Foot injuries

From Medical-Wiki

Some athletic maneuvers will effectively increase a person’s weight twenty-fold. We demand much of our feet.

Contents 1 Anatomy of the foot 2 Presentation of foot complaint 2.1 Patient history 2.2 Physical examination 2.3 Ottawa rules 2.4 Diagnostic testing 3 Fractures 4 Maladies of the un-fractured foot 4.1 Sesamoiditis 4.2 Turf toe 4.3 Sever disease 4.4 Posterior tibial tendonitis 4.5 Morton neuroma

Anatomy of the foot

The foot is divided into the forefoot—5 metatarsals and 14 phalanges, the mid foot—the cuboid, 3 cuneiforms, the cuboid, and the navicular, and the hindfoot—the talus and the calcaneus. [1]

A sheet of connective tissue, the plantar aponeurisus, sweeps from the anteromedial tubercle of the first phalanx of each toe. Slips of the aponeurisus run from the medial and lateral borders to the first and fifth metatarsals.

Running along the medial and lateral metatarsals are the neurovascular bundles. Four nerves supply the forefoot—the sural nerve, most lateral, the peroneal nerve, the deep peroneal nerve , and the saphenous nerve. [2]

Foot injuries present as acute and chronic. 10% of all fractures are located in the 26 bones of the foot. One of the more unusual features of the foot is that many fractures present in a chronic setting. Therefore, even when evaluating a chronic complaint, fracture must remain an important part of the differential.

Presentation of foot complaint

Patient history

When taking a history, it is important to ascertain a mechanism of acute injury or for chronic complaint the nature or existence of an event that heralded a complaint’s onset. One of the commonly overlooked features of such a history is footwear. Chronic pain may be the result of wearing shoes, or even one pair of shoes on an intermettant basis, that do not fit, do not appropriately cushion the forefoot, or place an unusual amount of stress on the Achilles mechanism. This history must be pursued with a bit of vigor because patients are often oblivious to its nature.

A history should also pursue the timing of injury or onset of complaints, the association of activities with a given complaint—i.e. what makes it better, what makes it worse, and any history of prior injuries. A general medical history should also be pursued. Diabetes has a profound impact upon the resilience of the foot.

Physical examination

Physical examination should begin with an inspection of the foot for swelling, bruising, obvious deformity, and wounds. Feet should be examined together for comparison. Pulses, capillary refill, areas of tenderness, foot stability, and crepitus should all be checked. Wounds should be explored. Neurologic function including motor and sensory function should be checked. Range of motion should also be examined.

Ottawa rules

Ottawa rules are a set of criteria used to predict the presence of fractures and thus the need for x-rays. Their accuracy has been well established over a decade’s experience. They may be used for assessing whether or not x-rays are necessary. In addition, an inability to take 4 steps, point tenderness over the base of the fifth metatarsal, and tenderness over the navicular are indications for radiographs.

Diagnostic testing

Bone scans, CT scanning, and MRIs are also of use when evaluating chronic complaints.

Fractures

If an acute fracture is diagnosed, initial care utilizing RICE (rest, immobilization, cold, and elevation) should be initiated. There are a number of options for immobilization. These include stirrup splints, reinforced bulky dressings, postoperative or Reece shoes, and a cylindrical cast bivalved for swelling.

Toe fractures are exceedingly common. They heal well, usually with little intervention. For fifth digit fractures, advice about cutting out the toe of an old shoe is often helpful. Buddy taping for the first few days after a fracture may also provide some relief. Sometimes the purchase of a rigid orthopedic shoe may be needed if a patient must immediately return to employment that requires considerable time walking or standing.

The exceptions to benign neglect are significantly displaced fractures, particularly of the first toe. These may require closed reduction and rigid immobilization. In the case of fractures that cannot be reduced, open reduction and internal fixation may be necessary. This is particularly true of fractures of the first toe that involve the MP or IP joints or that involve multiple fragments. The first toe is of crucial importance to proper gait.

Fractures of the first metatarsal are relatively uncommon. This metatarsal head bears twice the weight of others. Minimally displaced fractures should be immobilized and non-weight bearing. Displaced fractures will typically require internal fixation.

Fractures of the second, third, and fourth metatarsals are called “internal metatarsal fractures.” These are the most common metatarsal fractures. They heal well most of the time with treatment utilizing a rigid orthopedic shoe or elastic support bandages.

A “march fracture” is a stress fracture of the second and/or third metatarsal. This occurs in anyone who must walk or run for prolonged periods of time on hard surfaces. Typical populations prone to this injury include military recruits, joggers, and even retail clerks. Treatment of this fracture centers 4 to 6 weeks’ avoidance of the precipitating activity—a suggestion well received by retail clerks and new military recruits and virtually ignored by inveterate runners.

The fifth metatarsal is the most commonly fractured metatarsal. These fractures have been divided into two types, a Jones fracture and a tennis fracture (pseudo-Jones.)

A tennis fracture is at the proximal tuberosity. It is often associated with a lateral ankle sprain. It is at this site that the peroneus brevis attaches. Compression dressings and gradually increasing weight bearing will usually suffice to treat this fracture.

The Jones fracture is a greater problem. It occurs in a transverse fashion at the base of the fifth metatarsal. Weight bearing has a tendency to cause increased displacement. This can lead to chronic pain and eventually require surgical fixation. It is judicious to place Jones fractures in non-weight-bearing casts.

The Lisfranc joint is comprised of the articulation of the first. Second, and third cuneiforms and the first. Second, and third metacarpals. Fractures and dislocations at this joint arery commonly missed. A quick check for such fractures can be performed by grabbing the heads of the first and second metatarsals and moving them through dorsi and plantar flexion.

Radiographs may reveal these fractures, but if plain radiographs do not reveal a fracture and there is strong clinical suspicion, weight bearing films should be performed. CT scanning is sometimes needed. franc fractures require immediate orthopedic referral.

Calcaneal fractures are most commonly associated with a fall from height. The most common type of calcaneal fracture is an intraarticular joint depression fracture. These fractures require open reduction the vast majority of cases. An extraarticular fracture may be initially treated with a bulky dressing, ice and nonweight-bearing until the patient is seen in consult.

The talus is the second most fractured tarsal bone. Its poor blood supply results in a high incidence of avascular necrosis. It too should receive immediate orthopedic attention. [3]

Maladies of the un-fractured foot

A foot that is not fractured is subject to a wide range of acute and chronic maladies.

Sesamoiditis

Sesamoiditis is characterized by pain worsened by jumping and pushing off to run. The pain is beneath the ball of the foot. Exam reveals pain on dorsiflexion of the hallux, restricted motion at the first MTP joint or pain on the dorsum of a sesamoid. Treatment includes the use of cushioned-soled shoes with total contact inserts to relieve first metatarsal head stress and RICE. The orthosis should be worn for six months.

Turf toe

If the first MTP joint is hyperextended beyond 60 degrees, the resultant injury is called turf toe. The toe appears in a red, swollen, stiff state. There may be laxity in the anterior posterior plane. The joint actually appears as though it has a gouty arthropathy. Aspiration and joint fluid analysis for crystals as well as culture is sometimes necessary. RICE, strapping of the toe in plantar flexion and rigid orthotics help recovery. With a severe injury, sometimes 6 weeks of recovery are required.

Sever disease

When young adolescents develop chronic heel pain, it is called Sever disease. It is caused by excessive traction on the calcaneal apophysis during running and jumping, usually as a result of inflexibility of the gastrocnemius, hamstring, quadriceps, and hip flexors. Treatment consist of RICE, muscle stretching and heel inserts.

Posterior tibial tendonitis

Posterior tibial tendonitis is seen most commonly in middle-aged females and male athletes who are required to do repetitive start and stop motions—football, basketball, soccer, etc. The typical complaint is of pain inferior to medial malleolus. Examination usually reveals pain over the posterior tibial insertion, often with a swollen erythematous navicular prominence. This is a condition associated with pes planus. In addition to NSAIDs and RICE, severe cases sometimes require immobilization in a cast.

Morton neuroma

A Morton neuroma causes pain over the ball of the foot. This pain is typically followed by radiation of pain to the affected toes. Patients may also have the other symptoms of a neurasthenia—a sense of hot or cold, tingling, or numbness.

This malady is caused by recurrent pressure on the digital nerves. Wearing tight shoes or pointed high heels, or doing repeated starts in the fashion of a sprinter are activities that can create a Morton. Compressing the affected web space while squeezing together the metatarsal heads should precipitate pain in a foot with a neuroma.

Shoes should be properly sized to reduce the chance of further exacerbation of the causes of a Morton Neuroma. Fitting a felt pad under the heads of the affected metatarsals may serve to spread the metatarsal heads. Corticosteroid injection is sometimes effective. [4]