impact) at the time the fracture occurs and perhaps for a few hours later, but often the pain goes away after several hours.
  • Crooked or abnormal appearance of the toe.
  • Bruising and swelling the next day.

It is not true that “if you can walk on it, it’s not broken.” Evaluation by a foot and ankle surgeon is always recommended.

Stress fractures are tiny hairline breaks usually caused by repetitive stress. Stress fractures often afflict athletes who, for example, too rapidly increase their running mileage. They can also be caused by an abnormal foot structure, deformities or osteoporosis. Improper footwear may also lead to stress fractures. Stress fractures should not be ignored. They require proper medical attention to heal correctly.

Symptoms of stress fractures include:

  • Pain with or after normal activity
  • Pain that goes away when resting and then returns when standing or during activity
  • Pinpoint pain (pain at the site of the fracture) when touched
  • Swelling but no bruising

Consequences of Improper Treatment

Some people say that “the doctor can’t do anything for a broken bone in the foot.” This is usually not true. In fact, if a fractured toe or metatarsal bone is not treated correctly, serious complications may develop. For example:

  • A deformity in the bony architecture, which may limit the ability to move the foot or cause difficulty in fitting shoes.
  • Arthritis, which may be caused by a fracture in a joint (the juncture where two bones meet), or may be a result of angular deformities that develop when a displaced fracture is severe or has not been properly corrected.
  • Chronic pain and deformity.
  • Nonunion, or failure to heal, can lead to subsequent surgery or chronic pain.

Treatment of Toe Fractures

Fractures of the toe bones are almost always traumatic fractures. Treatment for traumatic fractures depends on the break itself and may include these options:

  • Sometimes rest is all that is needed to treat a traumatic fracture of the toe.
  • The toe may be fitted with a splint to keep it in a fixed position.
  • Rigid or stiff-soled shoe. Wearing a stiff-soled shoe protects the toe and helps keep it properly positioned. Use of a postoperative shoe or bootwalker is also helpful.
  • Buddy taping the fractured toe to another toe is sometimes appropriate, but in other cases, it may be harmful.
  • If the break is badly displaced or if the joint is affected, surgery may be necessary. Surgery often involves the use of fixation devices, such as pins.

Treatment of Metatarsal Fractures

Breaks in the metatarsal bones may be either stress or traumatic fractures. Certain kinds of fractures of the metatarsal bones present unique challenges.

For example, sometimes a fracture of the first metatarsal bone (behind the big toe) can lead to arthritis. Since the big toe is used so frequently and bears more weight than other toes, arthritis in that area can make it painful to walk, bend or even stand.

Another type of break, called a Jones fracture, occurs at the base of the fifth metatarsal bone (behind the little toe). It is often misdiagnosed as an ankle sprain, and misdiagnosis can have serious consequences since sprains and fractures require different treatments. Your foot and ankle surgeon is an expert in correctly identifying these conditions as well as other problems of the foot.

Treatment of metatarsal fractures depends on the type and extent of the fracture and may include:

  • Sometimes rest is the only treatment needed to promote healing of a stress or traumatic fracture of a metatarsal bone.
  • Avoid the offending activity. Because stress fractures result from repetitive stress, it is important to avoid the activity that led to the fracture. Crutches or a wheelchair are sometimes required to offload weight from the foot to give it time to heal.
  • Immobilization, casting or rigid shoe. A stiff-soled shoe or other form of immobilization may be used to protect the fractured bone while it is healing. Use of a postoperative shoe or bootwalker is also helpful.
  • Some traumatic fractures of the metatarsal bones require surgery, especially if the break is badly displaced.
  • Follow-up care. Your foot and ankle surgeon will provide instructions for care following surgical or nonsurgical treatment. Physical therapy, exercises and rehabilitation may be included in a schedule for return to normal activities.

Fractures of the Calcaneus (Heel Bone Fractures)

What Is the Calcaneus?

The calcaneus, also called the heel bone, is a large bone that forms the foundation of the rear part of the foot. The calcaneus connects with the talus and cuboid bones. The connection between the talus and calcaneus forms the subtalar joint. This joint is important for normal foot function.

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The calcaneus is often compared to a hardboiled egg because it has a thin, hard shell on the outside and softer, spongy bone on the inside. When the outer shell is broken, the bone tends to collapse and become fragmented. For this reason, calcaneal fractures are severe injuries. Furthermore, if the fracture involves the joints, there is the potential for long-term consequences, such as arthritis and chronic pain.

How Do Calcaneal Fractures Occur?

Most calcaneal fractures are the result of a traumatic event—most commonly, falling from a height, such as a ladder, or being in an automobile accident where the heel is crushed against the floorboard. Calcaneal fractures can also occur with other types of injuries, such as an ankle sprain. A smaller number of calcaneal fractures are stress fractures, caused by overuse or repetitive stress on the heel bone.

Types of Calcaneal Fractures

Fractures of the calcaneus may or may not involve the subtalar and surrounding joints.

Fractures involving the joints (intra-articular fractures) are the most severe calcaneal fractures and include damage to the cartilage (the connective tissue between two bones). The outlook for recovery depends on how severely the calcaneus was crushed at the time of injury.

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Fractures that do not involve the joint (extra-articular fractures) include:

  • Those caused by trauma, such as avulsion fractures (in which a piece of bone is pulled off of the calcaneus by the Achilles tendon or a ligament) or crush injuries resulting in multiple fracture fragments
  • Stress fractures caused by overuse or mild injury

The severity and treatment of extra-articular fractures depend on their location and size.

Signs and Symptoms

Calcaneal fractures produce different signs and symptoms, depending on whether they are traumatic or stress fractures. The signs and symptoms of traumatic fractures may include:

  • Sudden pain in the heel and inability to bear weight on that foot
  • Swelling in the heel area
  • Bruising of the heel and ankle

The signs and symptoms of stress fractures may include:

  • Generalized pain in the heel area that usually develops slowly (over several days to weeks)
  • Swelling in the heel area

Diagnosis

To diagnose and evaluate a calcaneal fracture, the foot and ankle surgeon will ask questions about how the injury occurred, examine the affected foot and ankle and order x-rays. In addition, advanced imaging tests are commonly required.

Treatment

Treatment of calcaneal fractures is dictated by the type of fracture and extent of the injury. The foot and ankle surgeon will discuss with the patient the best treatment—whether surgical or nonsurgical—for the fracture.

For some fractures, nonsurgical treatments may be used. These include:

  • Rest, ice, compression and elevation (RICE). Rest (staying off the injured foot) is needed to allow the fracture to heal. Ice reduces swelling and pain; apply a bag of ice covered with a thin towel to the affected area. Compression (wrapping the foot in an elastic bandage or wearing a compression stocking) and elevation (keeping the foot even with or slightly above the heart level) also reduce the swelling.
  • Sometimes the foot is placed in a cast or cast boot to keep the fractured bone from moving. Crutches may be needed to avoid weightbearing. For traumatic fractures, treatment often involves surgery to reconstruct the joint, or in severe cases, to fuse the joint. The surgeon will choose the best surgical approach for the patient.

Rehabilitation

Whether the treatment for a calcaneal fracture has been surgical or nonsurgical, physical therapy often plays a key role in regaining strength and restoring function.

Complications of Calcaneal Fractures

Calcaneal fractures can be serious injuries that may produce lifelong problems. Arthritis, stiffness and pain in the joint frequently develop. Sometimes the fractured bone fails to heal in the proper position. Other possible long-term consequences of calcaneal fractures are decreased ankle motion and walking with a limp due to collapse of the heel bone and loss of length in the leg. Patients often require additional surgery and/or long-term or permanent use of a brace or an orthotic device (arch support) to help manage these complications.

Bone Healing

How Does a Bone Heal?

All broken bones go through the same healing process. This is true whether a bone has been cut as part of a surgical procedure or fractured through an injury.

The bone healing process has three overlapping stages: inflammation, bone production and bone remodeling.

  • Inflammation starts immediately after the bone is fractured and lasts for several days. When the bone is fractured, there is bleeding into the area, leading to inflammation and clotting of blood at the fracture site. This provides the initial structural stability and framework for producing new bone

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  • Bone production begins when the clotted blood formed by inflammation is replaced with fibrous tissue and cartilage (known as soft callus). As healing progresses, the soft callus is replaced with hard bone (known as hard callus), which is visible on x-rays several weeks after the fracture.

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Bone remodeling, the final phase of bone healing, goes on for several months. In remodeling, bone continues to form and becomes compact, returning to its original shape. In addition, blood circulation in the area improves. Once adequate bone healing has occurred, weightbearing (such as standing or walking) encourages bone remodeling.

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How Long Does Bone Healing Take?

Bone generally takes 6 to 12 weeks to heal to a significant degree. In general, children’s bones heal faster than those of adults. The foot and ankle surgeon will determine when the patient is ready to bear weight on the area. This will depend on the location and severity of the fracture, the type of surgical procedure performed and other considerations.

What Helps Promote Bone Healing?

If a bone will be cut during a planned surgical procedure, some steps can be taken pre- and postoperatively to help optimize healing. The surgeon may offer advice on diet and nutritional supplements that are essential to bone growth. Smoking cessation and adequate control of blood sugar levels in people living with diabetes are important. Smoking and high glucose levels interfere with bone healing.

For all patients with fractured bones, immobilization is a critical part of treatment because any movement of bone fragments slows down the initial healing process. Depending on the type of fracture or surgical procedure, the surgeon may use some form of fixation (such as screws, plates or wires) on the fractured bone and/or a cast to keep the bone from moving. During the immobilization period, weightbearing is restricted as instructed by the surgeon.

Once the bone is adequately healed, physical therapy often plays a key role in rehabilitation. An exercise program designed for the patient can help in regaining strength and balance and can assist in returning to normal activities.

What Can Hinder Bone Healing?

A wide variety of factors can slow down the healing process. These include:

  • Movement of the bone fragments; weightbearing too soon
  • Smoking, which constricts the blood vessels and decreases circulation
  • Medical conditions, such as diabetes, hormone-related problems or vascular disease
  • Some medications, such as corticosteroids and other immunosuppressants
  • Fractures that are severe, complicated or become infected
  • Advanced age
  • Poor nutrition or impaired metabolism
  • Low levels of calcium and vitamin D

How Can Slow Healing Be Treated?

If the bone is not healing as well as expected or fails to heal, the foot and ankle surgeon can choose from a variety of treatment options to enhance bone growth, such as continued immobilization for a longer period, bone stimulation or surgery with bone grafting or use of bone growth proteins.