Author: Henry R Guly / Editor: Jason M Kendall / Reviewer: Jennifer Lockwood / Codes: C3AP2a, CAP33, HAP19 / Published: 31/10/2017 / Review Date: 31/10/2020
Foot injuries are common and because they affect mobility, they can have significant effects on a patients life and so are important. Unfortunately there is very little evidence for the treatment of these conditions. There are no current relevant Cochrane reviews, NICE nor SIGN guidelines. In a standard orthopaedic textbook of 781 pages, only 11 are devoted to foot fractures .
If the mechanism of injury suggests that there may be other multisystem injuries (eg following a road crash), it is important to do a full assessment to exclude other, more serious, injuries before turning attention to the foot as part of the secondary survey. However, if there are life-threatening injuries, it is easy for foot injuries to be overlooked, sometimes with serious consequences.
The mechanism of injury is of vital importance and may give valuable clues towards the diagnosis of injuries to the feet and other associated injuries.
- An inversion injury of the ankle may cause an ankle injury but may also cause a fracture at the base of the 5th metatarsal.
- A fall from a height onto the heel typically causes a fractured calcaneum. Patients may land on both heels so bilateral fractured calcaneum is not uncommon and the force that causes a fracture of the calcaneum may also cause a fracture of the lumbar spine. If there is any suspicion of back injury (or if a back injury cannot be ruled out because of distracting pain) the lumbar and thoracic spine must also be X-rayed.
- Dropping a weight onto the foot may cause a fracture but is unlikely to cause a dislocation whereas a stubbed toe may cause either a fracture or a dislocation.
- With major forces, one should expect serious injuries but some of these may be subtle on plain X-ray; CT may be required to clarify the presence / extent of injury if clinical suspicion is high but the X-ray appears normal
As with any other injury, note any past medical history that might influence the presentation or management of a foot injury e.g.
- Diabetic neuropathy may predispose to a neuropathic arthropathy
- Previous foot injuries or congenital foot deformity
- Conditions that might affect giving an anaesthetic
Examination will consist of:
- Look for deformity, bruising, swelling scars etc
- Feel for deformity, point of maximum tenderness
- Move examine for movement at all the joints subtalar, midtarsal, toes
- Function can the patient walk? Examine their gait
- Test for neurovascular function
- Examine the ankle
The history and mechanism of injury will give valuable clues as to the diagnosis
As noted above, inversion of the ankle may be associated with a foot injury. The Ottawa foot rules  (see Figure 1) give evidence-based advice on whom to X-ray. These state that in ankle injuries, foot X-rays are only required if:
There is pain in the midfoot zone and there is either:
1. Bone tenderness at C (the base of the 5th metatarsal) or
2. Bone tenderness at D (the navicular) or
3. Inability to weight-bear (4 consecutive steps) both immediately and in the ED.
Figure 1. Ottawa Ankle Rules
A standard foot series of X-rays consist of an AP, an oblique and a lateral of the foot. However for forefoot injuries, an AP and oblique are usually adequate as on a lateral X-ray of the foot, the metatarsals and the toes overlap and this obscures details. However, occasionally the lateral X-ray may be required to demonstrate any displacement of a fractured metatarsal (especially the 1st).
Suspected talar injuries will require ankle X-rays in addition to foot X-rays
The lateral X-ray is most useful for looking at the hind foot and mid foot and these areas are also well shown on a lateral ankle x-ray so if an ankle X-ray series has been obtained, a lateral foot x-ray will rarely be required
Fractures (and other abnormalities) always show best if the X-ray is centred over the abnormality so, for a toe injury, request X-rays of the toes rather than a foot X-ray.
Calcaneal fractures may not be easy to see on ankle or foot X-rays so if a fracture is suspected, request calcaneal views (a lateral view of the calcaneum or ankle and an axial view of the calcaneum).
Even if you forget to request specific views, if you state the injury you suspect or want to exclude, the radiographer should do the X-rays that you need.
Computed tomography (CT)
CT will often be needed to assess the extent of calcaneal and talar fractures and also mid-tarsal and tarso-metatarsal injuries. CT may also be useful if the diagnosis is not obvious.
When requesting X-rays, do not write: -Fracture X-ray foot but specify what injury you are expecting and the radiographer should do the views that are most likely to show that injury
As discussed above, fractures may not be obvious on the lateral X-ray and it is important to obtain an axial view.
On the lateral X-ray, look at Bohlers angle (Figure 2) which should be approximately 1400. Flattening of this angle suggests a fracture.
Figure 2: Bohlers angle
Fractures of the calcaneum are the commonest tarsal fractures and usually classified into:
- Extra-articular not involving the subtalar joint
- Intra-articular fractures involving the subtalar joint
(i) Extra-articular fractures
They include fractures of:
- The medial tubercle (figure 3a),
- The anterior process (figure 3b),
- The tuberosity (figure 3c),
- The sustenaculum tali (figure 3d)
- The body of the calcaneum posterior to the subtalar joint (figure 3e).
Figure 3: Extra-articular fractures of the calcaneum
Treatment is usually conservative unless there is significant displacement, in which case open reduction and internal fixation (ORIF) will be undertaken.
Treatment in the ED includes:
- If there is any doubt about whether the fracture involves the subtalar joint, a CT may be requested.
- If displaced, refer for orthopaedic opinion. Otherwise:
- Support bandage (eg wool and crepe) or below knee plaster of Paris. It would be expected that patients would regain movement faster without POP but there is no evidence for this 
- Advice on elevation
- Referral to fracture clinic for follow up.
Avulsion fractures of the Achilles tendon will need ORIF.
These fractures are relatively minor and have a good prognosis
(i) Intra-articular fractures
Intra-articular calcaneal fractures are usually caused by a fall from a height onto the heel. In older patients with osteoporosis, the height may be as little as half a metre. Extra-articular fractures of the body and the medial tubercle are also caused by the same mechanism, though with lesser degrees of force.
Bilateral fractures are common and, as discussed above, calcaneal fractures may be associated with lumbar spine fractures.
There are several patterns of fracture but the exact patterns need not be known by emergency physicians as all these injuries will be referred to orthopaedic surgeons for further management.
Figure 4: Intra-articular fracture of the calcaneum.
Figure 4 shows an intra-articular fracture of the calcaneum; the bone texture is abnormal and there are lucencies suggestive of a fracture but there are no obvious breaks in the cortex. Bohlers angle is grossly flattened.
In the ED patients should receive analgesia and the foot should be elevated. Patients will usually be admitted and investigated further by CT. There are a variety of treatment options including reconstructive surgery.
There is usually severe disruption of the subtalar joint and stiffness and arthritis of this joint requiring further surgery is very common.
- If you suspect a fractured calcaneum, ask for specific calcaneal views.
- When looking at a lateral ankle or foot X-ray, always evaluate Bohlers angle
Avulsion fractures of the talus and fractures of the talar dome are classified as ankle injuries and are discussed in a different session.
Fractures of the body of the talus are relatively uncommon injuries and are normally caused by major forces. The common site of a fracture is across the waist and this is caused by forced hyper-dorsiflexion of the ankle. The commonest cause for this is a road crash in which the car-drivers foot is forced backwards in a head-on collision. Injuries can also occur in a fall from a height.
Fractures of the neck of the talus are classified as:
Type I: undisplaced (see Figure 5)
Type II: displaced (however little) and associated with subluxation or dislocation of the subtalar joint (see figure 6)
Type III: displaced with dislocation of the talus from the ankle joint
Undisplaced fractures are easily missed and displaced fractures may be thought to be undisplaced and so CT is valuable in the assessment of talar injuries. As they are high velocity injuries, they may be associated with life-threatening injuries of the head and trunk and may be overlooked.
Dislocation of the talus can occur with or without an associated fracture.
Figure 5. Undisplaced fracture of the waist of the talus (type 1)
Figure 6. Displaced fracture of the talus (type II)
Truly undisplaced fractures can be treated in a below knee POP.
All others need to be referred to an orthopaedic surgeon as an anatomical reduction is needed and this usually requires ORIF. If the skin is tight over the fracture, this is urgent.
The major complication of these injuries is avascular necrosis of the proximal part of the bone.
Figure 7. Fracture navicular
Isolated fractures of the navicular are uncommon. If they are undisplaced, they will normally be treated conservatively; displaced fractures will need an orthopaedic opinion for consideration of ORIF.
Fractures of the navicular may occur in association with dislocations of the mid-foot. Any significant injury in this area requires a lateral X-ray of the foot in addition to normal foot X-rays. If there is suspicion of a dislocation, CT evaluation is required.
Minor avulsion fractures are common and usually require no specific treatment.
Most fractures are undisplaced and will be treated conservatively. Displaced fractures may be part of a more complex foot injury and will need an orthopaedic review.
The subtalar joint is the joint between the talus and the calcaneum. If this joint dislocates, the forefoot stays attached to the calcaneum and so the talo-navicular joint also dislocates (see figure 8). Subtalar dislocation occurs in excessive inversion or eversion and can occur medially or laterally. It may be associated with a fracture of the lateral malleolus.
Figure 8. Lateral subtalar dislocation (and fracture of the lateral malleolus)
Ideally the ankle and foot should be X-rayed to confirm the diagnosis. However if there is neurovascular impairment or if the skin is stretched and there is concern that tightness of the skin may risk skin necrosis, it is common practice to try to reduce significantly displaced ankle and foot injuries before X-ray. If a displaced fracture is reduced before X-ray, the fracture is still visible and so a diagnosis is still possible but if a dislocation is reduced before X-ray, the subsequent X-ray may be normal and it may be difficult to establish the true diagnosis.
These injuries should be reduced under sedation or general anaesthesia and immobilised in a below knee POP. They should be followed up by an orthopaedic surgeon.
In a midtarsal dislocation, the cuboid and navicular dislocate from the talus and calcaneum. The joint may dislocate medially (with an adduction force) or laterally (with an abduction force)
These dislocations may be associated with fractures of the tarsal bones (particularly the navicular) or with smaller avulsion fractures.
In major foot injuries always obtain a lateral X-ray of the foot in addition to the usual AP and oblique views. Similarly if standard X-rays show a fracture of the navicular, obtain a lateral X-ray of the foot.
If there is a significant mechanism of injury and the patient clinically has a fracture with much swelling but the X-rays appear normal or relatively normal, consider doing a CT.
Tarso-metatarsal dislocation (Lisfranc injury)
The tarso-metatarsal joint is also known as the Lisfranc joint and so dislocations at this site are also known as Lisfranc injuries.
These are commonly missed but the clue to their diagnosis is abnormalities in the alignment of the metatarsals with the tarsal bones. Figure 9 shows how the medial border of the 2nd MT normally align with the medial border of the intermediate cuneiform on the AP view and the medial border of the 4th MT should align with the medial border of the cuboid on the oblique view.
Figure 10 shows a severe tarso-metatarsal dislocation with severe misalignment and at least three bony fragments. Fig 11 shows a less obvious tarso-metatarsal dislocation with a small step between the base of the 2nd metatarsal and the intermediate cuneiform.
Figure 9: Normal alignment between tarsus and metatarsals
Figure 10: Severe tarso-metatarsal dislocation
Figure 11: Subtle Lisfranc injury
These injuries need orthopaedic referral. Most will be investigated with a CT and require internal fixation.
Not all injuries at this joint are obvious on initial X-rays. If it is suspected clinically but X-rays are normal, the patient should be kept under review and consideration given for a CT.
Fractures of the 5th metatarsal
Fractures of the 5th metatarsal base in association with an inversion injury of the ankle are avulsion fractures occurring at the insertion of the tendon of peroneus brevis.
They are normally treated symptomatically with either a supportive bandage or plaster, with or without crutches (depending on the patients mobility). Only one study (of low quality) has adequately compared plaster and supportive bandaging. This suggests that there is no difference in pain or time to bony union but that support bandaging significantly shortens the time to full activity and so is recommended. 
Most fractures heal quickly but occasionally go to non-union. This only needs treatment if it is symptomatic.
These fractures must also be differentiated from fractures at the base of the shaft. These are usually stress fractures and are commonly called Jones fractures though they can occur as a result of direct trauma. These are important as there is a significant incidence of non-union and so they are normally treated in plaster and should be referred for orthopaedic follow-up.
The apophysis at the base of the 5th metatarsal in children may be mistaken for a fracture. However the apophyseal line is longitudinal (parallel to the metatarsal see figure 12) whereas fractures are transverse (perpendicular to the metatarsal). The apophysis may be fragmented i.e. an apophysis and a fracture can co-exist.
Fig 12: A normal apophysis at the base of the 5th metatarsal in a child.
Fractures of the shaft of the metatarsal are treated symptomatically
Fractures of other metatarsals
Fractures of a single metatarsal (2nd, 3rd or 4th) are usually well splinted by the other, intact, metatarsals and require symptomatic treatment only.
However fractures of the 1st metatarsal may displace and need internal fixation.
If there are multiple metatarsal fractures, this allows each fracture to displace. These patients need orthopaedic admission both for elevation and treatment of the associated soft tissue swelling and for consideration of internal fixation of the fractures.
Fractures at the bases of the metatarsals (except for 5th) may be associated with injuries of the tarso-metatarsal joint.
Most toe fractures will be caused either by dropping a weight on the foot or by stubbing the toe. An undisplaced fracture requires no specific treatment but will usually be treated with neighbour strapping for a few weeks and advice on analgesia and footwear. Most patients seem more comfortable in sandals but some prefer wearing walking boots or similar as they are less likely to knock their toe.
Displaced fractures may require manipulation followed by neighbour strapping.
Displaced fractures of the big toe are more serious than injuries of the other toes. These may need internal fixation.
It has been argued that X-rays of clinically undisplaced injuries of the toe are unnecessary as they do not alter treatment. This is only true as long as the toe is examined carefully as it is important not to miss a dislocation of the toe as these need reduction.
A subungual haematoma is usually caused by a weight falling onto the toe which may also cause a fracture. The pressure from it often causes significant pain and this can be significantly relieved by trephining the nail to allow the release of blood. However there is no evidence that this treatment is better than no treatment. 
It is sometimes argued that patients with an underlying fracture should be given antibiotics as the act of trephining converts a closed fracture to an open one. There is no evidence to support this approach 
Dislocation of the toes
Dislocations usually occur at the metatarso-phalangeal joint or the inter-phalangeal joint of the big toe. They should be reduced under local anaesthesia and a post reduction X-ray obtained.
Tendon and nerve injuries should be examined for in any laceration around the foot and the ankle.
Foreign body (FB) in foot
People who walk in bare feet may tread on a sharp object (eg a needle or broken glass) and present with a possible foreign body on the sole of the foot. If there is any suspicion of a foreign body, an X-ray should be requested with a marker on the skin to help to localise it. Non radio-lucent FBs may be localised by ultrasound. However a normal ultrasound does not completely exclude a FB. This may present as a painful foot with no history of trauma.
If a foreign body is demonstrated, it will usually need to be removed but this can be difficult. If the foreign body can be seen or felt, it can be removed under local anaesthesia. If it cant be seen or felt, the inexperienced doctor should ask advice before trying to remove it. Undoubtedly the easiest way to remove a foreign body is under general anaesthesia with the use of a tourniquet and an image intensifier but this usually requires referral to an orthopaedic surgeon. An experienced doctor may elect to remove a foreign body in the ED under some type of local anaesthesia (eg a foot block).
If there is more than one FB, the foot should be X-rayed after removal to ensure that there is no remaining FB.
Puncture wounds of the foot are common. A frequent presentation is the patient who treads on a nail sticking up through a plank of wood. This penetrates the shoe and goes into the sole of the foot. There appears to be a significant risk of infection, particularly as the depths of the wound cannot be fully cleaned. Osteomyelitis is not unknown if the nail penetrates into bone. The wound should be cleaned as much as possible and dressed. If the hole is large, it should be irrigated. Tetanus prophylaxis should be provided. There are many opinions but currently no definitive evidence as to whether antibiotics should be used to try to prevent infection. 
Safety pearls and Pitfalls
- Calcaneal fractures may be difficult to diagnose on standard foot and ankle X-rays: if suspected based on the mechanism of injury, request specific calcaneal views.
- In patients with a calcaneal fracture, beware of associated injuries (eg. lumbar spine fracture). Always examine the back and X-ray if required.
- In patients with major trauma and life-threatening injuries, it is easy for serious foot injuries to be overlooked.
- Tarso-metatarsal injuries are often missed. Look for the alignment of the metatarsals on the tarsal bones. Fractures at the bases of the metatarsals may be associated with this joint injury. If in doubt, request a CT.
- The apophysis at the base of the 5th metatarsal in children may be mistaken for a fracture. However the apophyseal line is longitudinal whereas fractures are transverse.
- Solomon L, Warwick DJ, Nayagam S. Apleys System of Orthopaedics and Fractures 8th Edition. 2001. Arnold. London
- Stiell IG, Greenberg GH, McKnight RD, Nair RC, McDowell I, Worthington JR. A study to develop clinical decision rules for the use of radiography in acute ankle injuries. Ann Emerg Med. 1992;21:384-90.
- May G. In undisplaced, extra-articular calcaneal fracture is the use of a below knee POP associated with longer rehab period. 2006 www.bestbets.org/bets/bet.php?id=1309. accessed 16.3.09
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- Harrison M, Thomas M. 2000. Antibiotics after puncture wounds to the foot. http://www.bestbets.org/bets/bet.php?id=175 accessed 18.6.09