What is the management approach for nonhealing fractures of the foot?

Management of Nonhealing Fractures of the Foot

The management of nonhealing fractures of the foot requires an interdisciplinary care team approach with revascularization, appropriate offloading, infection control, and wound care as the cornerstones of treatment.

Initial Assessment and Diagnosis

• Evaluate vascular status:

  • Check pedal pulses, ankle-brachial index (ABI <0.9), toe-brachial index (TBI <0.7), toe pressure (<30 mmHg), and transcutaneous oxygen pressure (TcPO2 <25 mmHg) 1
  • Look for signs of ischemia: pale, cool extremities, delayed capillary refill, rest pain, gangrene or necrotic tissue 1

• Rule out infection:

  • Assess for clinical signs of infection (erythema, warmth, purulent drainage)
  • Consider deep tissue biopsy for microbiology and histopathology (>5 PMNs/HPF confirms infection) 2

• Imaging:

  • Obtain weight-bearing radiographs (anteroposterior, lateral, and oblique views) 3
  • Consider advanced imaging (MRI, CT) to evaluate extent of nonunion and surrounding soft tissue

Treatment Algorithm

1. Vascular Assessment and Revascularization

• Urgent vascular assessment is the first priority for nonhealing foot fractures 1
• Revascularization should be performed when possible to minimize tissue loss 2
• Endovascular procedures are recommended to establish in-line blood flow to the foot in patients with nonhealing wounds or gangrene 2
• Consider surgical revascularization based on lesion characteristics, patient comorbidities, and patient preference 2

2. Offloading and Immobilization

• For nonhealing fractures, a non-removable knee-high offloading device (total contact cast) is the first-line treatment 2
• Alternative: pre-fabricated knee-high walker rendered irremovable with cast or tie wrap 2
• For patients who cannot tolerate non-removable devices, a removable knee-high device can be considered, though this may lead to delayed healing 2
• Duration of immobilization:
  • Metatarsal shaft fractures: 4-6 weeks in short leg walking cast or boot 4
  • Jones fractures: 6-8 weeks in non-weight-bearing cast (healing may take 10-12 weeks) 4
  • Great toe fractures: 2-3 weeks in walking boot with toe plate, then 3-4 weeks in rigid-sole shoe 4
  • Lesser toe fractures: 4-6 weeks with buddy taping and rigid-sole shoe 4

3. Infection Control

• Prompt management of foot infection with antibiotics and surgical debridement is essential 2
• For osteomyelitis, consider surgical debridement and appropriate antibiotic therapy 2
• Negative pressure wound therapy (NPWT) may be beneficial after debridement when primary or delayed secondary closure is not feasible 2

4. Surgical Management for Persistent Nonunion

• Consider surgical intervention when:

  • Fracture shows no signs of healing despite adequate conservative treatment
  • Instability of foot and ankle joints is present
  • Deformity with high risk of ulceration develops
  • Pain cannot be adequately controlled with conservative measures 2

• Surgical options include:

  • Debridement and internal fixation
  • Bone grafting for osseous defects
  • External fixation for complex cases with poor soft tissue or infection 5
  • Arthrodesis for joint involvement

5. Wound Care

• Wound care should be performed with the goal of complete wound healing 2
• Sharp debridement is preferred to remove slough, necrotic tissue, and surrounding callus 1
• Select appropriate dressings based on exudate control, patient comfort, and cost 1
• Consider advanced therapies for non-healing wounds:
  • NPWT for post-operative wounds 1
  • Hyperbaric oxygen therapy may be considered for nonhealing ischemic ulcers, though evidence is limited 2

Special Considerations

• Charcot neuro-osteoarthropathy (CNO): Requires more aggressive offloading and may benefit from early surgical intervention if severe instability or deformity is present 2

• Peripheral Arterial Disease (PAD): Never attribute poor healing solely to "small vessel disease" or microangiopathy; always pursue vascular assessment and intervention 1

• Diabetic patients: Have higher risk of complications and require more intensive monitoring and care coordination 2

Monitoring and Follow-up

• Regular wound assessment to evaluate healing progress
• Periodic radiographic evaluation to assess fracture healing
• Adjust treatment plan if no improvement is observed within 4-6 weeks
• Continue offloading until complete fracture healing is confirmed

Common Pitfalls to Avoid

1. Delaying vascular assessment while treating infection 1
2. Inadequate offloading or patient non-adherence to immobilization
3. Attributing poor healing to "small vessel disease" without proper vascular evaluation 1
4. Failing to recognize and address infection
5. Inadequate surgical debridement when indicated
6. Not considering nutritional status and vitamin deficiencies (e.g., vitamin K) that may affect bone healing 6

By following this comprehensive approach with emphasis on revascularization, appropriate offloading, infection control, and wound care, most nonhealing foot fractures can be successfully managed with improved outcomes in terms of morbidity, mortality, and quality of life.