Assessment and Treatment of a Broken Foot
Radiography is the initial imaging modality of choice for assessing a suspected foot fracture, with standard three-view radiographs (anteroposterior, lateral, and oblique) recommended as the first-line diagnostic approach. 1
Initial Clinical Assessment
Ottawa Foot Rules
- Apply Ottawa Foot Rules to determine need for imaging:
- Pain in the midfoot zone AND
- Bone tenderness at the navicular, cuboid, or base of the fifth metatarsal OR
- Inability to bear weight for four steps immediately after injury 1
Exclusions to Ottawa Rules
Ottawa Rules should NOT be applied in these situations:
- Penetrating trauma or skin wounds
- Pregnancy
10 days after trauma
- Return visit for continued foot pain
- Polytrauma
- Altered mental status
- Neurologic abnormality affecting the foot (including diabetic neuropathy)
- Underlying bone disease 1
Diagnostic Imaging
First-Line Imaging
- Standard three-view radiographs (anteroposterior, lateral, and oblique) 1, 2
- Add weight-bearing views when possible, especially for suspected Lisfranc injuries 1
- Include both feet on AP radiographs to help detect subtle malalignment 1
Special Imaging Considerations
- For suspected calcaneal fractures: Add axial calcaneal view 1
- For suspected Lisfranc injury: AP view with 20° craniocaudal angulation 1
- For suspected foreign body: Radiographs for radiopaque objects (98% sensitivity); ultrasound for non-radiopaque objects like wood or plastic (90% sensitivity) 1
Advanced Imaging
- CT scan: For complex fractures, polytrauma patients, or midfoot injuries (detects 25% more midfoot fractures than radiographs in polytrauma) 1
- MRI: Not routinely used as first-line imaging but valuable for suspected soft tissue injuries 1
Treatment Approach by Fracture Type
Toe Fractures
- Most toe fractures: Buddy taping and rigid-sole shoe for 4-6 weeks 2, 3
- Great toe fractures: Short leg walking boot or cast with toe plate for 2-3 weeks, then rigid-sole shoe for 3-4 weeks (due to its important role in weight-bearing) 4, 3
- Referral indications for toe fractures:
- Circulatory compromise
- Open fractures
- Significant soft tissue injury
- Fracture-dislocations
- Displaced intra-articular fractures
- First toe fractures that are unstable or involve >25% of joint surface 3
Metatarsal Fractures
- Metatarsal shaft fractures: Short leg cast or boot for 3-6 weeks 2
- Fifth metatarsal tuberosity avulsion fracture: Compressive dressing initially, then short leg walking boot for 2 weeks 4
- Jones fracture (proximal fifth metatarsal): Short leg non-weight-bearing cast for 6-8 weeks (healing may take 10-12 weeks due to poor blood supply) 4
Lisfranc Injuries
- Often overlooked - look for widening of the tarsometatarsal joint on weight-bearing radiographs 2
- Unstable injuries typically require surgical referral 1
Other Tarsal Bone Fractures
- When nonsurgical treatment is indicated: Short leg cast or boot for 4-6 weeks 2
Rehabilitation Protocol
Early Phase (1-2 weeks)
- PRICE protocol: Protection, Rest, Ice, Compression, Elevation
- Ice for 15-20 minutes every 2-3 hours for first 48-72 hours 5
- Cover open wounds with clean dressing 5
Intermediate Phase (2-6 weeks)
- Progressive weight-bearing as tolerated in walking boot
- Consider assistive devices to reduce weight-bearing on affected limb
- Begin range of motion exercises when safe 5
Late Phase (6+ weeks)
- Strengthening exercises
- Proprioceptive training to prevent recurrent injury 5
Special Considerations
High-Risk Patients
- Diabetic patients: Higher complication risk (odds ratio 2.30) 5
- Peripheral vascular disease: Increased complication risk (odds ratio 1.65) 5
- Pediatric patients: Generally good prognosis with nonoperative treatment; older adolescents may need treatment similar to adults 6
Complications to Monitor
- Arthritis
- Infection
- Malunion or nonunion
- Compartment syndrome 2
Prevention of Recurrent Injury
- Ankle braces during high-risk activities
- Proprioceptive exercises (ankle disk training) 5
Remember that foot fractures can cause considerable residual disability and significantly affect quality of life, with 5-33% of patients still experiencing pain after 1 year 5, 7.