FOOT INJURIES

Talus fractures

Talar neck fractures result from an axial load which forces the foot into dorsiflexion. The neck of the talus is pushed against the anterior tibia, fracturing the neck (Figure 18.59). Continuation of this force produces a dislocation of the subtalar joint as the body of the talus extrudes posterior medially from the ankle joint.

Figure 18.59

Evaluation

Diagnosis is based on a history of a dorsiflexion injury, with swelling and pain about the ankle and hind foot. Obtain ankle and foot X-rays to confirm the location and extent of the fracture.

Treatment

Treat minimally displaced fractures in a splint followed by a short leg non-weight bearing cast for 6–8 weeks.

Reduce displaced fractures with gentle longitudinal traction, pulling the heel forward and dorsiflexing the foot. Next, evert the foot and bring it into plantar flexion to align the major fragments. Apply a short leg cast.

If the talus is dislocated, apply direct pressure over the extruded fragment during the reduction manoeuvre.

Calcaneus fractures

Calcaneous fractures result from a vertical load force driving the talus downward into the subtalar joint and the body of the calcaneus (Figure 18.60).
Avulsion fractures of the calcaneal tuberosity are produced by the contracting Achilles tendon (Figure 18.61). These fractures usually do not enter the subtalar joint and have a better prognosis.

Figure 18.60

Figure 18.61

Evaluation
The physical examination reveals swelling and tenderness about the hind foot. X-rays will confirm diagnosis. Ask about low or mid-back pain and palpate the spine to evaluate for a vertebral fracture.

Treatment

Treat calcaneal fractures with a compression dressing, short leg splint and elevation.

Keep the patient from bearing weight on the affected limb. Encourage toe and knee motion while the limb is elevated. Begin partial weight bearing 6–8 weeks after the injury and full weight bearing, as tolerated, by 3 months.

Fracture dislocation of the tarsal-metatarsal joint (Lisfranc injuries)

The injury causes dislocation of the tarsal-metatarsal joints and fractures of the metatarsals and tarsal bones (Figure 18.62).

Figure 18.62

Evaluation

Deformity is often not evident because of the large amount of swelling present. On the X-ray, the medial borders of the second and fourth metatarsals should be aligned with the medial borders of the second cuneiform and the cuboid respectively.

Treatment

Perform a closed reduction to return the mid-foot to the anatomic position. Apply a short leg splint and ask the patient to keep the limb elevated. If reduction cannot be attained or maintained, consider stabilization with pins or screws.

Fractures of the metatarsals and toes

Evaluation

Clinical findings are tenderness and swelling. Deformity is not always evident. X-rays confirm diagnosis.

Overuse fractures (stress fractures) occur in the metatarsal bones. The patient has pain and tenderness but no history of acute trauma.

Treatment

::	Treat dislocations and angulated fractures with closed reduction. Immobilize metatarsal fractures in a firm bottom shoe or a short leg cast.
::	Treat toe fractures and dislocations by taping the toe to a normal adjacent toe (Figure 18.63).
Figure 18.63
::	Treat stress fractures by limiting the amount of time the patient spends on his/her feet. If necessary, use a firm shoe or cast until pain free.