Introduction and anatomy

Fractures or broken the bones of the foot in order to understanding these fractures it should be first known the anatomy or structures of the bones of the foot as follow

Bones of the foot

The bones of the foot consists of three parts which are the tarsal bones metatarsals bones and phalanges of the toes

The tarsal bones

These consist of two rows proximal and distal
The proximal row consists of
  • Talus bone
  • Calcaneum bone
  • Navicular bone
The distal row consists of
  • Cuboid bone
  • Three cueiform bones medial lateral and intermediate cuneiform bones
Metatarsals bones
There are five metatarsals bones which named from inside from big toe side to outside from little toe side
from 1-5 metatarsals bones
The first metatarsal is thickest  and largest one which joint to big toe the second metatarsal is longest one the fifth metatarsal has a tuberosity on its base for insertion of peroneus brevis
 in standing position the metatarsal heads are in contact with the ground
The phalanges bones
There are 14 phalanx in each foot three phalanges in each toe except big toe has two phalanges
Fractures of the bones of the foot

  • Usually need major trauma
  • Fall from height
  • motor car accidents
  • fall of heavy object on the foot
  • stress or overuse injuries
  •  stress or fatigue fractures  by walking or running its gradual fractures
Special form of fractures
uncommon fractures result from major trauma most common site of fractures is neck of the talus
Classification of talus fractures
Classified into four types

Type I  non displaced fracture
Type II  displaced fracture and associated with subtalar dislocation
Type III  displaced fracture and associated with subtalar and ankle dislocation
 Type IV  displaced fracture associated with subtalar ankle and talonavicular dislocation
The risk of osteonecrosis is increased up to 100% in type IV

Calcaneus fracture

Calcnaueus fractures are common caused  commonly by fall from height
Common associated with lumber vertebrae fracture

Midfoot injury or fracture

Site between the tarsal bones and proximal metatarsals bones
may seen after minor trauma
the patient complains from pain and swelling in the midfoot

Metatarsal bones fractures

Caused common by direct trauma eg fall or drooping heavy object on the dorsum of the foot
in case of fractures of fifth metatarsal bone there are two types of fractures
Avulsion injuries occurs when the pernoneus brevis muscle pulls off the bone with a fragment of the bone
A jones fracture is a fracture to the proximal fifth metatarsal
this injury has an increased risk of delayed union or nonunion

Stress fractures of metatarsals bones

stress fractures or fatigue fractures of the metatarsals is common cause of pain in the forefoot
common affect second and third metatarsals
common in athletes or sporting  or dancing  peoples and patient associated with other underlying bone disorders this is due to overuse
 the patient complains from swelling and warmth in the foot with tenderness over the affected metatarsal
plain X rays may negative at the beginning and healing fractures start to appear by the third week of patient symptoms

Phalangeal fractures of the toes

fractures of phalanges of the toes are common caused by direct trauma as fall or drooping heavy objects on dorsum of the toes
 Clinical features
  • Severe pain immediately after trauma
  • Swelling and bruising and tenderness indicate site of the fractures
  • Deformity indicated dislocations or major soft tissue injury
  • Open fractures connected with outside with soft tissue injury or closed fracture
  • The patient unable to walking or put his or her foot on the ground common with tarsal and metatarsal  fractures
  •  Pain and swelling in the hind foot mainly due to tarsals fractures
  • Pain and swelling in midfoot mainly due to midfoot injury
  • pain and swelling in the forefoot mainly due to metatarsals fractures
History talking to know the source of trauma as motor car accident or fall heavy object or fall from height
also ask the patient what are the site of pain he or she feels and if there is family or present history of
associated chronic diseases like diabetes or immuno-compermized diseases which may interferes with wound healing or anaethesia if need for operation

Imaging study

Plain X rays its simple easy common to use to detect site and type of fracture either posteroanterior or lateral or oblique views
CT scanning may need in special fractures
MRI scanning may need for ligaments injuries
Treatment of tarsal fractures
Conservative treatment
Indications most tarsal fractures mainly undisplaced fractures are treated by cast immobilization for 4-6 weeks
Surgical treatment
By open reduction and internal fixation
 undisplaced fractures
type II and type III  and type IV talus fractures
treatment of the osteonecrosis associated with talus fracture treated by prolonged non weight bearing untill the talus has a chance to revascularize
calcaneus fracture when the bohler angle which is the angle measured between a line across the calcneal tuberosity and a line across the anterior and posterior subtalar joint on plain X rays the normal angle is between 25-40 degree if the angle more than that that is means indications for internal fixation
Treatment of midfoot injury
Conservative treatment
By closed reduction by cast immobilization for 4-6 weeks
Surgical treatment
By open reduction and internal fixation
indicated when the closed reduction is not anatomic or can not be held reduced
Treatment of metatarsal fractures
Conservative treatment
 Indicated in stable fractures by  non weight bearing or closed reduction by cast immobilization for 4-6 weeks
Surgical treatment
 By open reduction and internal fixation
 indicated in the fractures of the proximal fifth metatarsal through the metaphysic or proximal diaphysis because they associated with high risk of non union or delayed union
if the bone is not united within 3 months after cast immobilization
Treatment of phalangeal fractures of the toes
Conservative treatment

Indicated nearly always in all phalanges fractures by taping the fracture toe to the adjacent toe as by plaster taping for 4-6 weeks
Surgical treatment

 By pin fixation
Indicated in big toe displaced fracture
Like any fractures besides
 non union delayed union osteonecrosis common with talus fracture wound infection for more see the articles of complications of bones fractures

1 comment:

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