Leg, Ankle, and Foot Injuries

Dennis P. Hanlon,
KEYWORDS  Ankle  Calcaneus  Talus  Lisfranc
MD*

Injuries to the leg, ankle, and foot are common in patients seeking emergency care. In many cases, the emergency provider (EP) can provide initial care and have the patient follow up as an outpatient. In some cases, emergent orthopedic consultation is required. The EP must be aware of the anatomy, common injuries, important injuries, and potential complications associated with these injuries.
TIBIAL AND FIBULA SHAFT FRACTURES

Tibial fractures are the most common long-bone fracture. These injuries vary from minimally displaced fractures to acutely limb-threatening injuries because of vascular, neurologic, and extensive soft tissue involvement. The tibia has little protection on the anterior surface because the skin and subcutaneous tissue are thin (Fig. 1). As a result, it is the most common long bone to have an open fracture.1 As with most paired bones, a displaced fracture of the tibial shaft is associated with a fibula fracture 75% to 85% of the time (Fig. 2).2 Isolated fibula fractures are caused by direct trauma and usually are less serious than tibial fractures. Proximal fibula fractures may be associated with a peroneal nerve injury. Tibial and fibula shaft fractures are associated with multiple complications including osteomyelitis, delayed or nonunion, reflex sympathetic dystrophy, deep vein thrombosis, and compartment syndrome.3 The lower leg is divided into 4 major compartments by the fascia. Excessive pressure within any compartment produces ischemic pain and nerve damage unless treated expediently. Pain out of proportion to injury is a classic finding of compartment syndrome; however, this can be difficult to judge with an underlying distracting tibial and/or fibula fracture. Increased pain with passive stretching of the affected muscles and decreased sensation in the affected nerve distribution are reliable findings suggestive of compartment syndrome.4 The most commonly used method for classifying open fractures is the Gustilo classification. In this system, grade 1 open fractures have skin lesions of less than 1 cm and a clean, simple bone fracture with minimal comminution. Grade 2 open fractures

Operations, Allegheny General Hospital, 320 East North Avenue, Pittsburgh, PA 15212, USA * 200 Windermere Ct, McMurray, PA 15317. E-mail address: dhanlon@wpahs.org Emerg Med Clin N Am 28 (2010) 885905 doi:10.1016/j.emc.2010.09.001 0733-8627/10/$ see front matter 2010 Elsevier Inc. All rights reserved. emed.theclinics.com

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Fig. 1. Anteroposterior (AP) and lateral views of an open pen, comminuted tibia, and fibula fracture. The lateral view shows the scant soft tissue protection of these bones.

Fig. 2. Moderately displaced tibia and fibula fracture.

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have skin lesions greater than 1 cm, no extensive soft tissue damage, and minimal crush injury with moderate comminution. Grade 3 open fractures have extensive skin damage with muscle and neurovascular involvement, comminution of fracture, and instability. Grade 3 fractures are further subdivided into 3a (severe comminution or segmental fractures), 3b (periosteal bone stripping, severe comminution, and contamination), and 3c (arterial damage). Amputation is rare for grade 1 and 2 open fractures, but it is necessary in more than 20% of grade 3c fractures.5 Tibial shaft fractures are usually easily diagnosed. These fractures are the result of a high-energy mechanism, and patients must be evaluated thoroughly to exclude other injuries. Orthopedic consultation is required for most tibial and fibula shaft fractures. Urgent operative debridement is required for open fractures. While waiting for operative intervention, the leg should be splinted, sterile dressings should be applied to the overlying wounds, tetanus immunization updated if needed, and prophylactic intravenous antibiotics should be administered. Closed tibial and fibula shaft fractures, particularly if displaced, are at risk for compartment syndrome and may warrant admission for observation and subsequent operative intervention. In a recent study, diaphyseal tibia fractures had an 8% rate of compartment syndrome.6 Isolated fibular fractures rarely develop complications and can be managed with protected weight bearing. Closed tibial and fibula shaft fractures are splinted in a long leg splint with the knee at 10 to 20 of flexion.2

ANKLE SPRAINS

The evaluation of ankle injuries is a daily occurrence in the practice of emergency medicine. Ankle sprains make up most of these injuries. In addition, ankle sprains are the most common injury in sports, accounting for 15% to 20% of sports-related injuries.7,8 There are 3 main varieties of ankle sprains. The lateral sprain or inversion sprain is the most common. An isolated medial sprain or eversion sprain is uncommon because of the strength of the deltoid ligament. The medial malleolus will usually fracture before the deltoid ligament tears.9 The high or syndesmotic ankle sprain has received much attention recently from sports medicine specialists. These syndesmotic sprains take longer to heal and may require surgery.10 All types of ankle sprains are graded on the level of severity. In grade 1 injuries, only stretching of the involved ligaments has occurred. Grade 2 injuries have partial tears of the involved ligaments; grade 3 injuries have complete tears or ruptures of involved ligaments. Although the management of the different types of sprains has substantial overlap, there are some differences in findings and prognosis.8,9 The history, physical exam, and radiographic imaging must consider injuries that may mimic ankle sprains (Table 1). The lateral sprain is the most common sprain, accounting for 85% of such injuries because of the anatomic design of the ankle.11 The distal articulation of the tibia and fibula creates the ankle mortise. It is primarily a hinge-type joint allowing approximately 20 of dorsiflexion and 30 to 50 of plantar flexion. The ankle also has 25 of eversion and inversion that occurs at the subtalar joint. The ankle mortise is widest anteriorly so the joint is least stable with the foot plantar flexed. With the strength difference between the deltoid ligament medially and the lateral ligamentous complex, inversion injuries occur much more commonly than eversion injuries. The anterior talofibular ligament is the most commonly injured ligament.12 It runs from the front of the lateral malleolus to the anterolateral aspect of the talus. With further inversion stress, the calcaneofibular ligament is injured. This ligament runs from the tip of the lateral malleolus to the lateral aspect of the calcaneus. The posterior talofibular ligament is the strongest of the 3

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Table 1 Ankle sprain mimics Entity Avulsion fractures lateral malleolus Proximal fifth metatarsal fractures Lisfranc fractures Achilles tendon ruptures Talar avulsion fractures Navicular avulsion fractures Rupture of peroneal tendons Mechanism Same mechanism as sprain Vertical or medially directed force applied to a plantar flexed foot Axial load on a plantar flexed foot Sudden acceleration or forced dorsiflexion Inversion mechanism Inversion mechanism Forced dorsiflexion; snapping sensation posterolateral ankle Key to Avoiding Misdiagnosis Close scrutiny of radiographs (see Fig. 4) Point tenderness base of fifth metatarsal Ecchymosis on the plantar aspect of the midfoot Weak plantar flexion; positive Thompson test Dorsal tenderness (see Fig. 5) Bifurcate ligament Weakness of eversion

lateral ligaments. It is almost horizontal in its orientation and runs from the fossa in the inner aspect of the lateral malleolus to the posterior tubercle of the talus. The physical examination of a lateral ankle sprain will reveal tenderness and swelling of the lateral ankle. The anterior drawer test may reveal a more significant injury, a grade 3 sprain. To perform this test, with the patient sitting and the ankle in 10 to 15 of plantar flexion, cup the heel with one hand and provide counter traction to the tibia with the other while attempting to translate the fibula from anterior to posterior. Increased movement and pain indicates a positive test.9 Compare with the uninjured side because a 2-mm difference may be significant.9,12 In addition, a dimple may appear just anterior to the lateral malleolus. Finally, there may be the sensation of no definite endpoint compared with the other side. The talar tilt test is performed by applying slight adduction and eversion stress to the midfoot. If both the anterior talofibular ligament and fibulocalcaneal ligament are ruptured, there will be movement of the talus within the mortise.9 The medial sprain or eversion sprain is uncommon because of the strength of the deltoid ligament. The superficial component of the deltoid ligament connects the medial malleolus to the medial calcaneus, sustentaculum tali centrally, anteriorly to the tarsal navicular. The deep component of the deltoid ligament connects to the neck, body, and posterior portion of talus. There will be tenderness, swelling, and ecchymosis to the medial aspect of the ankle. In the external rotation stress test, an external rotation force is applied to a dorsiflexed ankle. If painful, the test is positive.9,13 In particular, the proximal fibula must always be examined with any medial ankle injury to evaluate for a possible Maissoneuve fracture. The high or syndesmotic ankle sprain is an injury to the ligaments of the distal tibiofibular syndesmosis. These ligaments include the anterior inferior tibiofibular ligament, posterior inferior tibiofibular ligament, the inferior transverse ligament, and the interosseous ligament. These sprains account for 10% to 20% of all ankle sprains, with an increased incidence in certain sports such as skiing and hockey.13 The most common mechanism of injury is external rotation. Usually the foot is planted on the ground with internal rotation of the leg and body with respect to the foot.10 The patient

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will complain of pain anteriorly between the distal tibia and fibula at the level of the ankle joint. There will usually be difficulty bearing weight.14 The physical examination of a syndesmotic ankle sprain will reveal a tender, swollen ankle. The squeeze test is performed by compressing the proximal tibia and fibula. It is positive if this maneuver produces pain at the ankle.9,13 Another test to detect syndesmosis injuries is the crossed-leg test. While sitting, the patient rests the midtibia of the affected leg on the knee of the unaffected leg. A downward force is applied to the medial side of the knee. If pain is produced in the area of syndesmosis, the test is positive.15 Tenderness length, the distance that tenderness extends proximal to the ankle joint, correlates with the degree of injury and return to sports.16 The indications for diagnostic imaging are discussed later. A standard ankle series includes anteroposterior (AP), oblique, and lateral views. With plain radiographs, a widened medial clear space will be noted on the mortise view. The medial clear space, which extends from the lateral border of the medial malleolus to the medial border of the talus, should not exceed 2 to 3 mm. A widened medial clear space implies a deltoid ligament rupture, syndesmosis disruption, or both (Fig. 3).17 A decrease in the amount of tibiofibular overlap, usually greater than 2 mm on the mortise view and greater than 6 mm on the AP view, suggests an injury to the syndesmosis. This finding may also be seen with a deltoid ligament rupture. A syndesmotic injury may also be radiographically unapparent.14 Stress films are not useful acutely, but may be beneficial for the orthopedist in follow-up. The initial treatment of ankle sprains incorporates the well-known RICE therapy (rest, ice, compression, and immobilization). The different types of sprains will have some modification of this therapy based on severity and type of sprain. The treatment of severe lateral ankle sprains is conservative, with either a posterior splint or an Aircast brace (DonJoy Inc, Vista, CA, USA) with initial non-weight bearing.1820 Boyce and colleagues20 showed improved ankle function at 10 days and 1 month after injury

Fig. 3. Disrupted mortise with widened medial clear space and a talar tilt.

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using an Aircast versus an elastic bandage. With first-time ankle sprains, a combination of elastic wrap and Air-stirrup brace (DonJoy Inc, Vista, CA, USA) allowed injured patients a faster return to preinjury status.21 In athletes, some authorities advocate surgical repair of isolated medial sprains.10 A suspected syndesmotic injury should be splinted, nonweight bearing, and have early orthopedic referral. Syndesmotic ankle sprains without diastasis can be managed conservatively.14 Acute, unstable syndesmosis injuries should be repaired surgically).10,16 The complications of ankle sprains include prolonged pain, recurrence, and chronic laxity. Almost one-third of athletes will have a recurrent ankle sprain within 1 year.22 One-third to one-half of patients will still have some symptoms at 3 years.22 In addition to these complications, syndesmotic ankle sprains are prone to the formation of heterotropic ossification within the interosseous membrane.16
ANKLE FRACTURES

The Ottawa ankle rules were developed because of the low yield of routine ankle radiographs in the assessment of ankle injuries. These rules decrease the number of films by up to 30% without missing clinically significant fractures.23,24 The Ottawa ankle rules state that an ankle series is indicated in the following circumstances: (1) tenderness along the distal 6 cm of the posterior tibia or the tip of the medial malleolus, (2) tenderness along the distal 6 cm of the posterior fibula or the tip of the lateral malleolus, and (3) the inability to bear weight for 4 steps, immediately and in the emergency department (ED). Similarly, the Ottawa foot rules state that a foot series is indicated in the following circumstances: (1) tenderness at the base of the fifth metatarsal, (2) tenderness at the navicular bone, and (3) the inability to bear weight for 4 steps, immediately and in the ED.23 There are 2 fracture classification schemes that are commonly used. The DanisWeber classification scheme is based on the location of the fibular fracture, which determines the need for operative intervention because it reveals the status of the

Fig. 4. Avulsion fracture of lateral malleolus with soft tissue swelling.

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Fig. 5. Talar and tarsal navicular avulsion fractures.

syndesmosis. The other major system is the Lauge-Hansen classification, which is based on mechanism of injury. The Danis-Weber classification scheme is more useful to EPs, with its anatomic basis and correlation with the need for surgery.9,25 In Weber type A injuries, the fibula fracture occurs distal to the mortise. These fractures are stable and managed conservatively with immobilization. In Weber type B injuries, the fibula fracture occurs at the level of the mortise. Generally, these fractures are unstable and require operative repair (Fig. 6). A truly isolated fibula fracture at the level of the plafond would be the exception, and this injury could be managed conservatively. In Weber type C injuries, the fibula fracture occurs above the level of the mortise.

Fig. 6. (A) AP and (B) lateral views of Weber B fracture: oblique fibula fracture at level of the plafond.

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These fractures are unstable and require operative repair because of disruption of the syndesmosis. The initial management includes immobilization, nonweight-bearing status, pain control, and early orthopedic referral. Some patients will be admitted because of swelling, pain control, comorbidities, or plans for early operative intervention. If there are fractures or ligament ruptures on both sides of the ankle, the resulting injury will be unstable. Because of the instability of these ankle fractures, these injuries are often fracture-dislocations of the ankle. If there is an obvious fracture-dislocation with any evidence of vascular compromise, the ankle should be reduced emergently (Fig. 7). Do not wait for radiographs unless they are immediately available. There are several important specific fractures of the ankle including pilon fractures, Maissoneuve fractures, and triplane fractures, which are discussed later.
PILON FRACTURES

Pilon fractures are intraarticular fractures of the distal tibia extending into the metaphysis. These fractures are also referred to as plafond fractures and account for 7% of tibial fractures.6 In French, the term pilon means pestle, which correlates with the mechanism of this injury. Pilon fractures are usually the result of a high-energy axial load force such as a fall from heights or a front-end motor vehicle collision. These fractures are often associated with other lower extremity injuries, pelvic fractures, and lumbar spine injuries.26 These fractures have been reported with a low-energy mechanism such as skiing. These injuries are not usually a diagnostic problem. Pilon fractures have obvious deformities and often associated soft tissue injury. Plain radiographs are diagnostic (Fig. 8). Computed tomography (CT) scan may help evaluate the degree of comminution to help in operative planning, but it is not required emergently in the acute setting. Although the diagnosis may be easy, the management can be difficult. These fractures have a high rate of nonunion and wound infections, and are particularly challenging to manage with extensive soft tissue injury.26 There are worse outcomes in patients who are diabetic,27 and outcomes are generally poor after nonoperative treatment. Surgery is indicated for open fractures, displaced fractures, rotational

Fig. 7. AP and lateral views of unstable ankle fracture-dislocation.

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Fig. 8. AP and lateral views of a typical pilon fracture: comminuted and intraarticular. Also, note the extensive soft tissue air.

deformity, and articular fragments with a step-off greater than 2 mm.26 These injuries need to be carefully assessed and observed for vascular compromise compartment syndrome.6
MAISSONEUVE FRACTURE

This fracture is caused by an external rotational force applied to the ankle. The Maissoneuve fracture consists of a proximal fibula fracture, syndesmosis disruption, and either a deltoid ligament rupture or medial malleolus fracture. Any medial ankle injury requires the careful evaluation of the proximal fibula. Ankle radiographs will show a widened medial clear space if the deltoid ligament is ruptured or a transverse medial malleolus fracture is present (Fig. 9). The tibiofibular overlap may also be decreased, but the proximal fibula fracture will be missed without a radiograph of the entire tibia and fibula bones. The initial treatment includes posterior splinting, nonweight bearing, and early orthopedic follow-up. Definitive treatment is open reduction and internal fixation (ORIF).

Fig. 9. (A) AP and (B) lateral view of the ankle showing widened medial clear space consistent with rupture of deltoid ligament. The arrow points to an associated posterior malleolus fracture. (C) A subtle proximal fibula fracture.

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TRIPLANE FRACTURES

This multiplanar fracture has a transverse component (growth plate), a sagittal component (epiphysis), and a coronal component (distal tibial metaphysis). It occurs during adolescence before complete closure of the distal tibial physis. The asymmetric closure of the distal tibia growth plate allows this type of fracture to occur with an eversion stress. This force moves along the nonfused lateral aspect of the distal tibia growth plate until it meets the fused area and is transmitted into the epiphysis and metaphysis. It accounts for 5% to 10% of pediatric intraarticular fractures.28,29 The physical examination shows the typical findings of a fracture with exquisite tenderness, swelling, and the inability to bear weight. A deformity may be present depending on the degree of displacement. Plain radiography usually reveals the fracture, (Fig. 10) although the findings may be subtle. The distal tibial metaphysis, the coronal component, is most readily identified on the lateral view.29 Approximately half of triplane fractures have an associated fibula fracture.30 CT provides invaluable preoperative information and better detail, including important information of the congruity of the articular surface (Fig. 11).31 The initial treatment will be immobilization in a posterior splint and nonweight bearing. Definitive treatment generally requires operative intervention unless the fracture is nondisplaced. Orthopedists may attempt closed reduction of a triplane fracture, but it is only successful 30% to 50% of the time.30 Whether a closed reduction should be attempted routinely before surgery in displaced triplane fracture is controversial.29,31
ACHILLES TENDON RUPTURE

Achilles tendon rupture is a common injury to recreational athletes that is missed up to 25% of the time on initial visits.32 Most patients are asymptomatic before

Fig. 10. AP and lateral views of a triplane fracture of the distal tibia. Widening of the lateral portion of the distal tibia physis. A vertical lucency extends through the middle of the epiphysis. Subtle fracture lines extend into the metaphysis.

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Fig. 11. (A, B) CT shows the extent of the fracture of the distal tibial metaphysis. (C) CT reconstruction of a triplane fracture.

rupture, without symptoms of Achilles tendonitis. Classically, patients feel a pop while accelerating, decelerating, or jumping. Although this injury is initially painful, the pain may be minimal or spontaneously resolved by the time of presentation. Most ruptures occur 2 to 6 cm above the insertion on the calcaneus.32,33 There is an increased incidence with gout, lupus, chronic renal failure, rheumatoid arthritis, fluoroquinolone use, and chronic corticosteroid use.33 The incidence of Achilles tendon rupture has increased as people have become more active in middle age and later.34 An accurate, focused physical examination is essential because the diagnosis is primarily clinical. A palpable defect may be present 2 to 6 cm above the calcaneus; however, this defect may be obscured by edema or hemorrhage.35 The patient may have some plantar flexion from the actions of the flexor digitorum, flexor hallucis longus, tibialis posterior, peroneus longus, and peroneus brevis. There may be increased dorsiflexion on passive range of motion if not limited by pain or swelling. A positive Thompson test confirms the suspected diagnosis.9 This test is performed, with the patient prone and the knee flexed to 90 , by squeezing the calf muscles just distal to its maximum width. With an intact Achilles tendon, the foot will plantar flex. If the Achilles tendon is ruptured, then there will be no plantar flexion. Diagnostic imaging is unnecessary unless there is concern for an associated fracture or the diagnosis is unclear. Radiographs will be negative or have some subtle soft tissue findings. Ultrasound can diagnose complete and partial tears, but it is operator dependent. Magnetic resonance imaging (MRI) is accurate even for partial tears, but it is usually not necessary in the ED. Most Achilles tendon ruptures are complete. The ED treatment is to splint in plantar flexion with no weight bearing and provide early orthopedic referral. The optimal definitive treatment is controversial. Surgical repair has a decreased risk of recurrent rupture and allows a faster return to sports or activities.36 Conservative management eliminates surgical complications including wound infections, but the rate of recurrent rupture ranges from 8% to 39%.35 Percutaneous surgical techniques decrease the surgical complication rate without an increase in the rate of rerupture compared with open methods.37

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LISFRANC FRACTURE/SPRAIN

Lisfranc injuries represent a spectrum of midfoot injuries from frank fracture-dislocations to sprains of the tarsometatarsal joint. This joint is known as the Lisfranc joint after Jacques Lisfranc de Saint-Martin, a field surgeon in Napoleons army. This surgeon developed an amputation technique at the tarsometatarsal joint to avoid infection and frostbite. Although fracture-dislocations are uncommon injuries, sprains to this joint are being increasingly recognized, particularly among athletes.38,39 Twenty percent of these rare, complex injuries are missed.40 The miss rate is even higher with subtle injuries in neuropathic diabetics.41 Motor vehicle collisions, falls, and athletic events are the most common mechanisms for Lisfranc injuries. Equestrian riders who get a foot caught in a stirrup after falling from the horse may injure this joint. Higher-energy mechanisms generally cause fracture-dislocations, whereas lower-energy mechanisms may cause only ligamentous injuries. In athletes, the mechanism often involves an axial load on a plantarflexed foot.42 Rotational force to a plantar-flexed foot may also produce a Lisfranc injury. The Lisfranc joint is the articulation between the midfoot and forefoot. This tarsometatarsal joint relies on both bony and ligamentous support for its stability. The middle cuneiformsecond metatarsal articulation is recessed providing additional stability to the Lisfranc joint and the transverse arch of the foot.43 The solitary Lisfranc ligament runs from the plantar lateral aspect of the medial cuneiform to the plantar medial aspect of the second metatarsal. Injury to this ligament results in loss of the longitudinal and transverse arch.44 The intermetatarsal ligaments connect all the metatarsals, but there are no intermetatarsal ligaments between the first and second metatarsals. The dorsal intermetatarsal ligaments are weaker than the plantar ligaments, resulting in an increased incidence of dorsal dislocations. The physical examination may reveal tenderness at the Lisfranc joint, and swelling and ecchymosis on the plantar aspect of the midfoot.45 This is not specific for Lisfranc injury, but it warrants further investigation.45 Intense swelling may mask a deformity.40 This swelling may be significantly out of proportion to a negative radiograph. Passive movement of the individual heads of the metatarsals produces pain at the tarsometatarsal joint. Passive pronation with adduction of the forefoot with the hindfoot stabilized will elicit pain and may reveal instability.40 These stress tests are difficult and unreliable in the unanesthetized patient. Diagnostic imaging of these injuries includes the standard radiographic series of the foot with an AP, lateral, and oblique view. On the AP view of a normal foot, the lateral border of the medial cuneiform should align with the lateral border of the first metatarsal, and the medial border of the base of the second metatarsal should line up with the medial border of the middle cuneiform. The second tarsometatarsal joint should be 1 cm proximal to the first tarsometatarsal joint and 0.5 cm proximal to the third tarsometatarsal joint. On the oblique view, the lateral border of the lateral cuneiform should align with the lateral border of the third metatarsal, and the medial border of the fourth metatarsal should line up with the medial border of the cuboid. On the lateral view, the superior border of the first metatarsal base should align with the superior border of the medial cuneiform. Diastasis greater than 2 mm between the first and second metatarsal suggests a Lisfranc injury and is consistent with a third degree sprain.42 The fleck sign, referring to an avulsion from the second metatarsal base or medial cuneiform, may be the only sign of a Lisfranc injury.42 Standard radiograph series appear normal in up to 50% of cases. Even significant injuries can reduce spontaneously, making the diagnosis of Lisfranc injuries difficult (Fig. 12).

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Fig. 12. Lisfranc fracture.

Weight-bearing AP and lateral views may help with the diagnosis but are not needed in the ED. These views may be technically difficult acutely because of significant pain. Advanced imaging including CT, bone scans, and MRI can greatly assist accurate diagnosis, but these tests are not indicated in the ED. CT provides excellent bony detail and may identify small avulsion fractures or detect misalignment that suggests Lisfranc injury. MRI can identify individual ligament ruptures and predict midfoot instability.43 The emergency management of Lisfranc injuries depends on the severity of the injury. Fracture-dislocations with significant swelling need to be observed for compartment syndrome and require orthopedic consultation. Displaced Lisfranc injuries require ORIF because most closed reductions cannot be maintained with casting alone. Nondisplaced Lisfranc injuries can be managed with a posterior splint and early orthopedic follow-up. These nondisplaced Lisfranc injuries usually require a short leg cast for 6 weeks with weight-bearing views of the foot at 4 to 6 weeks. Lisfranc injuries with less than 2 mm of diastasis on weight-bearing radiographs can be managed conservatively.39 The best predictor of outcome is stable anatomic alignment.46 There is a high incidence of posttraumatic arthritis with Lisfranc injuries. All patients with pain in the area of the Lisfranc joint should receive prompt referral to an orthopedist to avoid missing subtle injuries.
PROXIMAL FIFTH METATARSAL FRACTURES

The proximal fifth metatarsal is the most common site of midfoot fractures.47,48 The clinical presentation of fractures involving the proximal fifth metatarsal is similar to

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that of ankle sprains, often resulting in an inaccurate diagnosis if a cursory examination is performed at the initial presentation. Any patient with an inversion injury, or ankle sprain, must have the base of the fifth metatarsal palpated and filmed if tender. There are 2 basic types of proximal fifth metatarsal fractures: the avulsion fracture of the fifth metatarsal tuberosity and fracture of the proximal diaphyseal metatarsal shaft, a true Jones fracture.2,6 The Jones fracture of the fifth metatarsal occurs at least 1.5 cm distal to the metatarsal styloid in the area of the metaphyseal-diaphyseal junction and may be unimpressive radiographically (Fig. 13). These 2 fractures vary considerably in treatment, prognosis, and complications. A third type of proximal fifth metatarsal fracture is the proximal diaphyseal stress fracture.49,50 From an emergency medicine viewpoint, this fracture can be considered in the same manner as a true Jones fracture.49 Historically, the mechanism of injury can be similar for these 2 fractures. An inversion of the foot while the ankle is plantar flexed may produce an avulsion fracture of the fifth metatarsal tuberosity. Jones fractures result from a vertical or medially directed force applied to a plantar flexed foot.50 Acute onset of pain at the base of the fifth metatarsal with difficulty bearing weight will occur. The physical examination will reveal bony tenderness at the base of the fifth metatarsal. Passive inversion and resisted eversion cause pain. Also, compression of the metatarsal heads will produce pain at the base of the fifth metatarsal. Radiographically, the avulsion fracture of the fifth metatarsal tuberosity will generally be transverse and proximal to the distal cuboid (Fig. 14). An apophysis near the base of the fifth metatarsal may be mistaken for an avulsion fracture. Apophyses of early adolescence are oriented parallel to the bone rather than transverse or oblique. The treatment of nondisplaced avulsion fractures is symptomatic. It includes a walking boot or hard-soled shoe with weight bearing as tolerated. This conservative treatment should continue until symptoms subside, usually within 4 to 6 weeks. Displaced avulsion fractures greater than 2 mm, or articular surface step-off with the cuboid or involving more than one-third of the cubometatarsal articulation surface, require orthopedic referral and subsequent surgical treatment.51

Fig. 13. AP and lateral views of a Jones fracture.

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Fig. 14. AP and lateral views of an avulsion fracture of the fifth metatarsal tuberosity.

The early treatment of Jones fractures involves posterior splinting with nonweight bearing and early orthopedic follow-up. ORIF is the preferred treatment of athletes and active patients.52,53 Prolonged immobilization may be required if conservative treatment is used. These fractures have a high rate of nonunion, delayed union, and recurrence when managed conservatively.53 Proximal fifth metatarsal diaphyseal stress fractures heal even more poorly.50
CALCANEAL FRACTURES

Calcaneal fractures are associated with a high-energy, axial load mechanism.54 In 30% of cases, another lower extremity fracture is associated with a calcaneal fracture, and compression fractures of the lumbar spine occur in 10% to 15% of cases.54 In addition to being the largest tarsal bone, it is the most frequently fractured tarsal bone. These fractures are bilateral in 7% of cases. Approximately 25% to 30% of cases are extra-articular, so the subtalar joint (talocalcaneal joint) is involved in most cases.55,56 The patient will be unable to bear weight. The physical examination must include a search for associated injuries. In addition, the heel will be swollen, tender, and ecchymotic. The heel will be markedly tender with gentle cupping of the examiners hand. Mondor sign is a midplantar ecchymosis seen with calcaneal fractures.57 Although diagnostic of the fracture, the standard foot series does not always reveal the full extent of subtalar joint involvement, which is important for treatment decisions (Fig. 15). Evaluating the Bohler angle may help diagnose a fracture with compression. On the lateral view of the foot, a line drawn from the posterior tuberosity of the calcaneus to the apex of the posterior facet forms a 20 to 40 angle with a line drawn from the apex of the posterior facet to the apex of the anterior process.9,17 A calcaneal fracture must be suspected if this angle is less than 20 or greater than 40 . An axial view (Harris view) can be used to view the subtalar joint and calcaneal tuberosity if standard radiographs do not reveal a suspected fracture (Fig. 16). CT has greatly improved the ability to accurately evaluate complex fractures including the extent of subtalar joint involvement (Fig. 17). There is no consensus on optimal management. A substantial subset of these fractures does poorly regardless of management.58 A 15-year study of displaced, intraarticular calcaneal fractures failed to show any difference in clinical outcomes between

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Fig. 15. Lateral foot radiograph showing a calcaneal fracture.

operative and conservative treatment.58 Early complications include fracture blisters and compartment syndrome. Late complications include subtalar arthritis, chronic pain, wound infection, and sural neuritis.43 The goal of surgical management is to restore the height and length of the calcaneus, realign the posterior facet of the subtalar joint, and restore the mechanical axis of the hindfoot. Displaced calcaneal fractures require orthopedic consultation. Extra-articular fractures are treated conservatively with a few exceptions. These exceptions include displaced fractures

Fig. 16. An axial view of a calcaneal fracture.

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Fig. 17. (A) CT shows an intraarticular fracture with subtalar involvement. (B) CT shows the comminuted calcaneal fracture.

of the sustentaculum tali, posterior fractures, and some calcaneal body fractures.58 With a fracture of the sustentaculum tali, the flexor hallucis longus tendon may be interposed with nonoperative management of displaced fractures.6,58

TALAR FRACTURES

The talus is the second largest tarsal bone and the second most commonly fractured tarsal bone.6 Its fractures are typically divided into major and minor fractures. Major talar fractures include fractures to the body, head, or neck of the talus.6 Fifty percent of major talar injuries are talar neck fractures.6 Patients with major talar fractures typically describe a high-energy hyperdorsiflexion of the ankle joint as the mechanism of injury, such as motor vehicle crashes or falls from a height. Minor talar fractures include avulsion fractures of the lateral, medial, and posterior processes as well as those from the superior neck and head. These injuries are caused by sudden forces applied to an inverted, dorsiflexed foot.59 The presentation is that of lateral ankle pain after an inversion mechanism. A fracture of the lateral process of the talus has become a common snowboarding injury.60,61 There are no unique findings on physical examination. There may be loss of the hindfoot contour, swelling, tenderness, and ecchymosis. The foot and ankle must be assessed for any open wounds, ischemic skin changes, and neurovascular integrity. Radiographically, most major talar fractures will be shown on standard ankle and foot radiographs (Fig. 18). Many minor talar fractures may be occult on plain radiography and require a CT for visualization if these injuries are suspected.62 The initial management of minor talar fractures is posterior splinting, nonweight bearing, and orthopedic follow-up. Major talar fractures will usually require ORIF unless precise anatomic alignment is present.63 Any significantly displaced major talar fracture will require an early closed reduction attempt to decrease the risk of avascular necrosis.63 Urgent orthopedic consultation is recommended for all major talar fractures.2 Complications of major talar fractures include avascular necrosis, skin necrosis, posttraumatic arthritis, malunion, and nonunion. These fractures have a high risk of avascular necrosis because of the tenuous blood supply of the talus.61,62

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Fig. 18. (A) A subtle talar avulsion fracture. (B) Lateral view shows ankle effusion (asterisks).

SUMMARY

The EP must be aware of the anatomy of the leg, ankle, and foot. The varied presentation of common injuries must be recognized, as well as the unique presentations of uncommon injuries. The astute EP must rely on a focused history and a precise examination to avoid the pitfalls and missed injuries from an over-reliance on radiographic studies. Potential complications associated with these injuries must be anticipated and avoided if possible.
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