Characteristics

• Diverse group of injuries – note metatarsal/Lisfranc section above.

• Navicular fractures are divided into four types – dorsal lip (avulsion), tuberosity, body and stress fractures.

• Cuboid injury is usually undisplaced fracture which responds well to hard-soled shoe orthoses. Beware of the ‘Nutcracker fracture’, a high energy abduction injury, crushing the cuboid, shortening the lateral column and potentially extruding the cuboid. This requires ORIF usually.

• Cuneiform injury is rarely isolated and responds to POP immobilisation unless significantly displaced when ORIF is the normal treatment.

• Most phalangeal fractures occur in the proximal phalanx of the fifth toe following indirect trauma – stubbing of the toe.

• Metatarsophalangeal and interphalangeal dislocations should be reduced a soon as possible but rarely require surgery unless open injuries.

Clinical features

• Pain, swelling and sometimes deformity.

• Careful identification of the most tender area will be particularly beneficial when assessing the X-ray.

• Foot compartment syndrome must be suspected in a painful swollen foot and tested for by passively stretching the muscles of the relevant compartment.

Radiological features

• AP and lateral X-rays centred on the area of tenderness are essential.

• Look for significant angulation, intra-articular steps and joint subluxation.

• If there is doubt regarding fracture extent or joint congruity then CT scanning is extremely helpful.

Management

• ABCs, assess soft tissues, neurovascular status, reduce fractures/dislocations obviously threatening the skin and immobilise with backslab.

• Admit, elevate and assess for compartment syndrome in the severely injured foot even without fractures.

• General trauma principles apply such that joint congruity must be restored, either following joint dislocation or in intra-articular fractures.

• Navicular body fractures usually require ORIF.

• Nutcracker cuboid fractures are normally treated with ORIF and bone graft.

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