Foot and Ankle Fractures

Fractures of the foot and ankle include the anterior process of the calcaneus, fractures of the fifth metatarsal and toe fractures.

It is important to talk to the patient about the mechanism of injury. Did the patient twist their ankle on a 3 cm uneven piece of pavement? Did they slip on a wet surface in a supermarket? Did they fall 10 m out of a building? Was their foot run over by a 10 ton truck? Did they fall off a horse?   The former represent low energy injuries and the latter high energy injuries.   Most patients with foot and ankle fractures do not need an MRI scan

When examining a patient with a fracture the clinical signs are: swelling, deformity and point tenderness over bone.

Ankle fractures: 

Ankle fractures are extremely common and usually result from a twisting injury. They are often associated with sprains. As indicated above a fractured ankle sustained twisting it on a footpath is different to an ankle fracture sustained by falling 10 m out of a building.   

Ankle fractures are broadly classified as being below, at or above the syndesmosis. 

• Fractures below the syndesmosis will generally heal nonsurgically.
• Fractures at the syndesmosis sometimes require surgery and
• Fractures above the syndesmosis nearly always require surgery.

Ankle sprains often result in avulsion fractures from the distal fibula, lateral wall of the talus, lateral wall of the calcaneus or the anterior

process of the calcaneus. These avulsion fractures are generally small and are generally managed as ankle sprains would be with the customary rest, ice, compression, elevation.   

Larger fragments sometimes need to be reattached. The best way to image ankle fractures in this situation is a fine cut CT scan.  

Fractures of the fifth metatarsal:   

• These fractures frequently accompany ankle sprains. Again when examining a patient with an ankle sprain it is very important to palpate the fifth metatarsal for tenderness over bone.
• Broadly speaking fifth metatarsal fractures occur in the tuberosity proximally, the junction of the metastasis and the diaphysis and in the distal shaft.
• Tuberosity fractures will generally become pain free whether or not the fracture is displaced and whether or not the fracture unites. Indeed a painless pseudarthrosis with fibrous tissue bridging the gap will usually be painless and not require any further treatment.
• The long spiral fracture of the fifth metatarsal sometimes known as the dancer’s fracture has a somewhat sinister radiological appearance but generally unites uneventfully.
• The fracture which generally causes the most trouble is the fracture at the diaphysis/metaphysis junction. This is known as the Jones’ fracture. This fracture can either occur as an acute fracture or as a stress fracture. The optimal management is six weeks in plaster nonweight bearing. Unfortunately even with this treatment there is a 25% incidence of non-union.
• I usually consider open reduction internal fixation in the high demand patient or the athlete which increases the chance of union to approximately 90% and substantially decreases the risk of re-fracture. 

Toe Fractures: 

Toe fractures particularly fifth toe fractures are common and often result from getting the toe caught on a piece of furniture.   

If the toe is reasonably straight and the fracture does not involve the joint the patient will usually make an uneventful recovery but needs to be warned that the toe will swell for up to 6 months. This is particularly an issue in ladies who want to wear fashionable shoes!   

If the toe is not straight they can generally be straightened in the office under local anaesthesia and then buddy taped to the adjacent toe for a period of 3 to 6 weeks.   

In the great toe intra-articular fractures which are displaced sometimes need open reduction internal fixation to prevent the development of arthritis.