A fracture is a literal break in your bone or the surrounding cartilage. It will cause significant discomfort, especially when it is in a bone of weight bearing use, such as the foot. Fractures of the feet are most common in runners, basketball players, football players; anyone who exerts much force and strain on the feet. Another major cause of foot fractures would be some type of trauma or a medical condition that predisposes people to bone injuries. Fractures are very serious and should not be left untreated by a medical professional; however, you can treat a foot fracture on site if you suspect such an injury.
The Lisfranc Joint
The Lisfranc joint is the point at which the metatarsal bones (long bones that lead up to the toes) and the tarsal bones (bones in the arch) connect. The Lisfranc ligament is a tough band of tissue that joins two of these bones. This is important for maintaining proper alignment and strength of the joint.
How Do Lisfranc Injuries Occur?
Injuries to the Lisfranc joint most commonly occur in automobile accident victims, military personnel, runners, horseback riders, football players and participants of other contact sports, or something as simple as missing a step on a staircase.
Lisfranc injuries occur as a result of direct or indirect forces to the foot. A direct force often involves something heavy falling on the foot. Indirect force commonly involves twisting the foot.
Types of Lisfranc Injuries
There are three types of Lisfranc injuries, which sometimes occur together:
- Sprains. The Lisfranc ligament and other ligaments on the bottom of the midfoot are stronger than those on the top of the midfoot. Therefore, when they are weakened through a sprain (a stretching of the ligament), patients experience instability of the joint in the middle of the foot.
- Fractures. A break in a bone in the Lisfranc joint can be either an avulsion fracture (a small piece of bone is pulled off) or a break through the bone or bones of the midfoot.
- Dislocations. The bones of the Lisfranc joint may be forced from their normal positions.
What are the Symptoms?
The symptoms of a Lisfranc injury may include:
- Swelling of the foot
- Pain throughout the midfoot when standing or when pressure is applied
- Inability to bear weight (in severe injuries)
- Bruising or blistering on the arch are important signs of a Lisfranc injury. Bruising may also occur on the top of the foot.
- Abnormal widening of the foot.
How are Lisfranc Injuries Diagnosed?
Lisfranc injuries are sometimes mistaken for ankle sprains, making the diagnostic process very important. To arrive at a diagnosis, the foot and ankle surgeon will ask questions about how the injury occurred and will examine the foot to determine the severity of the injury.
X-rays and other imaging studies may be necessary to fully evaluate the extent of the injury. The surgeon may also perform an additional examination while the patient is under anesthesia to further evaluate a fracture or weakening of the joint and surrounding bones.
Anyone who has symptoms of a Lisfranc injury should see a foot and ankle surgeon right away. If unable to do so immediately, it is important to stay off the injured foot, keep it elevated (at or slightly above hip level), and apply a bag of ice wrapped in a thin towel to the area every 20 minutes of each waking hour. These steps will help keep the swelling and pain under control. Treatment by the foot and ankle surgeon may include one or more of the following, depending on the type and severity of the Lisfranc injury:
- Immobilization. Sometimes the foot is placed in a cast to keep it immobile, and crutches are used to avoid putting weight on the injured foot.
- Oral medications. Nonsteroidal anti-inflammatory medications (NSAIDs), such as ibuprofen, help reduce the pain and inflammation.
- Ice and elevation. Swelling is reduced by icing the affected area and keeping the foot elevated, as described above.
- Physical therapy. After the swelling and pain have subsided, physical therapy may be prescribed.
Certain types of Lisfranc injuries require surgery. The foot and ankle surgeon will determine the type of procedure that is best suited to the individual patient. Some injuries of this type may require emergency surgery.
Are there Complications?
Complications can and often do arise following Lisfranc injuries. A possible early complication following the injury is compartment syndrome, in which pressure builds up within the tissues of the foot, requiring immediate surgery to prevent tissue damage. A build-up of pressure could damage the nerves, blood vessels, and muscles in the foot.
Arthritis and problems with foot alignment are very likely to develop. In most cases, arthritis develops several months or longer following a Lisfranc injury, requiring additional treatment.
Fractures of the Fifth Metatarsal
What is a Fifth Metatarsal Fracture?
Fractures (breaks) are common in the fifth metatarsal – the long bone on the outside of the foot that connects to the little toe. Two types of fractures that often occur in the fifth metatarsal are:
- Avulsion fracture. In an avulsion fracture, a small piece of bone is pulled off the main portion of the bone by a tendon or ligament. This type of fracture is the result of an injury in which the ankle rolls. Avulsion fractures are often overlooked when they occur with an ankle sprain.
- Jones fracture. Jones fractures occur in a small area of the fifth metatarsal that receives less blood and is therefore more prone to difficulties in healing. A Jones fracture can be either a stress fracture (a tiny hairline break that occurs over time) or an acute (sudden) break. Jones fractures are caused by overuse, repetitive stress, or trauma. They are less common and more difficult to treat than avulsion fractures.
Other types of fractures can occur in the fifth metatarsal. Examples include mid-shaft fractures, which usually result from trauma or twisting, and fractures of the metatarsal head and neck.
What are the Symptoms?
Avulsion and Jones fractures have the same signs and symptoms. These include:
- Pain, swelling, and tenderness on the outside of the foot
- Difficulty walking
- Bruising may occur
How is a Fifth Metatarsal Fracture Diagnosed?
Anyone who has symptoms of a fifth metatarsal fracture should see a foot and ankle surgeon as soon as possible for proper diagnosis and treatment. To arrive at a diagnosis, the surgeon will ask how the injury occurred or when the pain started. The foot will be examined, with the doctor gently pressing on different areas of the foot to determine where there is pain.
The surgeon will also order x-rays. Because a Jones fracture sometimes does not show up on initial x-rays, additional imaging studies may be needed.
Until you are able to see a foot and ankle surgeon, the “R.I.C.E.” method of care should be performed:
- Rest: Stay off the injured foot. Walking may cause further injury.
- Ice: Apply an ice pack to the injured area, placing a thin towel between the ice and the skin. Use ice for 20 minutes and then wait at least 40 minutes before icing again.
- Compression: An elastic wrap should be used to control swelling.
- Elevation: The foot should be raised slightly above the level of your heart to reduce swelling.
The foot and ankle surgeon may use one of these non-surgical options for treatment of a fifth metatarsal fracture:
- Immobilization. Depending on the severity of the injury, the foot is kept immobile with a cast, cast boot, or stiff-soled shoe. Crutches may also be needed to avoid placing weight on the injured foot.
- Bone stimulation. A pain-free external device is used to speed the healing of some fractures. Bone stimulation, most commonly used for Jones fractures, may be used as part of the treatment or following an inadequate response to immobilization.
When is Surgery Needed?
If the injury involves a displaced bone, multiple breaks, or has failed to adequately heal, surgery may be required. The foot and ankle surgeon will determine the type of procedure that is best suited to the individual patient.
Fractures of the Calcaneus (Heel Bone Fractures)
What is the Calcaneus?
The calcaneus, also called the heel bone, is a large bone that forms the foundation of the rear part of the foot. The calcaneus connects with the talus and cuboid bones. The connection between the talus and calcaneus forms the subtalar joint. This joint is important for normal foot function.
The calcaneus is often compared to a hard boiled egg, because it has a thin, hard shell on the outside and softer, spongy bone on the inside. When the outer shell is broken, the bone tends to collapse and become fragmented. For this reason, calcaneal fractures are severe injuries. Furthermore, if the fracture involves the joints, there is the potential for long-term consequences such as arthritis and chronic pain.
How do Calcaneal Fractures Occur?
Most calcaneal fractures are the result of a traumatic event—most commonly, falling from a height, such as a ladder, or being in an automobile accident where the heel is crushed against the floorboard. Calcaneal fractures can also occur with other types of injuries, such as an ankle sprain. A smaller number of calcaneal fractures are stress fractures, caused by overuse or repetitive stress on the heel bone.
Types of Calcaneal Fractures
Fractures of the calcaneus may or may not involve the subtalar and surrounding joints. Fractures involving the joints (intra-articular fractures) are the most severe calcaneal fractures, and include damage to the cartilage (the connective tissue between two bones). The outlook for recovery depends on how severely the calcaneus was crushed at the time of injury.
Fractures that don’t involve the joint (extra-articular fractures) include:
- Those caused by trauma, such as avulsion fractures (in which a piece of bone is pulled off of the calcaneus by the Achilles tendon or a ligament) or crush injuries resulting in multiple fracture fragments
- Stress fractures, caused by overuse or mild injury.
The severity and treatment of extra-articular fractures depend on their location and size.
What are the Signs and Symptoms?
Calcaneal fractures produce different signs and symptoms, depending on whether they are traumatic or stress fractures.
The signs and symptoms of traumatic fractures may include:
- Sudden pain in the heel and inability to bear weight on that foot
- Swelling in the heel area
- Bruising of the heel and ankle
The signs and symptoms of stress fractures may include:
- Generalized pain in the heel area that usually develops slowly (over several days to weeks)
- Swelling in the heel area
To diagnose and evaluate a calcaneal fracture, the foot and ankle surgeon will ask questions about how the injury occurred, examine the affected foot and ankle, and order x-rays. In addition, advanced imaging tests are commonly required.
Treatment of calcaneal fractures is dictated by the type of fracture and extent of the injury. The foot and ankle surgeon will discuss with the patient the best treatment—whether surgical or non-surgical—for the fracture.
For some fractures, non-surgical treatments may be used. These include:
- Rest, ice, compression, and elevation (R.I.C.E.) Rest (staying off the injured foot) is needed to allow the fracture to heal. Ice reduces swelling and pain; apply a bag of ice covered with a thin towel to the affected area. Compression (wrapping the foot in an elastic bandage or wearing a compression stocking) and elevation (keeping the foot even with or slightly above the heart level) also reduce the swelling.
- Immobilization. Sometimes the foot is placed in a cast or cast boot to keep the fractured bone from moving. Crutches may be needed to avoid weightbearing.
For traumatic fractures, treatment often involves surgery to reconstruct the joint, or in severe cases, to fuse the joint. The surgeon will choose the best surgical approach for the patient.
Whether the treatment for a calcaneal fracture has been surgical or non-surgical, physical therapy often plays a key role in regaining strength and restoring function.
What are the Complications of Calcaneal Fractures?
Calcaneal fractures can be serious injuries that may produce lifelong problems. Arthritis, stiffness, and pain in the joint frequently develop. Sometimes the fractured bone fails to heal in the proper position. Other possible long-term consequences ofcalcaneal fractures are decreased ankle motion and walking with a limp due to collapse of the heel bone and loss of length in the leg. Patients often require additional surgery and/or long term or permanent use of a brace or an orthotic device (arch support) to help manage these complications.