Orthopaedic Emergencies 315INJURIES TO THE LOWER TIBIA, ANKLE AND FOOT3 A stress fracture may occur, usually in the neck of the second metatarsal,
known as the ‘march fracture’ after repetitive use.
4 Tarsometatarsal fracture-dislocation (Lisfranc fracture) is uncommon and
usually involves multiple bones, resulting in widening of the gap between the
base of the hallux and the second metatarsal, with lateral shift of the remain-
ing metatarsals.
(i) It is easy to miss, as the significance of the foot swelling is not
appreciated and interpretation of the X-ray is difficult.
(ii) Look carefully for any signs of circulatory impairment in the forefoot.
MANAGEMENT1 Refer immediately to the orthopaedic team all compound, displaced or
multiple fractures, fractures of the first metatarsal, tarsometatarsal fracture-
dislocations, injuries associated with crushing or marked oedema and any
signs of circulatory impairment.
2 Treat a ‘march fracture’, and an avulsion fracture of the base of the fifth
metatarsal as for an ankle sprain in a support bandage, or rarely in a below-
knee plaster if the pain is severe.
(i) A Jones fracture is a more distal fifth metatarsal fracture that
extends into the intermetatarsal joint with the 4th toe typically
in athletes. This requires a below-knee plaster and referral to the
orthopaedic team for consideration of operative intervention, as
non-union is common.
Fractures of the phalanges of the foot
DIAGNOSIS AND MANAGEMENT
1 These fractures are usually caused by direct trauma.
2 Clean all the wounds and release any subungual haematoma by trephining.
3 Otherwise, give an analgesic and a support bandage after buddy-strapping
the damaged toe.
4 Apply a below-knee plaster with a toe platform extension if pain is severe,
particularly with injury to the great toe.
5 Refer all patients to the next fracture clinic.
Dislocations of the phalanges of the foot
DIAGNOSIS AND MANAGEMENT
(^1) These occur by direct trauma, usually to bare or unprotected feet.
2 Insert a digital nerve ring block (see p. 491).
3 Request an X-ray, to exclude an associated fracture.
4 Reduce by restoring normal anatomical alignment, with axial traction.
5 Buddy-strap and refer to the next fracture clinic.