The FOot

By: DR. AUSTIN COSTA

When to order foot X-rays?:

• Ottawa midfoot rules
  • Pain with palpation of base of 5thmetatarsal
  • Pain with palpation of navicular
  • Inability to bear weight both at time of injury and in ED
• Suspected injury with high energy mechanism 

Anatomy (From proximal to distal):

• Hindfoot 
  • Calcaneus and talus
• Chopart joint 
• Midfoot 
  • Navicular, medial cuneiform, middle cuneiform, lateral cuneiform, and cuboid
• Lizfranc joint
  • Lizfranc ligament connects medial cuneiform and 2ndMT on plantar aspect of foot
• Forefoot 
  • Metatarsals, phalanges

​Standard Views:

• AP
  • Forefoot 
  • Midfoot
  • Lizfranc injury
    • Alignment of 1stMT and medial cunneaform
      
    • Alignment of 2ndMT and middle cunneaform

Oblique

• Forefoot
• Midfoot
• Calcaneus 
• Alignment for 3rdMT with lateral cuneiform
• Alignment of 4thMT with cuboid

• Lateral
  • Hindfoot 
    • Boehler’s angle
      • upper edge of the calcaneal body posteriorly to the upper edge of the posterior articular facet of the calcaneus (red)
      • upper edge of the posterior articular facet of the calcaneus to the upper edge of the anterior process of the calcaneus (blue)
      • Normal is 25-40 degress ​

• Dorsal foot arch
  • Weight bearing films (if able to tolerate)
  • Allows spreading of metatarsals

• 1. ​Approach to foot X-rays:
  • Assess cortical disruption for fractures in area of tenderness
    • Forefoot
      • AP, oblique
    • Midfoot
      • AP, oblique
    • Hindfoot
      • Oblique, lateral
      • Boehler’s angle < 25 degress = calcaneal depression fracture

•  2. Lizfranc Injury
  
  • Plantar ecchymosis
    
  • Stress tarso-MT joint
    
  • Get weight bearing films!
    
  • Instability ED Ortho consult

• 3. Base of 5thMetatarsal 
  • Pseudo-Jone(Zones)
    • Ankle inversion
    • Peroneus brevis insertion
  • Jones (Zone II) 
    • Metaphyseal-diaphyseal junction
    • At level of 4th-5thmetatarsal joint
    • High risk of non-union
  • Diaphyseal Stress Fracture (Zone III)
    • Repetitive microtrauma

Management:

• Hindfoot: Splint (Bulky Jones), NWB
  • Boehler’s angle
  • Look for spinal injuries
• Midfoot: Splint (sugar tong w/ posterior slab), NWB
  • Lizfranc. -> Weight bearing films
• Forefoot: 
  • Metatarsals: CAM boot, NWB -> WBAT. Except 1stand base of 5th zones 2&3
    
  • Phylanges: Buddy tape, post op shoe, unless significantly displaced/rotated

References

1. Londner M, Hammer D, Kelen GD. Foot injuries. In: Tintinalli JE, Kelen GD, Stapczynski JS, Ma, OJ, Cline DM, editors. Tintinalli’s Emergency Medicine. 8 th ed. New York: McGraw-Hill; 2004; (cited 2017, Sep 08)
2. Smith, M. S., Hatch, R., & Eiff, M. (2012). Calcaneous and Other Tarsal Fractures; Metatarsal Fractures; Toe Fractures; . In Fracture Management for Primary Care (3rd ed., pp. 276-326). Philadelphia, PA: Saunders.
3. Weatherford, B. (n.d.). 5th Metatarsal Base Fracture. Retrieved September 08, 2017, from http://www.orthobullets.com/foot-and-ankle/7031/5th-metatarsal-base-fracture
4. Hatch, R. L., & Hacking, S. (2003, December 15). Evaluation and Management of Toe Fractures. Retrieved September 08, 2017, from http://www.aafp.org/afp/2003/1215/p2413.html
5. Foot Fracture Treatment & Management. (2017, August 03). Retrieved September 08, 2017, from http://emedicine.medscape.com/article/825060-treatment#d10