FOOT FRACTURE

CALCANEAL FRACTURES

Calcaneal fractures are the most common fracture of the tarsal bones and represent 1%-2% of all fractures.  Of these fractures, roughly 75% are intra-articular in the posterior facet of the calcaneus.  These devastating injuries to the lower extremity usually occur as a result of high-energy trauma from falls or motor vehicle accidents causing axial loading. These fractures are often life-changing, and health outcomes have been found to be comparable to myocardial infarction and chronic renal disease.  Many challenges arise for surgeons because of early and late complications associated with intra-articular calcaneal fractures, and the optimal management of these fractures has been widely debated in the literature.  

Intra-articular calcaneal fractures are morbid injuries with well-documented complications associated with both operative and nonoperative management strategies. There appears to be some agreement that Sanders type I fractures are best managed nonoperatively, and that Sanders type IV fractures should be managed operatively with ORIF or primary subtalar fusion in the appropriate patient. Any open fracture or fracture pattern that places the soft tissue envelope at risk for necrosis, like the tongue-type fracture, should also undergo urgent surgical management. The optimal management of other fracture patterns within the Sanders and Essex-Lopresti classification schemes, however, remains a topic of debate.

Operative management appears to be beneficial in patients where anatomic restoration is possible, and recent literature has focused on minimally invasive approaches and trended toward improved outcomes with surgical management in comparison to nonoperative treatment. These surgical advancements in approaches have allowed for decreased wound and infectious complications in operative treatment of intra-articular calcaneal fractures without compromise of patient outcomes. At this time, however, further studies are needed to clarify specific operative indications and to determine the ideal surgical approach for displaced intra-articular calcaneal fractures when operative management is indicated.

LISFRANC INJURIES

The term “Lisfranc injuries” refers to a range of midfoot and tarsometatarsal (TMT) joint lesion that can vary from a simple single joint injury to a complex lesion that disrupts multiple different joints with multiple fractures, depending on the severity of the trauma. The name is attributed to a French surgeon of the Napoleonic era, which in 1825 was the first to describe injuries and amputations at this level of the foot.

Lisfranc injuries appear rare and account for 0.2% of all fractures, with approximately 20% of cases remaining undiagnosed or diagnosed late.

Lisfranc joint injuries are more frequent in the third decade of life and men are 2 to 4 times more likely than women to incur these injuries, possibly because they participate more frequently in high-speed activities. High-energy injuries are more common than low-energy injuries which in most cases involve sports activities, usually occurring during football, gymnastic and running. The two main mechanisms of injury are direct forces (crush injuries, fall from and height) and indirect forces (bending and torsion of the tarsus).

A thorough investigation of the mechanism of trauma and a clinical examination of the foot are essential. The exact mechanism of the injury must be ascertained, including foot position during trauma, direction of the force and the amount of energy involved.

Quickly identification and management of these injuries is crucial to reduce risk of progressive midfoot instability, arch collapse, forefoot abduction, or post-traumatic osteoarthritis (OA) that results in stiffness, chronic pain, and dysfunction of the foot and ankle complex.

Lisfranc complex injuries are a spectrum of injuries of the TMT joints, ranging from purely ligamentous sprains, usually occurring in athletes, to fracture dislocations, commonly a consequence of high-energy trauma.

5TH METATARSAL FRACTURES

Fractures of the fifth metatarsal are common injuries that must be recognized and treated appropriately to avoid poor clinical outcomes for the patient. The clinician must recognize all injury patterns of the fifth metatarsal and initiate the appropriate treatment plan or referral process to avoid potential complications. Classification of these fractures is crucial to making management decisions. Metaphyseal arteries and diaphyseal nutrient arteries provide the blood supply to the fifth metatarsal base. A vascular watershed area exists in zone 2, contributing to the high nonunion rates seen with these fractures. This activity describes the evaluation and management of fractures of the fifth metatarsal, illustrates the zones of proximal base fractures and more distal fractures, and examines the interprofessional team's role in evaluating and treating patients with these fractures.

STRESS FRACTURES

Stress fractures account for between 1% and 20% of athletic injuries, with 80% of stress fractures in the lower extremity. Stress fractures of the lower extremity are common injuries among individuals who participate in endurance, high load-bearing activities such as running, military and aerobic exercise and therefore require practitioner expertise in diagnosis and management. Accurate diagnosis for stress fractures is dependent on the anatomical area. Anatomical regions such as the pelvis, sacrum, and metatarsals offer challenges due to difficulty differentiating pathologies with common symptoms. Special tests and treatment regimes, however, are similar among most stress fractures with resolution between 4 weeks to a year. The most difficult aspect of stress fracture treatment entails mitigating internal and external risk factors. Practitioners should address ongoing risk factors to minimize recurrence.