Broken foot

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What is the structure of the foot?


The foot is designed to withstand the considerable forces placed on it by walking, running, and jumping. The 26 bones of the foot are connected by joints and supported by thickened ligaments to absorb the impact of movement. As well, the joints of the foot are acted upon by tendons that allow flexing and extending to permit walking and running to occur.

The bony anatomy can be described as follows:

    The talus articulates with the tibia (shin bone) to form the ankle joint.

    The calcaneus or the heel bone is attached by ligaments to the tibia to provide stability to the ankle joint.

    The midfoot consists of the navicular, the cuboid, and the three cuneiform bones. The midfoot is where inversion and supination of the foot occurs. These motions allow the sole of the foot to turn inwards and upwards.

    The five metatarsal bones are connected to each toe.

    The toe bones are called phalanges (single = phalanx) with the great toe having two and the other four toes having three each. These bones are named based upon their relationship to the body: proximal, middle and distal. Proximal means closest to the center of the body while distal is furthest from the center.

    The arch of the foot is maintained by the plantar fascia, a thick fibrous band of tissue that runs from the calcaneus to the metatarsal, preventing the bones of the foot from flattening.

    Injuries to the foot include fractures of the bone, sprains of the ligaments that stabilize the joints, and strains of the muscles and tendons that move the foot.

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What are the causes of a broken foot?

A fracture, break, or crack all mean the same thing when it comes to a bone injury: the integrity of the bone has been damaged. The cause of injury may be obvious, such as jumping from a height or a heavy object falling and landing on the foot, or it may develop gradually over time, such as the result of the constant stress of walking or running.

    Foot fractures account for 10% of all the broken bones in the body, and the mechanism of injury usually can give a clue as to what bone might be injured.

    Fractures of the calcaneus usually occur when a person jumps or falls from a height, landing directly on their feet. The force of the landing may also be transmitted up the body to cause fractures of the ankle, knee, hip, and lumbar spine.

    Injuries to the midfoot, the metatarsals, and phalanges often are caused by a direct blow sustained when a kick goes awry or from a crush injury when a heavy object is dropped on the foot.

    The most common causes of foot injuries include falls; crush injuries (including impacts from a heavy object or an automobile accident) missed steps, and stress/overuse injuries.

What are the symptoms of a broken foot?

Broken bones are painful, which is the most common symptom that will prompt a person to seek medical care. Swelling, bruising, and tenderness are the other common symptoms. Because the body tries to protect itself, walking may be too painful or the patient will present with a limp. If the bones are significantly displaced (the bone alignment has been lost or there is an associated joint dislocation) a deformity of the foot may be apparent.

In patients with altered pain sensation due to peripheral neuropathy (persons with diabetes are a classic example), pain may not be present, so a fracture may be missed initially. This may also occur in patients with spinal cord injury. Bruising, swelling, and deformity may be the only clues to a potential fracture.

Infants and toddlers may ignore the pain of injury and they may present to the health care practitioner refusing to bear weight on their leg. The child may sit comfortably on the parent's lap without complaint until asked or made to stand.

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When should I call the doctor for foot pain?

Most of the bones in the foot will eventually heal with rest, but some fractures may need surgery to repair.

Often, it is the mechanism of injury associated with the intensity of pain that makes the patient seek care. It is appropriate to seek medical care if the patient cannot walk normally without a limp.

Medical care should be accessed immediately if an injury to the foot also includes a laceration. The term "open fracture", previously named "compound fracture," describes a broken bone that is associated with a break in the skin. In threes cases there is significant risk for major infection of the bone.

Other reasons to seek care include the presence of numbness or tingling in the toes, which may be an indication of nerve damage, or if the foot becomes cool and white, which may signal damage to the blood supply of the foot.

How is a broken foot diagnosed?

The diagnosis begins with the health care practitioner taking a history of how the injury occurred. The mechanism of injury will give clues as to what type of injury may exist and importantly, what other associated injuries may also be potentially present. It is helpful to know how much time has passed from when the injury occurred to when the patient presents for care. Past medical history is important; those with diabetes are at greater risk for infection with foot injuries.

Physical examination may include the following:

    Inspection of the foot for swelling, bruising, deformities and open wounds.

    Palpation allows the health care practitioner to feel where the pain is located. This is very helpful if X-rays are taken, since it allows a more careful inspection of the area where the tenderness exists. (This is particularly important in children whose bones may not have yet calcified. Fractures may be easily missed since they occur through cartilage instead of bone.)

    An exam of the circulatory system, feeling for pulses, and a neurologic exam, assessing sensation such as light touch and pin prick sensation along with motor function, may also be done.

    A range of motion exam of the foot may be helpful in assessing ligament stability. However, if the fracture is obvious, the health care practitioner may choose to keep the foot immobilized to prevent further pain.

Imaging

X-rays are often taken to evaluate the status of the bones in the foot and check for fracture. Usually three pictures are taken to help the health care practitioner and radiologist adequately view the bones. Special views may be taken if there is concern for a fracture of the calcaneus.

X-rays may not be taken for simple toe injuries, since they may not affect the treatment plan.

For some foot fractures, X-rays may not be adequate to visualize the injury. This is often true for metatarsal stress fractures, where bone scans may be used if the history and physical examination suggest a potential fracture, but the plain X-rays are normal.

Computerized tomography (CT) may be used to assess fractures of the calcaneus and talus, since it may better be able to illustrate the anatomy of the ankle and midfoot joint and potential associated injuries.

The Lisfranc joint describes the connection between the first, second, and third metatarsals and the three cuneiform bones. A Lisfranc fracture dislocation often requires a CT scan to evaluate this region of the foot once plain X-rays delineate the injury.

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What is the treatment for a broken foot?

First aid at home may include RICE (rest, ice, elevation, and compression) and weight bearing as tolerated. If the decision is made to seek medical care, this regimen may still be considered once the patient is discharged from the hospital to go home.

The treatment of a foot fracture depends upon what bone is broken, the mechanism of injury, the underlying medical condition of the patient, and whether the fracture is open (the skin is broken) or closed (the skin is intact).

Broken toes are often treated symptomatically, with the injured toe "buddy taped" to an adjacent normal toe. It may be helpful to place cotton balls or other absorbent material between the toes to prevent dampness and skin injury. A stiff-soled shoe and crutches may be needed to help with walking. Healing should occur with in 4 to 6 weeks.

Fractures of the great toe that are displaced may require surgery to allow better healing. An orthopedic surgeon or podiatrist may choose this option, but often that decision is made electively a few days after the injury.

Open fractures of the toe usually require good wound cleansing to prevent infection. At the same time the health care practitioner will often explore the wound, looking for foreign objects and evaluate the condition of deep structures like tendons, looking for lacerations.

Metatarsal fractures often heal nicely with conservative care, meaning no operation is needed. The foot is wrapped for comfort to decrease swelling and placed in an orthopedic post-op or Reese shoe.

    First metatarsal fractures that are aligned nicely may be treated with a post-op shoe and avoidance of weight bearing. If the fracture is displaced, meaning the bone fragments do not align, an operation to pin or plate the fracture may be considered.

    Second, third, and fourth metatarsal fractures tend to heal nicely with an ace wrap for support and weight bearing as tolerated. Stress fractures usually involve the second and third metatarsals.

    Fifth metatarsal fractures are of two types. If the fracture is at the very base of the bone, then treatment is the same as the other metatarsal fractures.

    Jones fractures of the fifth metatarsal shaft have a non healing (non-union) rate of up to 50% and often require surgery to fix the fracture.

    Lisfranc fracture dislocation injuries require surgery for repair.

    The treatment of talus fractures depends upon where in the bone the fracture occurs.

    The top of the talus is dome-shaped and is part of the ankle joint, fitting into the base of the tibia or shin bone. This fracture may not be easily identified and sometimes can be mistaken for a non-healing ankle sprain. The treatment is rest and avoidance of weight bearing.

    Talar neck fractures often have difficulty healing because of poor blood supply. Surgery may be required if the bone is displaced, otherwise no weight bearing in a cast for 2-3 months may be required.

    A Shepherd fracture involves the posterior, or back part, of the talus and is seen in athletes who dance or kick. The treatment is immobilization in a cast.

    Lateral process fractures of the talus are becoming more common with the increased numbers of snowboarding injuries. Treatment includes no weight bearing in a cast.

    Calcaneus fractures require significant force to occur and are associated with a marked amount of swelling and pain. An orthopedic surgeon or podiatrist is often consulted emergently to decide whether surgery is needed to stabilize the fracture. The health care practitioner will also look for associated injuries of the ankle, knee, hip, and lumbar spine.

Immobilization of the fractured foot will help with pain control. Ibuprofen (Advil, Motrin) can be helpful with pain control by decreasing inflammation in the area. Narcotic pain medication may also be prescribed if needed.

Rest, ice, and elevation will help limit swelling and decrease pain.

[s.islam]

Thanks madam for your thoughtful and knowledgeable post.