Porter & Schon: Baxter's The Foot and Ankle in Sport, 2nd ed.

Section 2 - Sport Syndromes

Chapter 5 - Ankle and midfoot fractures and dislocations

William C. McGarvey






Clinical diagnosis






Ankle fractures



Lateral process talar fractures



Anterior process calcaneal fracture



Tarsometatarsal dislocations



Tarsal bone fractures



Fractures of the base of the fifth metatarsal





Fractures and dislocations of the foot are among the most common injuries in the musculoskeletal system. With the recent explosion of interest in athletic activity, the foot and ankle have been exposed to a variety of new stresses. The disability and time away from sports resulting from these injuries warrant close attention to diagnosis and management (Figs. 5-1, 5-2, 5-3, and 5-4 [0010] [0020] [0030] [0040]).


Figure 5-1  Conservative modalities for managing acute injuries.




Figure 5-2  Rehabilitation methods involve patient participation.




Figure 5-3  Athletes often will find ways to return to sport earlier than expected.




Figure 5-4  Inset from Figure 5-3 .




Clinical Diagnosis

In evaluating patients with trauma to the foot, it is essential to obtain a thorough, detailed history to direct the examiner in physical and radiographic examination. In addition, it will provide a clue to the associated degree of soft tissue injury.

Physical examination should be meticulous and systematic. It is recognized that although most forefoot injuries are easily diagnosed, midfoot injuries often go undetected. Because of the high incidence of multiple fractures or fracture/dislocations in the injured foot, careful examination and palpation of points of tenderness should be performed to detect evidence of occult injury. Evaluation of range of motion of the ankle, subtalar midtarsal, and metatarsophalangeal joints is incorporated into every routine examination. A careful motor examination, both intrinsic and extrinsic, as well as a sensory examination, is performed. Vascular examination, including Doppler studies, is essential. Radiographs are guided by the examiner's history and physical examinations. Standard views of the foot include anteroposterior (AP), lateral, and oblique views. The oblique view, for example, is particularly useful for evaluating joints, such as the calcaneal cuboid joint, that typically are hidden or poorly examined in AP view. Specialty views, such as axial views of the heel, Broden's view of the subtalar joint, and stress views of the foot also are helpful in certain circumstances. Because of the complexity of the anatomy and lack of uniform appreciation or interpretation of the foot radiographs, adjunctive studies, such as computed tomography (CT), bone scan, and magnetic resonance imaging (MRI), can be of tremendous value. These also are particularly useful because of the subtle nature of many foot and ankle injuries.

Standard radiographic examination of the ankle includes three views: AP, lateral, and mortise. From these, a remarkable amount of information may be obtained, not only about fracture patterns but, more importantly, about the relationship of the three bones that comprise the ankle mortise—tibia, fibula, and talus. Use of measurements of mortise width; medial or tibiofibular clear space; talocrural angle; “Shenton's” line of the ankle (that space that demonstrates a mirrored congruity between the lateral talar wall and the corresponding curvature of the distal medial fibula); and talar tilt all are helpful in determining the subtle abnormalities of the ankle mortise ( Fig. 5-5 ).


Figure 5-5  A to F, Schematic representation of radiographic parameters. (A) Medial clear space should equal the articular distance at any point around the mortise. (B) Talo-crural angle. (C) Talar tilt. (D) “Shenton's line” of the ankle. (E) Tibio-fibular clear space. (F) Tibio-fibular overlap.  From Myerson MS: Foot and ankle disorders, St Louis, 1999, Mosby.


When in doubt, the clinician also may obtain contralateral views to determine that which constitutes normal anatomy for that particular patient, because there tends to be a high degree of variability in what is considered normal from patient to patient. Medial clear space is as viewed in anterior/posterior radiographs. It is the measure of distance between the medial talar wall and lateral portion of medial malleolus. Although this is a linear measure, it reflects a rotational (external) abnormality of the talus with respect to the tibia. Injury leading to abnormality of this relationship with measurements of less than 1mm or greater than 4mm has been shown to correlate with poor outcomes, including chronic pain, instability, and arthrosis. [0010] [0020] [0030]

Mortise views should demonstrate relative congruity of the joint space circumferentially—medial tibiotalar, dorsal tibiotalar, and lateral fibulotalar. The distance between these bone margins should be equivalent. In addition, a congruous relationship should exist between lateral talus and medial fibula, the so-called Shenton's line of the ankle. Abnormalities, as evidenced by incongruity, provide clues to malalignment resulting from bony or soft tissue injury.

The talocrural angle helps to define the appropriate fibular length. This is measured as the angle between the line parallel to the distal tibial joint surface and another line drawn between tips of the medial and lateral malleoli. Normal values average 83 ± 4 degrees. Differences of more than 2 degrees to the contralateral normal side suggest fibular shortening.

Talar tilt is measured by determining the angle between articular surface lines drawn parallel to the distal tibia and proximal talus. Although uniform agreement on what is considered normal does not exist, a side-to-side difference of more than 5 degrees (or 2mm) is considered pathologic.

Syndesmotic space probably is the most confounding of all radiologic measures. Measurements should be performed to account for the space existing between the medial edge of the fibula and the lateral edge of the tibial incisura, determined at 1cm proximal to the joint line to ensure reproducibility. Average distance should be less than 5mm but may vary up to 6mm in larger individuals. Another measure of syndesmotic integrity is the tibiofibular overlap. The distance between the medial fibula and the lateral edge of the anterior tibia should be 10mm (see Fig. 5-5 ).

Ancillary studies, such as stress radiographs, CT scanning, and MRI are used liberally to provide more information regarding ankle relationships and stability.



Generic goals in the treatment of fractures and dislocations of the foot are as follows:



Avoiding stiffness and loss of mobility.



Removing bony prominences, which may result in pressure phenomena.



Restoring the articular surfaces.

Any fracture or dislocation of the foot or ankle that results in focal skin pressure or evidence of neurovascular compromise must be addressed immediately. Manipulation or even open reduction must be carried out to reduce the potential sequelae, including skin necrosis, neuropraxia, ischemia, and/or pressure-induced necrosis of articular surfaces, because of abnormal loading secondary to malpositioning after fracture or dislocation.

Even anatomic restoration does not guarantee optimal functional outcome, but it certainly provides the athlete with a significantly reduced risk of morbidity associated with sequelae of delayed or untreated injury. However, injuries that present without gross distortion of anatomy or imminent threat to the viability of the limb may be treated better after an appropriate “cooling down” period. This is not to say that they should be splinted and ignored, but a short period should be devoted to rest, ice, compression, and elevation (RICE) to allow the soft tissue integrity and oxygenation to reestablish itself, particularly before the clinician embarks on any invasive procedures.

The evolution of treatment of the traumatized foot and ankle of the athlete has directed more attention to aggressive intervention than to “benign neglect.” Recognition of the fact that long periods of immobilization after trauma may lead to muscular atrophy, myostatic contracture, reduction of joint mobility, associated connective tissue proliferation leading to scarring, synovial adhesion, and cartilage degeneration has prompted a more aggressive approach to foot and ankle injuries, using appropriate surgical intervention to stabilize injuries and institute earlier range of motion and weight bearing when possible. These tenets provide for the ability to institute potential prevention against previously disabling factors such as disuse osteopenia, limb atrophy, proprioceptive losses, and chronic, persistent pain.[0040] [0050] [0060] [0070] [0080] Introduction of early range of motion, physical therapy modalities, appropriate splinting, and bracing, as opposed to casting, allows for the earlier restoration of function and avoidance of complications. The static accumulation of hematoma, fluid extravasation, and resultant articular and tendinous adhesions is far less with treatment that promotes earlier rehabilitation.[4] This type treatment also helps to prevent disabling sequelae, such as arthrofibrosis and regional pain syndromes.[7]

Although the realm of athletically related foot and ankle injuries is too vast to be encompassed in this chapter, the more common injury patterns encountered are addressed. Diagnostic and management controversies are discussed and elucidated for the reader. Rather than a trauma compendium, this is meant to be a guide for the treatment of frequently occurring sports and athletic injuries to the foot and ankle for one's reference and perusal.


Ankle Fractures

Medial fractures

Isolated medial fractures are unusual but not rare ( Fig. 5-6, A and B ). One must have suspicion for a “bimalleolar variant” in which lateral ligamentous injury has occurred in deference to bony injury. Generally, medial malleolar fractures indicate loss of stability of the ankle. Anywhere from 5% to 15% of untreated fractures may go on to nonunion ( Fig. 5-7, A through D ). Fracture patterns may vary from vertical, oblique, or horizontal, depending on the mechanism of injury. However, because of the risk of sequelae and potential for instability and abnormal mechanics, all but those that are nondisplaced should be repaired. Even those demonstrating minimal (<2mm) displacement carry some advantage to stabilization, such as reliable fixation, early range of motion, lack of immobilization, and potentially early return to activity.



Figure 5-6  (A and B) Medial malleolar fracture in a 16-year-old basketball player. The athlete elected to undergo nonoperative treatment and healed uneventfully in 6 weeks.




Figure 5-7  (A and B) Computed tomography images of a 17-year-old offensive lineman with delayed union of repaired medial malleolar fracture. (C and D) Union was achieved with local bone grafting from the calcaneus and revision internal fixation.



As evidenced by Ramsey and Hamilton,[9] as well as Yablon,[10] ankle stability is dependent on medial integrity. Michelson and others [0010] [0110] [0120] [0130] [0140] [0150] [0160] [0170] [0180] [0190] [0200] have shown that the talus will not shift abnormally with integrity of medial structures. Therefore attention should be directed to anatomic restoration of the medial ankle if it is disrupted. Repair may be performed percutaneously with cannulated screw fixation but should be reserved for absolutely anatomic reductions. Any incongruity, as evidenced by articular irregularity, necessitates open repair with restitution of the articular surfaces. I prefer open techniques because radiographs often may disguise an occult malreduction. Often, anterior/posterior reduction appears anatomic, but evaluation via live fluoroscopy will demonstrate some degree of articular step-off with internal rotation toward a mortise view. I prefer an open reversed J incision with attention to interposed periosteum and unrecognized comminution at the fracture site. Additionally, open reduction affords the opportunity to inspect the articular surface, which provides useful prognostic information. Fixation is dictated by fracture pattern. Most often, one or two partially threaded cancellous screws are sufficient; however, with a more vertical fracture pattern, several screws with washers or even a small one-third tubular anti-glide plate will be indicated.

Once wound healing is stable, range of motion and resistance exercises are instituted. Weight bearing is restricted until 4 weeks and is advanced on the basis of symptoms. Results generally are good.

Lateral fractures

Isolated lateral malleolar fractures present one of the most challenging management dilemmas in the realm of sports injuries. Associated syndesmosis widening or medial injury, bony or ligamentous, make the choice of treatment fairly simple and obvious. [0150] [0210] [0220] [0230] However, fibular fractures at any level without concomitant injury or significant radiographic displacement generate varied and controversial opinions as to what is considered appropriate intervention.

On one hand, arguments may be made that surgery is unnecessary because, even though the lateral stability is compromised, it is not completely diminished. Intact medial structures, specifically the malleolus and deltoid ligament, provide primary resistance to lateral talar translation, thus limiting or preventing abnormal ankle mechanics. Several studies support displacement, lateral or posterior, of up to 5mm without significant compromise in clinical outcomes. [0220] [0230] [0240] [0250] [0260] Physiologic loading studies of the normal and compromised ankle suggest that the medial structures are, in fact, most important for stability. [0010] [0100] [0110] [0120] [0130] [0140] [0150] [0160] [0170] [0180] [0190] [0260] [0270] It also has been shown by CT analysis that fibular displacement occurring as a result of an external rotation force with intact medial structures (Lauge-Hansen SER2) is the result of internal rotation of the proximal fragment.[18] This implies that the distal fibula maintains its relationship with the mortise and that no functional incongruity is present ( Fig. 5-8, A through D ). Clinical studies have supported this notion, demonstrating good results with up to 30-year follow-up on nonoperative treatment of isolated lateral malleolar fractures. [0240] [0280] [0290] [0300]


Figure 5-8  (A and B) Nondisplaced distal fibula fracture that this athlete elected to treat without surgery. (C and D) Note that, despite clinical healing, radiographs still disclose fracture line at 4 months. The athlete was asymptomatic and back to full activity.



Alternatively, an argument may be made for repairing all but nondisplaced fibular fractures, the rationale being that even small increments of displacement may lead to fibular shortening or mortise widening. [0040] [0100] Early mechanical testing suggested that the lateral talar displacement of as little as 1mm would significantly increase contact pressures in the tibiotalar joint, thus creating a potential predisposition to early arthritic changes.[9] In addition, it was shown that the talus would routinely follow the displacement of the fibula, thus lending itself to anatomic malpositioning and subsequent abnormal loading stresses[10] ( Fig. 5-9, A through F ).


Figure 5-9  (A and B) Displaced fractures of the fibula with mortise widening require open reduction and internal fixation, with possible attention to the deltoid ligament if the mortise remains widened. (C and D) Even after anatomy is restored through closed reduction, stability is in question. (E and F) Open reduction and internal fixation (ORIF) ensures anatomic restoration of the joint and allows early institution of joint motion and therapy.



However, these studies [0090] [0100] are some of the most often misquoted or misinterpreted in the literature. These analyses were performed in vitro and, as such, focused specifically on the relationship between the fibula and talus after eliminating all other attachments. There was no medial restraint to motion; thus, even though the results can be viewed as reliable and truthful, they bear limited clinical applicability because the contribution of the medial osseous and ligamentous structures was ignored. Appropriate interpretation of these studies suggests that abnormal ankle mechanics may be encountered when a fibular fracture exists in the face of medial deficiency. In these cases, operative treatment should be used.[15] However, these studies fail to speak to the long-term, clinical consequences of a truly isolated lateral malleolar fracture.

More practical arguments for operative fixation in the athlete are more reliable reduction in the face of unclear medial injury; anatomic bone-to-bone contact, facilitating primary bone healing, faster recovery times, and earlier return to weight-bearing; and stabilizing weight bearing; rehabilitation; and shorter duration of pain. All are anecdotal, and none have been demonstrated in a prospective comparison study of operative versus nonoperative treatment specific to this injury pattern.

Controversy persists surrounding the process of decision making. Despite evidence to the contrary, many surgeons perform, and athletes elect to undergo, repair of the injured lateral malleolus, presumably for fear of abnormal and untoward results of pathologic mechanics and to resume activity as quickly as possible. A large body of clinical evidence favoring this faction is the demonstrated lack of reliability of reproducible medial tenderness on clinical examination in disclosing the presence or absence of deltoid ligament injury.[31] It is unclear as to what degree of deltoid injury in the face of the fibular fracture will allow for clinical instability.[10] Therefore many surgeons ascribe to the philosophy that it is better to be aggressive, especially in someone whose livelihood may depend on the anatomic function of an ankle or lower extremity. Again, the perspective is anecdotal but reasonable. Surgical treatment often is pursued, as detailed later.

Nonoperative management consists of immobilization until swelling and pain allow motion, usually about 10 to 14 days. Subsequent weight bearing ensues in a walking boot, again, when symptoms abate. In most instances, athletes are back to protected weight bearing somewhere between 3 and 4 weeks. The walking boot is maintained until full weight bearing and nearly normal range of motion are restored. Physical therapy focuses on maintaining muscle tone, joint mobility, and proprioception during the healing phase. Return to activity is dictated by relief of pain, normal symmetric joint range, and strength equal to 75% of that in the normal, unaffected side. Sports-specific activities are resumed with protective taping or bracing as necessary. Radiographs are monitored frequently in the first month to ensure no displacement, but after 4 weeks these typically are not helpful as long as no changes are noted, specifically no mortise widening.

Should one embark on the surgical management of the isolated lateral malleolus fracture, operative principles of anatomic restoration and rigid fixation apply. The goal is to allow early mobilization and quick recovery. Debate still exists regarding the use of interfragmentary fixation combined with lateral buttress plating versus posteriorly placed, anti-glide fixation. Lateral plating is technically easier, whereas posterior plating theoretically provides greater mechanical stability. [0320] [0330] Both seem to perform well clinically. No current consensus exists, and the method remains the preference and comfort level of the surgeon.

A recent resurgence of interest has been noticed in an older technique of fibular fixation—intramedullary nailing. This method of fixation has some limited application in the treatment of fibular fractures but really has no place in the operative fixation of a high-demand individual or high-performance athlete. What little advantage one can gain from biomechanical stability of an intramedullary device quickly is counteracted by the notorious inability to correct or control rotation and length. In fact, my experience suggests that the insertion of the device often will alter or displace a previously anatomic reduction because of the force required to install it, as well as the angled flange on the interlocking nails. These are not recommended when one is in need of an anatomic restoration of the joint and should be reserved for lower-demand, medically compromised patients in need of surgical stabilization.

One indication for this type of fixation would be in the athlete with a displaced, low (Weber A) fibula fracture. In this instance, an intramedullary, 4.0-mm, cancellous screw would be reasonable, provided that an anatomic reduction can be achieved.

Bimalleolar/trimalleolar fractures

Little debate exists regarding treatment of bimalleolar/trimalleolar ankle fractures. In an athletic population, uniform agreement exists regarding the need for operative intervention [0210] [0220] ( Fig. 5-10, Athrough D ).


Figure 5-10  (A through D) Bimalleolar and trimalleolar fractures require open treatment.



Some caveats do exist, however. Particularly attention should be paid to the fibular length and rotation. Any degree of malreduction may lead to abnormal mechanics and possibly could hasten the advance of degenerative arthritis.

High fibular fractures associated with bimalleolar fracture patterns should be stabilized rigidly and anatomically. All injuries should be tested for syndesmotic stability, but especially those demonstrating a medial soft tissue injury. This test can be done by directly visualizing the syndesmotic ligaments while applying a laterally directed pull on the fibula with a towel clamp, reduction tool, or other grasping object. Any laxity in tibiofibular stability associated with a fibular fracture more than 3.5 to 4.0cm from the joint should be stabilized with syndesmotic fixation[11] ( Fig. 5-11, A through D ).


Figure 5-11  (A through D) Syndesmosis repairs should be performed at the level of injury occurrence and be based on the stability of the joint after malleolar repair. (A and B) Displaced bimalleolar fracture in an adolescent wrestler. Note the avulsion of the anterior inferior tibiofibular (AITF) ligament from the distal tibia. (C) Malleolar repair with a screw in the syndesmotic fragment. (D) More traditional fixation for a higher level fibula fracture and persistent tibio-fibular widening.



I prefer to use a 3.5-mm screw with three cortex fixation and a plate long enough to incorporate the screw proximally to the distal-most hole (see Fig. 5-11, D ). Routine screw removal is performed after 12 weeks on the basis of biomechanical evidence of abnormal ankle mechanics in the face of restricted talofibular motion.[34] This reduces the risk of a free-standing screw hole as a stress riser and theoretically allows quicker, safer, and more reliable return to activity.

Trimalleolar fractures at least should have the medial and lateral components repaired. Fixation of the posterior fragment of tibia is performed on the basis of size of the segment and, more importantly, percentage of articular surface involved. Those with more than 25% to 30% of the joint involved in the fracture should undergo stabilization with at least one anterior to posterior screw (see Fig. 5-10, C andD ).

Pediatric ankle fractures

Pediatric ankle fractures constitute a wide variety of patterns and complexity. However, these often are encountered in the growing population of high school, junior high, and primary school athletes.

Salter-Harris (S-H) fractures not involving the joint adhere to principles of all generic, pediatric fracture management protocols ( Fig. 5-12 ). Closed anatomic reduction often is successful simply by reversing the mechanism of injury. Cast immobilization typically is effective for management, and bony remodeling usually compensates for any minor malalignments. Immobilization usually is required for 6 to 8 weeks, at which point gradual weight bearing and range of motion may be advanced as tolerated. Any articular incongruity necessitates open management ( Fig. 5-13, A and B ).


Figure 5-12  Dias, Tachdjian modification of Salter-Harris' classification of ankle fractures in the immature skeleton.  From Green NE, Swiontkowski MF: Skeletal trauma in children, Philadelphia, 2002, WB Saunders.




Figure 5-13  (A and B) Supination-inversion injury of the ankle. (B) With repair. Care is taken to avoid the tibial physis and articular surface. The fibular pin is removed after 4 to 6 weeks.



Complexity increases in the diagnosis and management of the adolescent variants of the Tillaux (S-H III) and triplane (S-H IV) fractures. These typically occur in the 12- to 14-year age range as the medial tibial physis begins to close, creating an irregular stress distribution and resistance to forces applied across the ankle ( Fig. 5-14 ).


Figure 5-14  Demonstrating the unusual closure of the distal tibial physis. First, it starts in the middle of the growth plate, then moves anteromedially and finally laterally.  From Green NE, Swiontkowski MF: Skeletal trauma in children, Philadelphia, 2002, WB Saunders.


Tillaux and triplane fractures are considered adult, and issues regarding treatment should be viewed as such ( Fig. 5-15 ). The focus of treatment should be based on congruity of articular reduction because the complications surrounding these injuries arise from nonanatomic incongruous relationships, leading to early degenerative changes rather than the more popular but erroneous presumption of growth arrest. Abnormalities or asymmetry in growth actually are rare and not terribly consequential in these scenarios.


Figure 5-15  (A and B) Tillaux and triplane ankle fracture variants in the adolescent athlete.  From Green NE, Swiontkowski MF: Skeletal trauma in children, Philadelphia, 2002, WB Saunders.


Any question of articular irregularity should be settled by obtaining advanced imaging studies, specifically CT scanning, to eliminate the possibility of articular step-off. Separations of more than 2mm in distance along the joint surface, regardless of congruity, should be repaired. No compromise should be accepted at the articular surface for fear of early degenerative changes.

Percutaneous techniques using large reduction clamps or devices and cannulated screw fixation are acceptable, but the surgeon must be certain of anatomic restoration and no interposed tissue. If there is any question regarding adequacy of reduction, open treatment is required. Once stability is ensured, motion may be introduced; however, weight bearing should be withheld for 6 to 8 weeks until healing is confirmed.


Lateral Process Talar Fractures

Fractures of the lateral process of the talus previously have been considered an uncommon injury. Historically, this injury was thought to occur as the result of high-energy trauma and would result from a peritalar dislocation that caused avulsion of the subtalar ligamentous attachments on loading. More recently, however, this injury has gained notoriety because of its strong predilection for presentation after snowboarding injuries. Before the advent of this relatively new winter sport, reports were infrequent. However, with the explosion of attention to this activity by a predominantly young, risk-taking population, the incidence and recognition have risen dramatically—so much so that this injury has been deemed by some as the “snowboarder's ankle.” [0350] [0360] One review demonstrates 74 lateral process fractures of the talus that occurred as the result specifically of snowboarding, accounting for 2.3% of all snowboard injuries. This is, to date, the largest series reported.[36]

Lateral process fractures often are missed, commonly masquerading as chronic ankle sprains. It is easy to understand why this happens because of the relative anatomic proximity of this injury to the anterior talofibular ligament, as well as the lack of reliability of reproducible evidence of fracture on standard radiographic studies. Early diagnosis and treatment, however, are important because studies have suggested that late recognition and failure to implement treatment routinely lead to poor outcomes, such as chronic pain, stiffness, instability, and arthritis. [0370] [0380] [0390] [0400] [0410] [0420] [0430] [0440]

Traditionally, lateral process fractures were purported to arise from a sudden dorsiflexion inversion force on a fixed foot. However, mechanical loading studies have demonstrated that an acute external rotation or shear force is a key element in reproducing this fracture pattern in a cadaveric model.[35]

Hawkins[39] has classified these fractures into three subcategories ( Fig. 5-16 ). Type I is a simple fracture of the lateral process extending from the tibiofibular articulation down to the posterior talocalcaneal articular surface of the subtalar joint, with or without displacement of the fragment. Type II fractures involve comminution of the fibular and posterior calcaneal articular surfaces, as well as the lateral process. Type III is an avulsion or chip fracture off the anterior and inferior part of the posterior articular processes of the talus. Another classification system has been proposed by Fjeldborg,[38] who described stages of injury with type I fissuring, type II lateral process fracture with displacement, and type III lateral process fracture with subtalar dislocation. Diagnostically, this fracture pattern presents a dilemma, and a high index of suspicion is needed by the clinician. Injury pattern reports by the patient often are unreliable and inaccurate. Physical examination findings often are similar to those found with an acute, severe ankle sprain with tenderness just anterior and inferior to the tip of the fibula, along with swelling and ecchymosis.


Figure 5-16  (A through C) Hawkins classification of lateral talar process fractures.  From: Boon AJ, Smith J, Zobitz ME, Amrami KM, et al: Am J Sports Med, 29(3):333, 2001.


Radiographs sometimes are helpful when large fragments or significant comminution are present but, again, are not reproducibly diagnostic because of the irregular anatomy and overlap of joints in this area. [0370] [0450] Special radiographic views have been proposed to help elucidate these fractures, including a 20-degree internal rotation view with the foot in neutral dorsiflexion.[46] Alternatively, Dimon[37] has suggested that the ankle be placed in 45-degree internal rotation and the foot plantarflexed at 30 degrees to show the posterior facet in profile. If the diagnosis is entertained, the best and most reliable study remains CT scanning. This not only provides the examiner with diagnostic evidence but also demonstrates the degree of displacement and comminution of fragments. Because of the poor outcomes obtained, all fractures must be sought and treated aggressively. Nondisplaced fractures should not be ignored but immobilized in a cast for 6 to 8 weeks with no weight bearing and then reevaluated at that time for bony union. Failure to aggressively treat larger displaced fracture fragments or comminuted fractures may and often does result in malunion, nonunion, heterotopic overgrowth, subtalar instability, and, ultimately, disabling arthritis. [0390] [0400] [0420] [0430] [0470] [0480] [0490] [0500] [0510] [0520] [0530] Late symptoms have been shown often to not respond to excision of the offending fragments. [0370] [0470] [0510]

Treatment is fracture type dependent. Large displaced fractures are managed with anatomic restoration of the articular surface with internal fixation ( Fig. 5-17, A through E ). These often are large enough to accept at least one small fragment screw for fixation (2.7 or 3.0mm usually will suffice). This most often can be done through a typical Ollier approach to the sinus tarsi and subtalar joint region. Comminuted fracture patterns are more ominous and carry a more unpredictable outcome. These often are refractory to repair and necessitate excision for all fragments. This at least removes any potentially abrasive surfaces and areas of future impingement. If repaired, early range of motion, focusing on inversion/eversion, will promote restoration of subtalar mechanics.


Figure 5-17  (A) Schematic of a lateral process talus fracture. (B and C) Direct visualization of the lateral process fragment before (B) and after (C) reduction. (D and E) Fixation is achieved with a posteromedially directed screw. A talar neck fracture is fixed here, as well. A from Myerson MS: Foot and ankle disorders, St Louis, 1999, Mosby.


Sequelae of untreated or missed fractures are well documented. Malunion, nonunion, instability, overgrowth, and/or arthritis of the subtalar joint can be debilitating. Missed fractures that present late often are refractory to repair or remove fragments and will necessitate subtalar arthrodesis. [0370] [0470] [0510] Therefore it is critical that awareness of this injury pattern remains prevalent and a high index of suspicion be maintained for any patient presenting with atypical or persistently painful ankle sprains. [0350] [0360] [0470]


Anterior Process Calcaneal Fracture

Anterior process calcaneal fractures often are missed in the acute setting. This fracture must be sought in anyone with recalcitrant lateral foot pain or ankle sprain; if untreated, it will lead to problematic sequelae. There are two types of anterior process fractures, and they occur by opposing mechanisms of injury: avulsion and compression. [0500] [0540]

Avulsion injuries occur as a result of a plantarflexion, inversion force ( Fig. 5-18 ). As such, these often are misrepresented as lateral ankle sprains. [0550] [0560] [0570] The overall presentation is similar with respect to mechanism in the onset of lateral foot or ankle pain, ecchymosis, and swelling. However, tenderness typically occurs 1 to 2cm more distally in the region of the sinus tarsi. The fracture fragment often is small and extra-articular, occurring as a plantarflexion and inversion force tensions the bifurcate ligament, which overcomes the attachment of the distal-most calcaneus.



Figure 5-18  Anterior process fracture of the calcaneus.  From Myerson MS: Foot and ankle disorders, St Louis, 1999, Mosby.


Alternatively, compressive injuries occur with sudden abduction forces across the foot and are much more ominous. These often will be intra-articular and involve variably sized fragments of joint surface, as well as causing displacement of the fragments posterior, dorsal, or lateral, sometimes leading to substantial incongruity. Because of the similarity in presentation to lateral ankle sprain, a high index of suspicion should be maintained and careful clinical inspection performed. Radiographs are helpful, but a clear and obvious fragment is not always visible. Because these often are confused with ankle sprains, it is not uncommon that only ankle x-rays are obtained. Suspicion should prompt the clinician to obtain foot radiographs, particularly obliques, to verify the diagnosis.[58] Occasionally, a small fragment or ossicle, the calcaneus secondarium, will be noted on a lateral ankle or oblique foot radiograph. This is smooth and regular in its contours and should be differentiated from the rough, irregular edges of an acute anterior process fracture. CT may be helpful to determine specific characteristics of acute fracture versus ossicle presence. [0500] [0580] Additionally, this is recommended for those patients presenting with compressive injuries to determine the degree of articular involvement.

Early diagnosis aids in the quality of treatment for this injury. Healing, particularly of the avulsion type of fracture, is reliable if identified early. Typically, immobilization in a walking boot or a cast for 4 weeks is sufficient. Delay in diagnosis and lack of immobilization can lead to persistent symptoms and affect the ultimate outcome. Occasionally, excision will be required to remove a nonunited fragment after delayed or missed diagnosis. Compressive injuries, especially those with displacement, are more complex and carry less-predictable outcomes because of the articular damage sustained at the time of the injury. Displacement of the fragments requires early reduction and fixation to restore congruity. Still, these patients may develop degenerative disease at the calcaneal cuboid articulation, depending on the energy of the injury. Results of treatment for any form of these fractures are few and anecdotal. Degan et al.[59] reported on surgical treatment of seven patients who developed symptomatic nonunions after anterior process fractures. Late excision provided pain relief in five of six. Surgical treatment may involve a need to osteotomize the calcaneus just below the area of nonunion to excise the entire affected area. Care should be taken to immobilize the foot for 6 weeks after this procedure, because destabilization may occur as a result of removing the bifurcate ligament, which connects the hind foot to the midfoot at the navicula and cuboid, respectively. Resumption of full athletic activity after surgical treatment may take up to 6 months; and rarely, in some patients, persistent residual degenerative joint disease symptoms may persist and limit return to sport. [0500] [0590]


Tarsometatarsal Dislocations

The tarsometatarsal joint, consisting of the bases of the five metatarsals and their articulation with the three cuneiforms and the cuboid, is named after Lisfranc, a French surgeon in the army of Napoleon, who originally described an amputation through that joint. [0040] [0500] [0540] [0600] The dislocations or fracture/dislocations of the tarsometatarsal joint are reported to occur at the rate of one injury per 55,000 people per year. [0500] [0600] These are recognized more commonly in a polytrauma patient because of the severity, [0610] [0620] [0630] but also are increasingly recognized to occur in the athletic population.

Faciszewski et al.[64] have reported on patients with “subtle” injuries to the Lisfranc joint, defined as diastasis of 2 to 5mm between the bases of the first two metatarsals. A third of their patients' injuries were sports related. Other reports support the increasing frequency of occurrence of Lisfranc injuries in athletic events. [0650] [0660] [0670] [0680] Any patient diagnosed with a midfoot sprain should arouse suspicion for an undiagnosed tarsometatarsal ligament disruption.

In the athletic population, the occurrence and severity varies by sport. Lisfranc injuries are reported to be the second most common athletic injury to the foot, after metatarsophalangeal joint injuries, presenting in 4% of football players per year, with a preponderance occurring in linemen (29.2%).[67] Although complete injuries resulting in diastasis of more than 5mm are easier diagnostically and more dogmatic in treatment plan, more subtle injuries (1 to 5mm) often are overlooked and, even when diagnosed, may lead to therapeutic dilemmas for the surgeon, as well as frustration for the injured athlete. Partial capsule tears with no diastasis, for instance, can be a compounding problem resulting in prolonged disability for the elite performer.

The tarsometatarsal joint really is more of an articulating complex providing both motion and stability—much more so the latter. The osseous anatomy reveals multiple, wedge-shaped bones coalescing to form an arch in the transverse plane. The second metatarsal often has been referred to as the keystone of this Roman arch analogy, reflecting its overall importance to the integrity of the maintenance of this structure. Structural rigidity of the shape of the foot is dependent on the stability of this relationship of the midfoot bones. Because the bases of the metatarsals are wider dorsally, collapse of the arch in any plane is prevented in the face of weight-bearing load.

The 2nd through 5th metatarsals are interconnected by a dense weave of short, broad-based ligaments and capsular ligamentous structures. These tend to be bundled together and often will move as one unit. However, there is a notorious absence of ligamentous connection between the bases of the first and second metatarsals. This is thought to account for the predominance of diastasis in this interval. Instead, there exists a dense, plantar-based, oblique ligament extending from the base of the second metatarsal to the lateral portion of the medial cuneiform—Lisfranc's ligament. This ligament anchors the lesser metatarsal complex to the medial column of the foot.

The tibialis anterior, with its insertion on the medial aspect of the proximal first metatarsal and the peroneus longus, which inserts into the lateral proximal first metatarsal, also contributes to the stability of the Lisfranc articulation. In certain phases of gait, these two tendons provide dynamic restraint. Plantar fascia, intrinsic musculature, and plantar tarsometatarsal ligaments provide additional structural support against arch collapse and plantarward dislocation. The midfoot articulation may be divided mechanically by columns. The medial column includes the first metatarsal and medial cuneiform. The middle column consists of the second and third metatarsals, as well as the middle and lateral cuneiforms. The lateral column is formed with the fourth and fifth metatarsals, along with the cuboid bone. This column provides the greatest motion throughout the tarsometatarsal joint.

Vascular structures in this region deserve mention because of their proximity to the area of potential injury. The dorsalis pedis artery and the plantar arterial arch are structures at risk, particularly when the dorsalis pedis dives down between the bases of first and second metatarsals. Disruptions here, especially with a tethered vessel, can result in kinking, vasospasm, and, ultimately, ischemia. Lisfranc dislocation derives its name, in fact, as previously stated, from the Napoleonic surgeon who so definitely amputated cavalrymen after midfoot injuries resulting in vascular catastrophes. [0500] [0600] [0610] [0620] [0630] Although less common compared with the high-energy version of this injury, anecdotal reports of associated vascular injuries abound and should be sought for fear of missing an ischemic sequela.

Patterns of injury to the tarsometatarsal joint have been described as a result of both direct trauma to the foot and indirect violence. The majority of nonathletic traumatic midfoot injuries can occur as a result of significant direct force, usually applied to a foot in plantarflexion or abduction, and typically will accompany high-velocity or high-energy trauma, such as motor vehicle accidents or falls from heights. [0600] [0610] [0630] [0690] These can result in significant soft-tissue compromise, neurovascular injury, and compartment syndrome.[62]

Indirect injury is more relevant to this discussion. Athletes may sustain direct violence to the foot as the result of an awkward collision or in the melee of a collision in certain sports. However, more commonly the athlete is injured because of low-velocity, indirect energy imparted to the foot. Most will describe some sort of axial longitudinal force while the foot is plantarflexed and, often, slightly rotated.[67] Two specific patterns have been described. Simple lateral dislocations result from eversion of the hind foot on a fixed plantarflexed foot, as may be seen in ballet dancers en pointe. [0700] [0710] [0720] Alternatively, supination or inversion of the hindfoot on a fixed plantarflexed forefoot will result in a more dissociative pattern of injury because the medial column is disrupted, followed by the lateral dislocation of the lesser metatarsal and associated tarsal cuneiforms.[73] A third type of injury occurs when the fixed plantarflexed foot is forced into extreme equinus as a result of being struck from behind.[60] This is more common in turf sports such as football. Elements of torque, rotation, and compression are all present and cumulatively lead to a dorsal capsule ligamentous disruption.

Many classification systems have been proposed to describe the multitude of injury patterns that may occur. [0600] [0610] [0630] [0690] [0740] [0750] Because of the tremendous variation, no one system has been universally accepted. These classification systems usually apply to high-energy injuries and are based on segmental patterns of metatarsal-tarsal bone displacement.

Recently a useful classification has been proposed specifically for the athletic midfoot injury, including undisplaced sprains, and is based on clinical findings, weight bearing, x-rays, and bone scan results[67] ( Fig. 5-19 ). Stage I patients were found to have pain at the midfoot and were unable to play sports but had no radiographically visible changes. Bone scan results did demonstrate increased uptake in the area of Lisfranc joint. Pathoanatomy is thought to include dorsal capsular tear without elongation of Lisfranc's ligament. Stage II is described as clinical findings similar to those in stage I, but with diastasis of 1 to 5mm between the bases of the medial two metatarsals present on plain AP radiographs. No loss of longitudinal arch was noted on weight-bearing lateral x-rays. Pathoanatomy here differs from stage I in that the Lisfranc ligament is elongated, but the plantar structures remain stable and prevent arch collapse. Stage III was defined as diastasis greater than 5mm and loss of lateral arch height, defined by loss of space between the fifth metatarsal and the medial cuneiform on lateral radiograph. [0380] [0670] [0750] All capsuloligamentous structures are thought to be injured in stage III. Other forms of injury, such as gross disruption with fracture and/or dislocation, were defined by these authors in the method originally proposed by Myerson,[76] which was based on segmental instability ( Fig. 5-20 ). The advantage of such a classification is that treatment may be predicated on the level of injury.


Figure 5-19  Nunley classification of athletic Lisfranc injuries.  From: Nunley JA, Vertullo CJ: Am J Sports Med, 30:6, 2002, p.872, Figure 1.



Figure 5-20  Myerson classification of Lisfranc injuries.  From Myerson MS: Foot and ankle disorders, St Louis, 1999, Mosby.


Up to one in five Lisfranc injuries are missed or improperly diagnosed on initial screening, whether it be in the emergency department or at practitioner's office. This often can be ascribed to the presentation of these injuries as part of a polytrauma, with other, more severe and more obvious injuries demanding the bulk of attention. [0770] [0780] [0790]

In the athlete, however, it is the subtle or complete absence of radiographic diastasis that may occur that confounds the examiner. [0640] [0670] [0770] [0800] A high index of suspicion must be maintained for athletes presenting with midfoot pain after athletic contact or activity, even without radiographic evidence of injury. Consideration should be given to stress radiographs as a means of furthering diagnostic abilities.

Physical examination is especially important with subtle injury. Gross distortion of the bony architecture of the foot is readily identified. Clinical and radiographic findings of fractures and dislocations are relatively simple to determine. The patient presenting with no overt disruption or equivocal radiographic divergence becomes a diagnostic dilemma.

Examination typically demonstrates tenderness at the midfoot that is worsened by provocative maneuvers such as pronation or abduction of the foot. Swelling is often significant, and ecchymosis is variably present. Neurovascular injuries are unusual in the lower energy traumas, but the possibility of impending compartment syndrome always should be considered, because there often is tremendous edema accompanying these injuries.

Classic radiograph findings and markers have been well established. A minimum of three radiographic views of the foot (AP, lateral, and oblique) should be obtained. Assessment in suspicious injuries should be made of all of the following relationships:



Diastasis of metatarsals 1 and 2.



Cuneiform diastasis, especially medial and middle.



Widening between the second and third metatarsals.



Widening between middle and lateral cuneiforms.



Small fracture, “fleck sign” at the medial base of the second metatarsal or medial cuneiform, representing an avulsion of Lisfranc's ligament.



Horizontal plane malalignment of metatarsals on lateral x-ray.



Relationship of medial border of the second metatarsal should be parallel to the medial edge of the middle cuneiform.



Relationship of the medial fourth metatarsal should be parallel to the medial edge of the cuboid.



General loss of parallelism of metatarsal bases with respect to one another.



A small compression fracture at the lateral edge of the cuboid. [0450] [0520] [0740] [0760] [0770] [0800] [0810] [0820] [0830] [0840] [0850]

Even after perusing the radiographs with these parameters in mind, the clinician may find it difficult to make a diagnosis. Weight-bearing, contralateral radiographs often are helpful in discerning any asymmetry.

In more subtle and problematic cases, multiple advanced imaging studies have been suggested, including CT, MRI, static stress radiographs, and stress fluoroscopy under anesthesia. [0540] [0630] [0650] [0860] [0870] [0880] However, the best and most reliable studies seem to be a set of standing radiographs ( Fig. 5-21, A through E ) and bone scan, if necessary, in the completely undisplaced metatarsal that manifests persistent pain. [0670] [0680] There are two advantages to weight-bearing radiographs. First, the dynamic nature of the injury can be determined in a more appropriate physiologic and mechanical state, thus determining the need for treatment. Second, prognostic value exists in determining the presence of collapse or instability.[64]


Figure 5-21  (A) Radiograph of a 34-year-old professional waterski jumper with acute midfoot pain after a fall. There is a suggestion of subtle intermetatarsal diastasis. (B through D) Various advanced imaging studies confirm the Lisfranc ligament disruption by avulsion of the base of the second metatarsal. (B) Bone scan shows increased uptake about the midfoot. (C) Computed tomography demonstrates the avulsed fragment. (D) Magnetic resonance imaging reveals edema in the region of the ligament with suggestion of bony injury. (E)Plain anteroposterior weight-bearing x-rays of the injured and comparative contralateral side clearly disclose the diastasis.



Principles of treatment of Lisfranc injuries are universal and include providing an anatomic reduction in stabilization. Care must be taken to observe and manage the soft tissue and neurovascular consequences, as well.

Debate still exists as to how much diastasis is acceptable in the injured athlete. The literature is heavily weighted toward high-energy trauma management, and little has been proposed regarding management of the athletic midfoot sprain. Most recent literature suggests that residual diastasis may result in a poor outcome, such as persistent pain, deformity, and arthrosis. [0450] [0600] [0650] [0670] [0760] [0810] [0870] [0880] [0890] [0900] [0910] [0920] Nonanatomic reductions have been shown to be inferior with respect to outcome and the need for secondary procedures, such as revision repairs or fusions.

Athletic injuries are sparsely documented, but the evidence that is available seems to support the conclusion that injuries resulting in diastasis will lead to poor outcomes. Curtis, et al.[65] reviewed 19 athletes with varying degrees of tarsometatarsal (TMT) injury, citing poor functional results despite “relatively nondisplaced injuries” in patients with delays in diagnosis and those not treated adequately, with three failing to return to sport. Meyer et al.[66] reported on nonoperative management of 23 collegiate football players with good outcomes after nonoperative treatment of midfoot injuries. In this study, 20 of 23 had no diastasis, but of those that did, one of three had significant pain with high-demand activity. Nunley and Vertullo[67] showed that 14 of 15 patients had good results when treated within the algorithm based on a classification they proposed that guided treatment on the basis of displacement. Patients were assessed on the basis of plain x-rays and bone–scan-documented injury. Only completely nondisplaced injuries (seven patients) were treated nonoperatively. All others were treated by open reduction with internal fixation. The only patient with residual pain was one treated by open reduction and internal fixation after 10 months of failed conservative treatment. Return to sport in the operative group averaged 14.4 weeks, which was comparable to nonoperative results.

Only one study demonstrates reasonable results with nonanatomic reductions. Shapiro et al.[68] reported on nine athletes with diastasis between 2 to 5mm. Eight elected for nonoperative treatment and returned to sport within 3 months, with good results reported in an average of 33 months after the injury.

On the basis of these reports and personal experience, my recommendation is for operative treatment in all but nondisplaced injuries of the tarsometatarsal joint. Although percutaneous techniques have been proposed, an open approach is more reliable and eliminates the possibility of retained or interposed tissue, as well as allowing direct visualization of the joint for an anatomic reduction ( Fig. 5-22 ). Closed or percutaneous techniques using the large Weber reduction clamp carry the risk of malreduction, especially in a horizontal plane, even in the face of an anatomic appearing anterior/posterior image ( Fig. 5-23 ).


Figure 5-22  Planned incision for approach to the diastasis of Lisfranc's joint.  From Myerson MS: Foot and ankle disorders, St Louis, 1999, Mosby.



Figure 5-23  Percutaneous reduction technique with a large Weber clamp. Surgeons must be aware of the tendency for dorsal plane malalignment as a result of overtightening or improper clamp placement. Lateral fluoroscopy should always be employed to verify anatomic reduction.  From Myerson MS: Foot and ankle disorders, St Louis, 1999, Mosby.


Open treatment affords the surgeon the opportunity to extricate any incarcerated bony fragments or soft tissue that may have been interposed, including the Lisfranc's ligament itself or, in high-energy injuries, the tibialis anterior tendon. Anatomic restoration of the arch is achieved and verified, as well as providing direct visualization for hardware placement.

Screw fixation is preferable because K-wire fixation is tenuous, at best, and not as reliable in maintaining an anatomic reduction. In addition, especially in unstable injuries, the motion at the joint surfaces will induce pin loosening and migration with predictable loss of stability, thus requiring concurrent cast immobilization, which prevents early rehabilitation. Conversely, screw fixation is reliable and allows for early mobilization of the foot and ankle, as well as edema control after wound healing has been achieved.

Screw configuration is dependent on injury pattern and extent of ligamentous disruption. My preference is to use fully threaded, 4.0mm or larger screws. Partially threaded screws are acceptable, but because this is a “position screw” to maintain reduction, the surgeon must guard against the tendency to compress across the TMT joints. Typically, the first screw is placed on the orientation of the disrupted Lisfranc's ligament, that is, from medial cuneiform to second metatarsal base. Additional screws are placed as needed across the base of the first and third TMT joints from distal to proximal ( Fig. 5-24, A through C ). Should the injury extend through the medial and middle cuneiforms, an intercuneiform screw should be placed first.


Figure 5-24  (A and B) Repair of injury seen in Figure 5-19 performed through dorsal incision. (C) Patient returned to sport in 6 months.



The patient is kept on weight bearing for 6 to 8 weeks. Early motion and therapy modalities such as muscle stimulation can begin as soon as soft tissue healing allows. Partial weight bearing in a boot begins at 6 to 8 weeks and is advanced until 12 weeks. Screws are maintained for no fewer than 16 weeks and often, but not routinely, are removed. The athlete is returned to athletic activity with a molded, semirigid insole and a semirigid extended steel shank device.

Frank disruptions are treated in the way that trauma guidelines dictate and uniformly are managed with open reduction and internal fixation. Postoperative protocols are similar to those described previously, but usually require larger periods of rehabilitation, and return to activity is less predictable in these patients.


Tarsal Bone Fractures

Anatomic variants of Lisfranc's injuries do exist. There have been reports citing evidence of bipartite cuneiforms and anatomic variations in anatomy throughout the midfoot bones ( Fig. 5-25, A through F ). These should be encountered but pursued and treated aggressively, with the same guidelines as those for the previously described injuries. [0930] [0940] [0950]



Figure 5-25  (A) Weight-bearing anteroposterior radiograph, with comparison, of a high school quarterback with acute midfoot injury. (B) Close-up suggests unusual arrangement in the area of medial cuneiform. (C) Lateral radiograph demonstrates separation of dorsal and plantar halves of medial cuneiform. (D) Computed tomography confirms bipartite tarsal bone. (E and F) Open repair requires attention to both the separated bipartite cuneiform with removal of synchondrosis and closure of the intermetatarsal diastasis, as well.



Fractures or dislocations exclusive to the cuneiforms or cuboid area are unusual. These often are present in conjunction with a tarsometatarsal joint injury, in which the force of the injury has disrupted further proximally through the navicula, cuneiform, or talonavicular joints, or even through the body of the cuboid. Although rare, these injuries have been identified. [0960] [0970] Because cuneiform fractures and dislocations often occur as part of a midfoot dislocation, treatment principles should follow those of the injured tarsometatarsal joint.

Isolated cuboid injuries most often present as insignificant “chip” fractures along the lateral side. Typically, these occur as a result of an inversion injury and often are seen secondarily after the patient has been diagnosed with “sprain.” Treatment requires supportive immobilization in either a walking cast or hard-soled shoe for approximately 4 weeks or until symptoms allow resumption of activity. A rigid orthosis may allow earlier return to sport. Fracture instability is not usually a concern.

Compressive cuboid injuries can occur with a sudden abduction force. So-called nutcracker injuries are far more severe. Again, this is considered a variant of the mechanism for Lisfranc injuries, and the same principles are applied. Early anatomic reduction is necessary ( Fig. 5-26, A through E ). Manipulation alone is often unsuccessful in restoring the length of the lateral column. Open treatment frequently is required. Placing a small plate to span the collapsed intercalary segment is necessary on occasion. Often, there is poor-quality bone fixation in the subarticular cuboid; therefore a spanning plate to the distal calcaneus represents a good alternative. For severe comminution, I prefer structural tricortical graft to reestablish the length. This may be interposed between subchondral bone proximally and distally, because the articular surfaces often are not severely comminuted. If necessary, fixation can be applied as previously stated, or a spanning external fixator from distal calcaneus to proximal metatarsals may be used to distract the lateral column.


Figure 5-26  (A through C) Radiographs of an 18-year-old female athlete with acute injury after awkward landing. Note the homolateral metatarsal displacement pattern and the cuboid compression injury. (D and E) Open repair addresses the metatarsal displacement but also distracts the cuboid to buttress the lateral column of the foot.




Fractures of the Base of the Fifth Metatarsal

Fractures of the base of the fifth metatarsal are the most common metatarsal fracture. However, there are many misconceptions regarding the description, the understanding, and thus the treatment of these injuries throughout the literature. The classic Jones fracture was named after Sir Robert Jones,[98] who originally described the fracture in his own foot in 1902. He sustained the fracture “Whilst dancing, I trod on the outer side of my foot, my heel at the moment being off the ground. Something gave way midway down my foot…the 5th metatarsal was found fractured about ¾ inch from its base.” Jones originally described the fracture of the metaphyseal diaphyseal junction without extension distal to the anterior metatarsal (4–5 intermetatarsal) junction. Currently, a Jones fracture is recognized as any fracture involving the fifth metatarsal metaphyseal-diaphyseal junction. This fracture often is confused with, although less commonly encountered than, its cohort, the avulsion of the tuberosity encountered more proximally. The significance of the true Jones fracture is that it can develop delayed or nonunion. Zelko et al.,[99] Kavanaugh et al.,[100] and DeLee[101] have reported difficulty treating the fractures of this region in which diagnoses initially were missed or that, in reality, were stress fractures.

Stewart[102] originally introduced a classification to help clarify fractures in this region. Type I fractures are at the junction of the base and shaft of the metatarsal. Subgroups include noncomminuted (IA) and comminuted (IB) variants. Type II fractures involve only the styloid process. Again, these are subdivided into extra-articular (IIA) and intra-articular (IIB). Stewart established a treatment plan that is based on his classification system.

Zelko et al.[99] tried to define fractures on the basis of clinical history and initial radiographic findings. Group 1 patients reported an acute injury with no previous symptoms. Radiographs demonstrated what appeared to be acute fracture line and no evidence of any chronic change, defined as periosteal reaction or intramedullary sclerosis. Group 2 demonstrated an acute injury but also reported a prodrome of mild lateral foot pain. Radiographs in these patients evidenced a clear fracture pattern. However, there also was demonstration of some periosteal reaction. Group 3 patients were categorized as a reinjury after one or more previous injuries. Radiographs of these patients demonstrate lucent fracture line, periosteal reaction, and intramedullary sclerosis, and this group presented with chronic pain or multiple recurrent injuries with sclerotic margins bordering a lucent fracture line.

DeLee and colleagues [0500] [1010]have attempted to combine classifications and divides these into multiple fracture types. Type I fractures are those at the junction of the base of the shaft and the base and are subcategorized into Type A for nondisplaced and Type B for comminuted fractures in this area. Type II fractures occurred again at the junction of the shaft and the base but carried clinical and radiographic evidence of prior injury. To fall into this category, patients had to report prior lateral foot pain and/or an established radiographic periosteal stress reaction or frank fracture line. Type III fractures included those of the styloid process or tuberosity and again were classified into subcategories A, nonarticular, and B, articular.

The recommended current classification includes a combination of all the classifications discussed and divides the metatarsal injuries into classification that correlates to zones of vascular anatomy ( Fig. 5-27 ). Currently, preferred classification uses three separate zones. Zone 1, or the most proximal zone, includes the cancellous fifth metatarsal, the so-called tuberosity fragment. It includes the insertion of the peroneus brevis tendon and calcaneometatarsal ligamentous branch of the plantar fascia. Fractures in this zone typically extend into the fifth metatarsal cuboid joint but may be extra-articular. Zone 2 injuries involve the metaphyseal-diaphyseal junction. This encompasses the articulation of the proximal fourth and fifth metatarsals. The ligaments holding the fourth and fifth metatarsals together proximally are secure both dorsally and plantarly and provide tremendous stability. Finally, zone 3 injuries are fractures of the fifth metatarsal shaft. This zone begins just distal to the fourth and fifth intermetatarsal ligaments and extends distally into the tubular portion of the diaphysis approximately 1.5 to 2.0cm. Most current management protocols use some form of zone concept in classifying and reporting fractures. Therefore the bulk of the discussion regarding treatment will reflect this trend and be focused on management of fractures by type and location.


Figure 5-27  Fracture zone classification at the base of the fifth metatarsal.  From Lawrence SJ, Botte M: Foot Ankle 14:360, 1993.


An alternative classification system also exists that defines fractures on the basis of chronicity of symptoms, presence of stress fracture, and recurrence of injury.[103] Again, these are poorly defined and not terribly useful from a management standpoint. Stress fractures involving the proximal shaft of the fifth metatarsal differ in their behavior and somewhat in their treatment, and therefore are not discussed in this section on acute injuries.

The fifth metatarsal itself has been subdivided into main segments, including the head, neck, shaft, base, and tuberosity or styloid process. The metaphyseal portion of the bone tapers into a tubular diaphyseal segment. The size and the shape of this bone vary somewhat but typically demonstrate that a larger, wider, more triangular proximal portion becomes a fairly narrow tubular structure that has a slightly lateral curve as it traverses distally. The radius of curvature as the bone proceeds distally is highly variable and can lead to tremendous distortions in the shape and stress applied to the distal end of this structure.[104]

The proximal end of the fifth metatarsal not only articulates with the cuboid at the tarsometatarsal joint but also has an intermetatarsal articulation with the base of the fourth metatarsal. This is a true joint. The bases of the fourth and fifth metatarsals are bound closely to the cuboid by dense, ligamentous structures on every side. The stability of the tarsometatarsal complex is provided by capsular ligamentous structures, the dorsal and plantar cubometatarsal ligaments, the lateral band of the plantar aponeurosis, and the broad insertion of the peroneus brevis tendon ( Fig. 5-28 ). It is believed that these capsular ligamentous structures contribute greatly to the genesis of a true Jones fracture [0450] [1000] because the proximal portion of the fifth metatarsal and its articulation with the cuboid is held fast while torsional forces produce stress that is relieved through the fracture line just distal to these structures, approximately 0.5cm distal to the insertion of the peroneus brevis and just distal to the joint between the fifth and fourth metatarsals. The base of the fifth metatarsal proceeds laterally and inferiorly beneath the inferior edge of the cuboid on the lateral radiograph. There is a tremendous variability in size and shape of this prominence, accounting for its variable susceptibility to injury.


Figure 5-28  Anatomy of tendon attachments at the base of the fifth metatarsal.  From Lawrence SJ, Botte M: Foot Ankle 14:360, 1993.


The vascular anatomy in this region also is relatively important ( Fig. 5-29 ). This has been thought to be a fairly tenuous vascular supply, particularly at the proximal diaphysis. The arterial plexus at this level has been well established by Shereff et al.[105] and Smith et al.,[106] demonstrating only a small nutrient vessel in the so-called watershed area. This is unique contradistinction to the fairly abundant blood supply more proximal to this watershed area.


Figure 5-29  Vascularity of the fifth metatarsal.  From Smith J, Arnoczky SP, Hersh A: Foot Ankle 13:144, 1992.)


Direct and indirect mechanisms have been implicated in the genesis of the fifth metatarsal fracture.[45] Certainly, the prominence of the tuberosity makes it particularly at risk to a more direct mechanism of injury when discussing this version of the fracture.[104] Jones himself alluded to the indirect nature of injuries, describing a “cross-breaking strain directed anteriorly to the metatarsal base and caused by body pressure on an inverted foot while the heel is raised.”[98] Presumably, he is describing the commonly accepted foot in fixed equinus sustaining rotatory and/or tensile forces overcoming the thinning cortical bone in the proximal metaphyseal-diaphyseal junction.

Fractures of the tuberosity occurring indirectly are more common because of the number of structures that attach to the prominence.[104] These structures have been identified previously. The importance of the pull of the peroneus brevis has been emphasized in the creation of a separation stress that forces the proximal fragment of the metatarsal away from the shaft. Because of the strong peroneus brevis contraction in stance phase, the tendon already is contracted when an inversion stress is applied to a weight-bearing, plantarflexed foot. This tendon holds fast while the force causes the shaft to be pulled away from it. Avulsion of the base away from the shaft is the result.[45] Kavanaugh et al.[100] used high-speed cinematography and force platform analysis in an attempt to recreate the position of the foot at the time of the index injury. Conclusions of this study suggested either an axial or mediolateral force or a combination of these acting on the fixed base of the fifth metatarsal. This would bring the patient up on the metatarsal heads, concentrating the axial and mediolateral forces on the lateral metatarsal. It was postulated that failure to invert the foot would produce a tremendous axial and mediolateral ground force culminating in fracture.

Other factors also have been implicated in the genesis of the injury here, including repetitive use, such as prolonged running or jumping activities; vascular contribution, particularly at the avascular or watershed zone; and certain morphologies of foot shape. Individuals with more cavus foot alignment have been shown to be more likely to develop this injury pattern because of the increased rigidity of the foot, as well as the propensity to have a stress transfer to the lateral foot. [0500] [0990] [1000] [1010] [1030] [1050] [1060] [1070] Individuals with planovalgus foot also have been suggested to be predisposed to this injury because of increased loads forced along the lateral border of the foot during the latter part of stance, phase, and gait. These relationships have not been demonstrated in any formal mechanical studies.

Clinical diagnosis of the Jones fracture is dependent on making an appropriate diagnosis and localizing the specific type of injury with respect to zone as well as acuity. History may be vague, but typically involves an aching sensation on the lateral aspect of the foot related to some sort of push-off or inversion-type injury. Prodromal symptoms may be reported for up to several weeks before any evidence of the actual documented injury suggestive of a prefracture state or impending fracture. [0990] [1010] [1030]

Physical examination findings are fairly reproducible and include an improved tenderness, specifically over the base of the fifth metatarsal. Ecchymosis and swelling are present to variable degrees and, again, depend on the acuity of the injury. There is typically an accentuation of pain by inversion of the foot. However, there is little motion at the fracture site, and therefore no crepitus or palpable mobility of the fracture site on manipulation.

Radiographs often will confirm the diagnosis, although in some instances some fractures may present as occult or incomplete. Careful radiographic assessment is important to determine the presence of a fracture line because this may be particularly subtle. If the diagnosis is in question, studies such as MRI or bone scintigraphy tend to be particularly helpful. [0450] [1020]

Diagnosis of fractures can be especially confounding in the adolescent athlete because secondary centers of ossification at the base of the fifth metatarsal are present and sometimes are confused with acute fractures. The ossification center typically occurs between 8 and 12 years of age and usually is united by 12 years in girls and by 15 years in boys. A secondary ossification center occurs in approximately one-fourth of all children.[104]

Distinction between these secondary centers of ossification and acute fracture is relatively straightforward. Distinguishing characteristics include the orientation of the apophyseal line, which reproducibly traverses the tubercle parallel to the long axis of the shaft. Additionally, the apophysis occurs lateral to and does not extend into the tarsometatarsal joint.[104] Ossification centers also tend to have smooth, regular edges, as opposed to a more irregular appearance of fracture.

Two other ossicles often will occur in this region. The os peroneum is present in approximately 10% to 15% of all radiographs. The os vesalianum is variably present as well. Again, a smooth, sclerotic, appositional surface often is present and differentiates this from fracture. These ossicles, which are independent, sesamoidal-type bones, should be distinguished easily from acute fracture situations.

Treatment is injury specific and fracture type dependent. Treatments vary and range from weight bearing in a protective shoe as soon as pain allows to various forms of open reduction and internal fixation and, sometimes, bone grafting. The literature is replete with information to support just about any stance one may want to take. It is crucial that a clear understanding of the injury pattern, the outcomes of nonoperative versus operative treatment, and the potential complications be understood by the surgeon before embarking on a treatment plan. Various forms of surgical treatment have been described and are addressed independently by procedure.

First, the technique of medullary curettage and inlay bone grafting has been well established. [1030] [1070] The base of the fifth is approached via a curvilinear dorsolateral incision. The fracture site is exposed subperiosteally. A rectangular section of bone measuring 0.7 × 2.0cm centered over the fracture is outlined by four drill holes and removed with a sharp osteotome. The medullary canal is curetted free of all sclerotic bone, and the continuity of this cavity is reestablished. The original description includes a tibial corticocancellous graft that is fashioned and replaced into the fracture defect. No fixation typically is applied because the graft often is slightly oversized, yielding a tight fit. The postoperative protocol includes nonweight-bearing cast applied for 6 weeks, with gradual resumption of activities determined on the basis of pain tolerance after that.

Percutaneous intramedullary screw fixation also has been described. [0500] [0540] [1010] [1080] [1090] [1100] [1110] [1120] [1130] [1140] [1150] [1160] [1170] [1180] [1190] [1200] This is performed through a small incision initially at the base of the fifth metatarsal between the peroneus brevis tendon and the lateral band of the plantar fascia. The interval is developed, and a guidewire for a cannulated screw is inserted under fluoroscopic guidance. The key point to remember about placement of the screw is that, on the basis of the anatomy, the wire should be initiated “high and inside.” Theis suggests that the guidepin should be started on the dorsal and medial aspect of the bone just inside and superior to the edge of the tuberosity. Once the guidepin is positioned appropriately and verified under fluoroscopic guidance, a canal is drilled and an appropriate length screw is placed. Choices for the size of the screw typically are based on the size of the bone, and it is well accepted that the largest screw that the canal can accommodate should be placed. One technique tip is to overdrill using the cannulated guidepin system and then to remove the guidepin and place a solid screw to provide greater tensile strength to the bone. It is crucial to avoid fracturing the metatarsal, and thus maintenance of the intramedullary position is of utmost importance. No cortex should be violated on passage of the screw. Postoperatively, the patient is placed in a splint for approximately 1 week, and a short-leg, nonweight-bearing cast is applied for an additional 2 to 3 weeks. At 3 weeks, stationary bicycling, swimming, and stair climbing are allowed in a protective boot, with weight bearing progressed as tolerated, depending on pain. Running is encouraged only when evidence of significant fracture healing is present radiographically, and typically this takes 5 to 7 weeks. Return to sports-specific activity is prohibited until the patient can run and cut painlessly. Caveats with respect to this procedure involve injury to the sural nerve, which is as close as 2 to 3mm from the position of the screw head.[109]

Lastly, a combination of the previous two procedures mentioned has been applied.[54] The technique for screw placement is as previously stated. However, this is done with a larger incision, and access is gained through the canal before placement of the screw. Bone graft should be placed dorsally, medially, and plantarly before insertion of the screw. Once bone graft is placed, the screw is inserted and the wound is closed. An alternative to this method is a so-called strain-relieving cancellous bone graft, which can be placed in similar fashion, but specifically in a dorsomedial trough spanning the fracture site. Once the screw has been placed, additional bone graft can be packed in and around the fracture site. Return to activity is similar to that as previously stated for screw fixation alone.

As previously stated, literature abounds regarding multiple forms of fractures. It is somewhat confusing because, in some of the earlier literature, either specific type of fracture is not specified or uniform treatment is applied to all fracture types. An attempt will be made to dissect the literature and apply it in a relatively simple yet appropriate fashion. [0500] [0540] [0990] [1070] [1080] [1090] [1100] [1110] [1120] [1130] [1140] [1150] [1160] [1170] [1180] [1190] [1200] [1210] [1220]

Extra-articular tuberosity fractures typically require no more than supportive therapy and weight bearing as tolerated as soon as the patient is able to manage pain and swelling appropriately. Multiple forms of “benign neglect” have been described, including suggestions for compressive dressings, adhesive taping, supportive footwear with padding around the prominence, and even short-leg casting. [0450] [1020]There has been no consensus on the type of protective device necessary. However, it has been reported that even short-leg walking casts probably are overprotective in the management of this fracture. [0450] [0830] The pain usually has subsided significantly by the second week to allow reasonably functional walking and transition into a more sports-specific shoe and resumption of activity, again, as pain would allow. It also is important to note that radiographic union may not be present for a minimum of 4 to 6 weeks, and often longer. However, this should not preclude an athlete's returning to sport should symptoms subside appropriately. It also has been suggested that, on occasion, the fracture will heal with fibrous union, and that typically this also is not symptomatic and, again, will allow the athlete to return to activity appropriately.[123]

Indications for surgery in this region are reserved for those patients that have either significantly displaced tuberosity fractures or intra-articular involvement with displacement. [1020] [1230] Open reduction need not require an intramedullary screw as previously described, but only a small interfragmentary screw. Recognition and treatment after delayed presentation may require that excision of the fragment be performed, as opposed to standard open reduction. My experience with this fracture, even with intra-articular, nondisplaced varieties, suggests that the nonoperative treatment is and continues to be the standard of care. However, if there is any question regarding management, a more aggressive approach should be instituted. Poor results with tuberosity fractures are largely anecdotal [1240] [1250] and may be a result of a painful fibrous union, because lack of bony consolidation can approach 19%.[126] Other factors involved in poor outcomes would be articular incongruity or sural nerve entrapment in the fracture after healing ensues, necessitating surgical management.

Treatment of the true acute Jones fracture has evolved. Initially, universal treatment was considered to be the application of short-leg walking cast. [0450] [1220] However, even in reports advocating this form of treatment, there were found to be nonunions occurring that required subsequent surgical treatment. Review of the literature demonstrates a rate of delayed union as high as 38% and a definite nonunion rate of 14% with nonoperative treatment of these fractures.[127] It was additionally noted by Zelko et al. that, even after an extended period of nonweight-bearing, short-leg casting for a period of 10 to 12 weeks, refracture was possible, and surgical treatment would be indicated for these patients.[99] Still, there exists a fairly large and reputable group of surgeons who suggest that only in circumstances in which previous conservative treatment has failed should surgical treatment be implemented. These authors suggest that fractures that occur with no intramedullary sclerosis or no prior attempts at treatment not only will heal, but will allow athletes to return to weight bearing within 6 weeks and to activity by 12 weeks [1220] [1280] [1290] ( Fig. 5-30, A through D ).


Figure 5-30  (A and B) Acute fifth metatarsal or “Jones fracture.” (C and D) The patient elected for conservative treatment and healed uneventfully after 6 weeks of nonweight-bearing casting.



In general, however, most authors agree that because of the potential for refracture, the cited delayed union rate, and the incapacitation required from nonweight bearing and immobilization as a result of casting, high-performance athletes and high-demand individuals be given the option for and be treated with some form surgical management. [0990] [1010] [1150]

Paired comparisons of operative versus nonoperative treatments have been analyzed. Josefsson et al.[113] described 63 patients in which one third of the patients were treated operatively and two thirds conservatively. Average follow-up was 5 years, and, on the basis of delayed union or refracture, in almost 25% of the nonsurgically treated patients subsequent surgical treatment was required. Late surgery was required in 12% of the acute fractures and 50% of chronic fractures. Clapper indirectly supported operative intervention, based on a review of 100 patients treated for acute Jones fractures with 8 weeks of nonweight-bearing casting. Results demonstrated only a 72% success rate with this form of treatment and average time to union of 21 weeks.[121]

On the basis of the historical literature and currently available techniques and prevailing opinions, a protocol has been established that is my preference for the approach to the fifth metatarsal-based fracture. This should be fractures of zone 1, acute fractures of the tuberosity portion that are nondisplaced, typically are treated with a removable boot, and typically require 6 to 8 weeks for full healing. Surgery virtually is never indicated in this type of patient unless a painful nonunion develops. Should the fracture be displaced or comminuted, the activity level of the patient must be assessed. In a younger, high-performance athlete, surgical management certainly is offered and may be helpful to reduce the risk of late complications and speed to recovery.

In zone 2 injuries, the classic acute Jones-type fracture, completely nondisplaced fractures may be treated in a nonweight-bearing cast for 6 to 8 weeks in a moderate-demand to low-demand type of patient. High-performance athletes should be offered intramedullary percutaneous screw fixation in a technique as previously described ( Fig. 5-31, A and B ). Displaced fractures as a result of higher-energy trauma actually may require a true open reduction. Fixation is performed in similar fashion as that described for nondisplaced fractures. An exception to this would be an excessively comminuted metaphyseal-diaphyseal junction, which might require bone grafting or possibly even a minifragment plate and screw fixation.



Figure 5-31  (A and B) Percutaneous fracture reduction and treatment with intramedullary screw fixation.



A zone 3 injury, a true shaft fracture, usually involves a distraction-type force and typically behaves differently from a Jones fracture. These injuries often will present in a delayed fashion and may in fact even be stress fractures. An acute fracture in this region typically will heal with a nonweight-bearing cast in a lower-demand individual, but again, operative treatment as described for the Jones fracture should be offered to a high-demand or high-performance athlete.

In a more delayed or recurrent injury at this level with prodromal symptoms, these patients should be treated with surgical management with intramedullary screw, with or without application of bone graft.

Frank nonunions and chronic injuries should be treated with internal fixation and bone grafting. My preference here is for the large intramedullary screw fixation and concomitant bone grafting as described.



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