Foot and Ankle Fractures
Fractures of the foot and ankle include the anterior process of the calcaneus, fractures of the fifth metatarsal and toe fractures.
It is important to talk to the patient
about the mechanism of injury. Did the
patient twist their ankle on a 3 cm uneven piece of pavement? Did they slip on
a wet surface in a supermarket? Did they fall 10 m out of a building? Was their
foot run over by a 10 ton truck? Did they fall off a horse? The
former represent low energy injuries and the latter high energy injuries. Most patients with foot and ankle fractures do not need an MRI scan
examining a patient with a fracture the clinical signs are: swelling, deformity and point tenderness over bone.
fractures are extremely common and usually result from a twisting injury. They
are often associated with sprains. As indicated above a fractured ankle
sustained twisting it on a footpath is different to an ankle fracture sustained
by falling 10 m out of a building.
fractures are broadly classified as being below, at or above the syndesmosis.
- Fractures below the syndesmosis will generally heal nonsurgically.
- Fractures at
the syndesmosis sometimes require surgery and
- Fractures above the syndesmosis
nearly always require surgery.
sprains often result in avulsion fractures from the distal fibula, lateral wall
of the talus, lateral wall of the calcaneus or the anterior process of the
calcaneus. These avulsion fractures are generally small and are generally
managed as ankle sprains would be with the customary rest, ice, compression,
fragments sometimes need to be reattached. The best way to image ankle
fractures in this situation is a fine cut CT scan.
Fractures of the fifth metatarsal:
fractures frequently accompany ankle sprains. Again when examining a patient
with an ankle sprain it is very important to palpate the fifth metatarsal for
tenderness over bone.
speaking fifth metatarsal fractures occur in the tuberosity proximally, the
junction of the metastasis and the diaphysis and in the distal shaft.
fractures will generally become pain free whether or not the fracture is
displaced and whether or not the fracture unites. Indeed a painless
pseudarthrosis with fibrous tissue bridging the gap will usually be painless
and not require any further treatment.
- The long
spiral fracture of the fifth metatarsal sometimes known as the dancer's
fracture has a somewhat sinister radiological appearance but generally unites
- The fracture
which generally causes the most trouble is the fracture at the
diaphysis/metaphysis junction. This is known as the Jones' fracture. This
fracture can either occur as an acute fracture or as a stress fracture. The
optimal management is six weeks in plaster nonweight bearing. Unfortunately
even with this treatment there is a 25% incidence of non-union.
- I usually
consider open reduction internal fixation in the high demand patient or the
athlete which increases the chance of union to approximately 90% and
substantially decreases the risk of re-fracture.
Toe fractures particularly fifth toe fractures are common
and often result from getting the toe caught on a piece of furniture.
If the toe is reasonably straight and the fracture does not
involve the joint the patient will usually make an uneventful recovery but
needs to be warned that the toe will swell for up to 6 months. This is
particularly an issue in ladies who want to wear fashionable shoes!
If the toe is not straight they can generally be
straightened in the office under local anaesthesia and then buddy taped to the
adjacent toe for a period of 3 to 6 weeks.
In the great toe intra-articular fractures which are
displaced sometimes need open reduction internal fixation to prevent the
development of arthritis.