Trauma
Question 90 of 180
A triage nurse approaches you and asks for advice regarding a patient she is assessing. The patient is complaining of foot pain following a football injury. The nurse asks if she should arrange a foot x-ray. Which of the following would meet the Ottawa rules criteria for a foot x-ray series?
Answer:
The Ottawa foot rules state that a foot radiographic series is only required if there is pain in the midfoot zone and any of the following findings:- Tenderness over the base of the 5th metatarsal
- Tenderness over the navicular
- Inability to bear weight both immediately and in the emergency department
Foot Injuries
Trauma
Last Updated: 21st March 2021
Talar injuries
- Falls onto the feet or violent dorsiflexion of the ankle (e.g. against car pedals in a crash) can result in fractures to the anterior body or articular dome of the talus.
- Displaced fractures and dislocations frequently result in avascular necrosis.
- Treat with analgesia and immobilisation in a backslab POP, and refer promptly for orthopaedic treatment (may require MUA and/ or ORIF). Dislocations of the talus require prompt reduction under GA.
Upper/midfoot dislocations
- These injuries follow violent twisting, inverting, or everting injuries of the foot.
- Peritalar/ subtalar dislocations involve the articulation between the talus and the calcaneus. Give adequate analgesia, and refer to orthopaedics for prompt reduction under GA.
- Mid- tarsal dislocations involve the midtarsal joint (comprising the calcaneus and talus posteriorly and the navicular and cuboid anteriorly) and are treated similarly.
- Isolated dislocation of the talus is rare and requires prompt reduction under GA.
Calcaneal fracture
- Calcaneal fractures most often follow a fall from height directly onto the heels.
- Always exclude associated injuries of the cervical and lumbar spine, pelvis, hips, or knees.
- Examine for swelling, bruising, and tenderness over the calcaneus, particularly over the sides. Examine both calcanei for comparison, remembering that fractures are commonly bilateral. Examine the Achilles tendon for injury.
- Request specific calcaneal x-rays and scrutinise carefully breaks in the cortices, trabeculae, or subtle signs of compression (reduction in Bohler’s angle). Bohler’s angle (seen on x-ray below) describes the angle of 20 – 40 degrees which exists between the upper border of the calcaneal tuberosity and a line connecting the anterior and posterior articulating surfaces. With calcaneal fractures, particularly compression fractures, this angle becomes more acute (less than 20 degrees). It can be used to detect a more subtle calcaneal fracture, but also prognostically to predict poorer outcomes.
- Refer all fractures to orthopaedic staff. The majority will require admission for elevation, analgesia, and, in selected cases, ORIF following CT scanning.
- Sometimes, clinical suspicion of a calcaneal fracture is not confirmed by initial X- rays. Either arrange CT or treat clinically with analgesia, rest, elevation, and crutches, and arrange review at 7– 10 days when consideration can be given to further imaging if symptoms persist.
Normal Bohlers Angle. Image courtesy of Wikimedia.
Metatarsal fractures and dislocations
- Multiple MT fractures may follow heavy objects falling onto the feet or, more commonly, after being run over by a vehicle tyre or wheel.
- In all such cases, consider the possibility of tarsometatarsal (Lisfranc) dislocation. This can be easily missed on standard foot X- rays, which do not usually include a true lateral view— look to check that the medial side of the second MT is correctly aligned with the medial side of the middle cuneiform.
- Check for the dorsalis pedis pulse.
- Support in a backslab POP, and refer if there are multiple, displaced, or dislocated MT fractures.
Isolated avulsion fractures of the fifth MT base
- Inversion may avulse the base of the fifth MT by the peroneus brevis.
- Always examine this area in ankle injuries, and request foot X- rays if tender.
- Do not mistake accessory bones or the epiphysis (which runs parallel, not transverse, to the fifth MT base).
- Give analgesia, elevation, and support in a padded crepe bandage or, temporarily, in a boot if symptoms are severe. Discharge with advice or fracture clinic follow- up, according to local policy.
Jones fracture (of the fifth MT)
- This is a transverse fracture of the fifth MT just distal to the inter-MT joint. It is a significant fracture, as it is prone to non- union.
- Treat with analgesia, crutches, BKPOP or boot, and orthopaedic follow- up.
Stress fractures of MTs
- These typically follow prolonged or unusual exercise (‘march fracture’) but often occur without an obvious cause.
- The most common site is the second MT shaft.
- Examine for swelling over the forefoot (there may be none) and localised tenderness over the MT shaft.
- X- rays are usually normal initially— callus or periosteal reaction is seen at ~2– 3 weeks.
- Treat symptomatically with analgesia, elevation, rest, and modified daily activity, as required. Suggest a padded insole. Firm shoes or boots may be more comfortable than flexible trainers. Expect full recovery in 6– 8 weeks. If unable to weight- bear, consider a brief period in a BKPOP or boot.
Toe fractures
- The treatment of isolated closed fractures of the toe phalanges without clinical deformity or other complicating factors is not altered by X- rays.
- X-ray the following:
- Obvious deformity, gross swelling, or suspected dislocation.
- Suspected compound injuries.
- If any tenderness over the MT head or metatarsophalangeal joint (MTPJ).
- Suspected FB.
- Treat uncomplicated phalangeal fractures with simple analgesia, elevation, and support with padded buddy strapping. Advise the patient to resume normal activities as soon as possible, but explain that some discomfort may be present for up to 4– 6 weeks. Hospital follow- up is not normally required.
- Manipulate displaced fractures under LA digital block. Angulated toe phalangeal fractures can be difficult to manipulate— a useful trick is to use a pen (or needle holder) placed between the toes as a fulcrum. Once satisfactorily reduced, buddy strap and confirm the position with X- rays.
Dislocated toes
- Untreated, toe dislocations may cause troublesome, persistent symptoms.
- Reduce promptly under LA digital block and splint by buddy strapping.
- Always confirm reduction by X- ray, and discharge with analgesia and advice on elevation and gradual mobilisation.
Compound toe injuries
- Careful wound toilet, debridement, and repair are essential to ensure rapid healing and avoid infective complications.
- Ensure that there is adequate tetanus prophylaxis.
- Always clean wounds thoroughly under adequate anaesthesia (usually LA digital block); provide antibiotics and analgesia.
- Advise the patient to elevate the injured foot, and arrange follow- up according to local practice.
- More severe injuries will require exploration and repair under GA. Refer these cases to the orthopaedic team.
Mangled or amputated toes
- Functional results of attempted re-implantation of amputated toes or repair of badly mangled toes are often poor.
- Provide analgesia, and refer to the orthopaedic surgeon for wound management and amputation of unsalvageable toes.
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- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
