What is the approach to managing fractures of the foot?

Approach to Foot Fractures

Foot fractures require immediate radiographic evaluation with three standard views (anteroposterior, lateral, and oblique), followed by treatment based on fracture location and stability, with most managed conservatively using immobilization and early rehabilitation, though specific fractures require surgical intervention. 1, 2

Initial Assessment and Diagnosis

Clinical Evaluation

• Assess for bony point tenderness, swelling, and ability to bear weight at the fracture site 2
• Apply the Ottawa foot rules to determine imaging necessity: obtain radiographs if there is point tenderness at the base of the fifth metatarsal, navicular bone, or inability to bear weight immediately and in the emergency department 1, 2
• Document pain severity using standardized pain scales before initiating treatment 3

Imaging Protocol

• Obtain anteroposterior, lateral, and oblique radiographs with weight-bearing views when possible to assess fracture stability 1, 2
• Weight-bearing radiographs are particularly important for Lisfranc injuries to detect tarsometatarsal joint widening that may be missed on non-weight-bearing films 2
• Consider CT imaging for complex fractures requiring surgical planning or when the full extent of osseous injury needs clarification 1

Pain Management

• Provide immediate analgesia before diagnostic investigations 3
• Use paracetamol as first-line regular analgesia unless contraindicated 3
• Add opioids cautiously, particularly in patients with renal dysfunction (approximately 40% of fracture patients have GFR <60 mL/min/1.73m²) 3
• Avoid NSAIDs in patients with renal impairment 3
• Consider femoral or fascia iliaca nerve blocks for proximal fractures when appropriate 3
• Early fracture fixation provides the most effective analgesia when surgical intervention is indicated 3, 1

Treatment by Fracture Location

Metatarsal Shaft Fractures

• Treat with short leg walking boot or hard-soled shoe for 3-6 weeks 2, 4
• Initial management includes posterior splint with avoidance of weight-bearing, then transition to walking boot after 4-6 weeks 4
• Weight-bearing is permitted as tolerated based on pain level and fracture stability 2

Fifth Metatarsal Fractures (Zone-Specific)

Tuberosity avulsion fractures (Zone 1):

• Apply compressive dressing acutely, then transition to short leg walking boot for 2 weeks 4
• Progress mobility as tolerated after initial immobilization 4

Jones fractures (Zone 2):

• Require at least 6-8 weeks in short leg non-weight-bearing cast due to high nonunion risk from poor blood supply 2, 4
• Healing time may extend to 10-12 weeks 4
• Consider early orthopedic referral given healing complications 2

Great Toe Fractures

• Treat with short leg walking boot or cast with toe plate for 2-3 weeks, followed by rigid-sole shoe for additional 3-4 weeks 4
• Pay close attention given the great toe's critical role in weight-bearing 2
• Follow specific guidelines for orthopedic referral 2

Lesser Toe Fractures

• Manage with buddy taping and rigid-sole shoe for 4-6 weeks 2, 4
• Most can be managed nonsurgically 2

Lisfranc Fractures

• These injuries are frequently overlooked—maintain high index of suspicion 2
• Obtain weight-bearing radiographs and look specifically for widening of the tarsometatarsal joint 2
• Require orthopedic referral for definitive management 2

Other Tarsal Bone Fractures

• Treat with short leg cast or boot for 4-6 weeks when nonsurgical management is appropriate 2

Rehabilitation Protocol

Early Phase (Post-Immobilization)

• Begin physical training and muscle strengthening immediately after immobilization removal to prevent stiffness and muscle atrophy 3, 1
• Implement impairment-based manual physical therapy targeting lower limb deficits 5
• Expect clinically meaningful improvements in function and range of motion within 4 weeks of starting rehabilitation 5

Long-Term Management

• Continue balance training and multidimensional fall prevention beyond initial healing 3
• Monitor for complications including arthritis, malunion/nonunion, infection, and compartment syndrome 2

Special Populations

Patients with Diabetes and Neuropathy

• Provide rigorous offloading to prevent complications, particularly in those with active Charcot neuro-osteoarthropathy 3, 1
• Consider surgical intervention for active Charcot with joint instability, high ulcer risk in offloading device, or inadequate pain control in total contact cast 3
• Recognize that surgery in Charcot patients carries significantly higher complication rates 3

Elderly Patients (>50 years) with Fragility Fractures

• Implement multidisciplinary orthogeriatric comanagement to improve functional outcomes and reduce mortality 3
• Perform comprehensive geriatric assessment including evaluation for malnutrition, electrolyte disturbances, anaemia, and cognitive function 3
• Systematically evaluate all patients ≥50 years for subsequent fracture risk using clinical risk factors, DXA, and vertebral imaging 3
• Initiate pharmacological treatment with agents proven to reduce vertebral, non-vertebral, and hip fractures 3

Surgical Indications

Refer for orthopedic consultation when:

• Fracture displacement compromises stability or weight-bearing function 3
• Lisfranc injury is identified 2
• Jones fracture in active patients or athletes 4
• Open fractures (immediate surgical debridement and fixation reduces hospitalization time without increasing infection risk) 6
• Great toe fractures with significant displacement 2

Monitoring and Follow-Up

• Obtain regular radiographic assessment to ensure proper healing and alignment 1
• Monitor for delayed union, particularly in fifth metatarsal base fractures 2, 4
• Assess for chronic complications including persistent swelling, stiffness, and functional impairment 6, 5