To whom should a patient with a foot fracture be referred for proper management and treatment, considering factors such as age, medical history, and fracture severity?

Foot Fracture Referral

Patients with foot fractures should be referred to an orthopaedic or trauma surgeon for acute fracture care, with additional multidisciplinary involvement including rheumatology or metabolic bone specialists for patients over 50 years with fragility fractures to address both immediate surgical needs and secondary fracture prevention. 1

Immediate Referral to Orthopaedic Surgery Required For:

• Open fractures with circulatory compromise or significant soft tissue injury 2
• Displaced intra-articular fractures requiring anatomic reduction 2, 3
• Fracture-dislocations including Lisfranc injuries (look for widening of tarsometatarsal joint on weight-bearing radiographs) 4, 3
• Jones fractures (proximal fifth metatarsal metaphyseal-diaphyseal junction) due to high nonunion risk requiring 6-8 weeks non-weight-bearing cast, potentially up to 10-12 weeks 5
• Great toe fractures that are unstable or involve >25% of joint surface 2
• Displaced fractures of the first toe requiring stabilization 2
• Chopart-Lisfranc combined fracture dislocations, which show significantly worse long-term outcomes and require early open reduction with internal fixation 3

Multidisciplinary Orthogeriatric Referral for Patients ≥50 Years:

All elderly patients with foot fractures require systematic coordination between orthopaedic surgeons and rheumatologists/metabolic bone specialists through a Fracture Liaison Service model. 1 This is critical because:

• Fragility fractures (including foot fractures in this age group) carry high subsequent fracture risk and increased mortality 6
• A dedicated coordinator (often a specialized nurse under supervision of orthopaedic surgeon, endocrinologist, or rheumatologist) should identify all elderly fracture patients, organize diagnostic investigations, and initiate osteoporosis treatment 1
• Orthogeriatric comanagement significantly reduces morbidity, mortality, and hospital length of stay 7, 6, 8

Comprehensive Preoperative Assessment Must Include:

• Chest X-ray, ECG, complete blood count, clotting studies, renal function 1, 8
• Nutritional status, electrolyte/volume status, anemia screening 7
• Cardiac and pulmonary comorbidities evaluation 1
• Cognitive function baseline assessment 7
• Complete medication review 7

Primary Care Management (No Referral Needed):

Stable, nondisplaced fractures can be managed by primary care physicians:

• Metatarsal shaft fractures: Initial posterior splint with non-weight-bearing, then short leg walking cast or boot for 4-6 weeks 5, 4
• Fifth metatarsal tuberosity avulsion fractures: Compressive dressing acutely, then short leg walking boot for 2 weeks with progressive mobility 5
• Lesser toe fractures: Buddy taping with rigid-sole shoe for 4-6 weeks 5, 4, 2
• Nondisplaced great toe fractures: Short leg walking boot or cast with toe plate for 2-3 weeks, then rigid-sole shoe for additional 3-4 weeks 5

Critical Pitfall to Avoid:

Do not miss Lisfranc injuries—these are frequently overlooked. Obtain weight-bearing radiographs and specifically look for widening of the tarsometatarsal joint. 4, 3 These require immediate orthopaedic referral as they have poor long-term outcomes without early anatomic reduction and stable internal fixation. 3

Secondary Fracture Prevention Pathway:

For all patients ≥50 years, initiate systematic fracture risk evaluation within 3-6 months including: 1

• DXA of spine and hip for bone mineral density 1
• Spine imaging for vertebral fractures 1
• Falls risk evaluation 1
• Laboratory screening for secondary osteoporosis (ESR, serum calcium, albumin, creatinine, TSH, vitamin D) 1
• Pharmacological treatment for high-risk patients to reduce subsequent fracture risk 1, 6