What about fractures of bones other than the toes?

Management of Non-Toe Foot Fractures

For fractures of bones other than the toes in the foot, radiography is the initial imaging modality of choice, followed by MRI for persistent pain with negative radiographs to evaluate for occult fractures and soft tissue injuries. 1

Initial Assessment and Imaging

Radiography

• Standard protocol should include three views: anteroposterior, lateral, and mortise views 2
• Weight-bearing views should be included when possible to assess fracture stability 2
• Initial radiographs may miss up to 10% of fractures that become visible only on follow-up imaging 1

When to Image

• Ottawa rules guide imaging decisions for ankle injuries but should not be used in:
  • Patients with peripheral neuropathy or neurological disorders
  • High-energy trauma mechanisms
  • Penetrating trauma
  • Polytrauma patients
  • Altered sensorium
  • Visible deformity or significant swelling 1, 2

Management by Fracture Location

Metatarsal Fractures

1. Metatarsal Shaft Fractures

   • Treatment: Short leg walking cast or boot for 4-6 weeks 3, 4
   • Weight-bearing: Progressive as tolerated after initial immobilization

2. Fifth Metatarsal Fractures (require special attention)

   • Tuberosity Avulsion Fracture:

     • Compressive dressing initially, then short leg walking boot for 2 weeks 4
     • Surgical intervention if displaced >2mm or involves >30% of cubometatarsal joint 5

   • Jones Fracture (at metaphyseal-diaphyseal junction):

     • Higher risk of nonunion due to poor blood supply
     • Requires 6-8 weeks in short leg non-weight-bearing cast 4
     • Healing time: 10-12 weeks
     • Consider surgical fixation for active patients or Torg type II/III fractures 5

Tarsal Bone Fractures

• Treatment: Short leg cast or boot for 4-6 weeks when nonsurgical treatment is indicated 3
• CT is essential for appropriate treatment planning in complex midfoot fractures 1
• In polytrauma patients, approximately 25% of midfoot fractures identified on CT are overlooked on radiographs 1

Advanced Imaging for Persistent Pain

MRI

• Indicated for persistent pain (>1 week) with negative radiographs 1, 2
• Sensitivity: 93-96%, specificity: 100% 2
• Allows visualization of bone marrow edema patterns, improving detection of occult fractures 1
• Particularly useful for detecting occult fractures of:
  • Navicular bone (79% of cuboid fractures in diabetic patients are radiographically occult) 1
  • Fifth metatarsal (Jones fracture) 1
  • Subtalar joint 1

Ultrasound

• Can detect occult foot fractures as cortical irregularities 1
• Most frequently identifies occult fractures in the calcaneus and metatarsals 1
• Less frequently detects fractures in the navicular, cuboid, and cuneiform bones 1

Indications for Referral

Immediate Referral

• Circulatory compromise
• Open fractures
• Significant soft tissue injury
• Fracture-dislocations
• Displaced intra-articular fractures 6

Delayed Referral

• Failure to respond to conservative treatment with persistent pain after 6-8 weeks 2
• Lisfranc injuries with widening of the tarsometatarsal joint 3

Complications to Monitor

• Approximately 20% of patients with fractures may develop chronic pain 2
• Potential complications include:
  • Osteonecrosis (especially with talus fractures)
  • Post-traumatic arthritis
  • Malunion or nonunion
  • Infection 2

Rehabilitation

• Early mobilization without cast immobilization leads to faster return to full activity (13-14 weeks post-surgery) 2
• Proprioceptive training is essential to prevent chronic instability 2
• Progressive weight bearing based on radiographic evidence of healing 2

By following this evidence-based approach to the management of non-toe foot fractures, you can optimize outcomes while minimizing complications and disability.