Fractures of the Foot & Ankle
The ankle is a complex joint made up of 3 bones, the talus, tibia, and fibula. A fracture of the ankle is usually due to and external trauma like a sprain or a fall. It is important to seek immediate treatment for any suspected ankle fracture.
The calcaneus (heel bone) is the main weight and load bearing bone of the foot. It lies just under the talus (ankle bone). The joint between these bones is essential for walking as it helps the foot move inward and ourward and side to side.
A fracture of the calcaneus, or heel bone, is usually the result of an automobile accident or fall from a great height. Symptoms include pain on the outside of the ankle or under the heel; inability to bear weight and swelling and stiffness. Severe and significant swelling and widening of the heel will be noted. The heel bone is much like an egg and will fracture into many pieces as its outer wall breaks. Depending on the amount o forces put through the bone during the injury, the joints may fall into the fracture. This fracture may be accompanied by back or knee injury due to the amount of force required to break the heel bone.
In some cases, the alignment of the bones are appropriate for casting of the foot and use of crutches for 6 to 8 weeks.
In most cases, the fracture is severe where the joint is misaligned and there are too many pieces to the fracture. Surgery will be needed to realign the bones and the joints and the proper height and anatomy of the heel bone to preserve function and the joint. This will require many screws and a plate and up to 8 weeks in a cast and crutches. In some patients, arthritis of the joint will develop over time and a second surgery may be needed.
There are 5 metatarsals behind each toe in the foot. Any of these bones can be fractures or broken. Most commonly, the 2nd or 5th can be fractured. These breaks occur from a trauma or overuse.
Direct trauma to the bone can cause a fracture or crush to the bone, like a heavy object falling on the foot, or a fall from a height. In most cases, these fractures will be placed in a cast with crutches. In severe fractures, the bones will need to be realigned with surgery using plates and screws.
Stress Fracture of the Metatarsal:
A stress fracture is a unique type of fracture where the bone has undergone repetitive stress without a full break. Continued pressure on the bone will eventually lead to a complete break of the bone. The 2nd metatarsal can most commonly incur a stress fracture. These fractures will need rest in a walking boot for 3 to 6 weeks to avoid further damage to the bone.
5th Metatarsal Fracture:
The 5th metatarsal is susceptible to certain fractures due to its unique position on the outer side of the foot.
A traumatic twist or sprain of the foot or ankle can cause a fracture of the base (tuberosity) of the 5th metatarsal. This is the most common type of 5th metatarsal fracture. These fractures occur at the base of the bone where it has an attachment of a tendon. A small piece of the bone will pull off (avulse) due to the tendon and ligament attachment. These fractures can often be placed into a walking boot with crutches for about 6 weeks. Those avulsion fractures that are slightly misaligned, or involve the joint will need to be in a cast with crutches for up to 6 weeks. In some cases if the bone is significantly misaligned, surgical realignment with screws will be needed.
A fracture just before the base (or end) of the 5th metatarsal is called a Jones fracture. It does not involve the joint. This is a rare fracture that is usually caused from a twisting of the ankle or foot. This area of the 5th metatarsal has the least amount of blood flow, which lends to the increased chance of delayed union or non-union of the fracture. When treated immediately, treatment consists of a cast with crutches for up to 6 weeks. An old Jones fracture will need to be fixed with surgery using screw fixation.
In the middle of the foot between the bases of the 1st and 2nd metatarsals and midfoot bones (cuneiforms) is a specialized ligament that joins these bones together. A sprain or fracture through this area is called a Lisfranc’s Fracture Dislocation.
A fracture of the Lisfranc’s joint of the midfoot is often caused by dropping something heavy on the top of the foot or by falling after catching the foot in a hole, or a severe foot sprain. Symptoms are similar to a sprain and include swelling and pain at the top of the foot, bruising, possible inability to bear weight and pain when moving the foot while the ankle is held steady. If you think you have a sprain and it does not improve with rest and ice after one to two days, you may have a Lisfranc’s joint fracture and should see a doctor to prevent further injury. Left untreated, this type of fracture will lead to chronic pain and arthritis of the midfoot.
In mild cases, casting of the foot with some time on crutches will be needed to allow time for the ligament and bones to heal.
In severe cases of rupture of the ligament with dislocation and fracture of the bones, surgical repair is needed. Specialized equipment is used to realign the joints and the bones to achieve perfect anatomical alignment. This is important to prevent future arthritis and chronic pain.
The navicular bone rests just in front of the ankle bone (talus) and behind the midfoot bones (cuneiforms). Along with its joint to the ankle bone, the navicular aids in holding the formation of the inner arch. Part of the bone is most noticeable on the inner arch as a bone protuberance, that can be larger in some people than others. This part of the bone is an important attachment point for a tendon called the Posterior Tibial tendon. Some people are born with an extra bone in this area called an os tibiale externum.
The navicular bone can fracture after small repetitive injury or a significant injury. Repetitive injury can cause a stress fracture of the navicular bone, while a substantial injury, like a foot sprain or a fall from a height, will cause a complete fracture of the bone. Most cases of navicular fractures are after a foot sprain that will cause an avulsion or pull off fracture of the bones inner prominence. In rare cases, the navicular can dislocate with severe sporting injuries.
People at high risk for navicular fractures are those participating in: ballet, equestrian sports, basketball, soccer, football, and gymnastics.
Navicular fractures are often missed on regular x-rays, for this reason, when there is a suspicion of a navicular fracture, Dr. Soomekh will perform an in office CT scan of the foot to evaluate the navicular in3 dimensions.
Most patients will require a 4 to 6 week period of being in cast and crutches. Severe fractures will require surgical repair with screws. Dislocations will need reduction under anesthesia.
The talus is the main bone of the 3 bones that make up the ankle, positioned between the heel bone and the tibia and fibula. It is a very complex and unique bone. It acts as a connection between the foot and the leg.
A fracture of the talus is often due to a significant trauma, like an automobile accident or fall from a height or a severe sprain. Talus fractures are very painful, causing swelling, tenderness and an inability to bear weight on the foot.
Treatment for talus fractures is essential because if it does not heal correctly, the foot’s mobility may be reduced and chronic pain and arthritis may develop. Some talus fractures can be treated with casting and the use of crutches for 6 weeks, followed by physical therapy to regain strength and flexibility.
In most cases, however, surgery is necessary to realign the injured bones and properly support the joint to diminish the chance of arthritis. It is important to maintain the proper anatomy of the talus bone so that the blood supply is maintained and the joints are preserved.
The big toe has 2 bones and 1 joint, while the 2nd, 3rd, 4th, and 5th toes have 3 bones and 2 joints. These bones are called phalanges. Any of these bone can fracture or break.
Toe fractures usually occur after a trauma like stubbing the toe into a piece of furniture. The impact will cause a break to one of the bones, usually the closest one to the tip, or the one closest to the rest of the foot.
In most cases, the bone will break but stay in a good position where realignment is not needed due to the tight space the bones are in. The toe will need to be bandaged to reduce swelling and avoid a “sausage” toe, while splinting it to the adjacent toe to stabilize the fracture. Bones take about 6 weeks to heal. The toe may be sore for many months.
Dislocation Fracture of the Toe:
In some cases, the shifting of the bones is far enough where realignment is needed. The foot will be numbed, and the doctor will pull on the toe to reposition the bones into their proper position. The toe will then be splinted. A special fracture shoe needs to be worn.
If the trauma is severe enough, there may be a dislocation of the toe at the level of the joint or in the middle of the bone. These cases will always require realignment in the office and splinting.
In rare cases, the fracture is misaligned or dislocated so much that surgical repair and realignment with pins is needed.