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Fractures & Trauma

Foot & ankle fractures: navicular, calcaneus, 5th metatarsal—high-risk patterns, nonunion risk, and surgical vs non-operative management.

Overview

Fracture management across the hindfoot and lower extremity requires precise initial diagnosis, particularly for anterior-process calcaneal fractures where fragment size dictates the necessity of early intervention [4]. While nonsurgical approaches frequently succeed for acute hindfoot process and tubercle fractures, late surgical correction can substantially improve pain and function in chronic cases [5]. Similarly, treatment for cuboid fractures is well-described, though lateral malleolus fragments indicating higher trauma do not predict clinical outcomes [1, 2].

Distal tibial pilon fractures present significant challenges where long-term outcomes correlate directly with the severity of bone and soft-tissue injury, the quality of reduction, and the initial fracture severity [9]. Calcaneus fractures remain difficult to manage due to high complication rates and poor outcomes regardless of the treatment modality, rendering surgical indications controversial and dependent on fracture pattern, patient demographics, and surgeon experience [16, 24]. In pediatric distal femoral fractures, both conservative and surgical options are valid, with the choice driven by specific fracture type characteristics [6].

For specific pathologies, primary surgical intervention for type II snowboarder's talus fractures yields superior outcomes, reduced sequelae, and a return to pre-injury sports activity levels [11]. Tibial shaft imaging analysis aids in developing treatment options for concomitant posterior malleolar fractures [8], while intramedullary screw fixation for Jones fractures offers advantages over nonoperative care in select patients despite associated postoperative risks [56]. Finally, open tibial fractures in children are often managed with techniques preferred over external fixation to mitigate potential complications [28].

Anatomy & Pathophysiology

Foot fractures and dislocations represent common traumatic injuries associated with high rates of morbidity and dysfunction [13]. Stress fractures of the talus generally do not cause serious damage to the foot [31], whereas stress fractures of the metatarsals under fatiguing loading conditions may be explained by an alteration of the rollover process with increased forefoot loading [70]. Hallux valgus can be an integral part of the causes of stress fractures of the proximal phalanx of the great toe [71].

Biomechanical Risk Factors: Multiple stress fractures are associated with a high longitudinal arch of the foot, leg-length inequality, and excessive forefoot varus [39]. A high medial longitudinal arch may contribute to increased load on the lateral side of the foot [55]. The majority of patients sustaining Jones fractures present with varus hindfoot alignment, which may predispose them to developing or refracturing the injury [69].

Morphological and Structural Determinants: The shape of the talus and calcaneus, along with the architecture within the calcaneus—specifically the arrangement of trabeculae—are essential factors for calcaneal fractures [67]. In children, anteromedial cannulated screw fixation for Hawkins II/III talus fractures does not affect ankle joint stability and is conducive to the recovery of ankle function [50]. Parameters such as BMI, the shape of the first metatarsal head, or the amputation level were not identified as risk factors for the development of hallux valgus deformity or ulcer occurrence after second toe amputation [68].

Functional Consequences: A decrease in maximum force in the middle forefoot in patients with a previous stress fracture may result from gait alterations following the fracture [42]. Hallux valgus deformity and its severity are positively associated with the magnitude of anteroposterior postural sway [54].

Classification

AO/OTA: The revised 2018 AO/OTA classification simplified the previous classification of intracapsular femoral neck fractures but remains unreliable with only fair interobserver reliability [37].

Medial Malleolar: The proposed classification system for medial malleolar fractures is helpful in understanding injury mechanisms and guiding diagnosis, as well as surgical strategies [33].

Posterior Malleolar: Posterior malleolar ankle fractures (PMAFs) are three separate entities based on fracture morphology, with different predictors of outcome for each PMAF type [21]. Analysis of pre-operative radiographic findings can provide imaging basics for the development of accurate and appropriate treatment options for concomitant posterior malleolar fractures in tibial shaft fractures [8].

Talar Posterior Process: Different types of the posterior process of the talus may be related to the probability of fracture, and it may be better to consider different treatment strategies for different types of fractures [44].

Calcaneal: Computed tomography is an absolute necessity for comprehensive assessment of calcaneal fracture patterns, accurate classification, and treatment planning [48].

Other Considerations: Cuboid fracture patterns and management are described in the literature [1]. In type B lateral malleolus fractures, bone fragments indicating higher trauma do not predict clinical outcomes [2]. Accurate identification of partial avulsion patterns in the pediatric humeral medial epicondyle is likely important for understanding the natural history of these injuries and the outcomes of different treatment strategies [3]. Conservative and surgical management are valid alternatives for distal femoral fractures in children, with the choice depending on factors related to the fracture type [6]. Fatigue fracture of the tarsal navicular was not previously reported in man at the time of the 1970 study [10]. Foot fractures and dislocations are common traumatic injuries associated with high rates of morbidity and dysfunction, requiring an understanding of classifications and management to ensure anatomic alignment and functional recovery [13]. Almost two thirds of pelvic fractures are complicated by a wide variety of other fractures and injuries to soft tissues [22].

Clinical Presentation

Foot fractures and dislocations represent common traumatic injuries associated with high rates of morbidity and dysfunction [13]. Accurate diagnosis and understanding of classifications are required to ensure anatomic alignment and functional recovery [13]. In pediatric patients, hand and foot fractures frequently involve accompanying injuries that require attention during diagnosis and treatment [32].

Acute Fracture Patterns: Cuboid fracture patterns and management are described in the literature [1]. In type B lateral malleolus fractures, bone fragments indicating higher trauma do not predict clinical outcomes [2]. Accurate identification of partial avulsion patterns in pediatric humeral medial epicondyle injuries is likely important for understanding their natural history and treatment outcomes [3]. Primary surgical treatment for type II snowboarder's talus fractures has led to better outcomes, reduced sequelae, and allowed patients to regain pre-injury sports activity levels [11]. Missed anterior process calcaneus (APC) type IIIA fractures are at risk to develop complications [38].

Chronic and Stress Injuries: Clinical symptoms of calcaneal stress fractures appear insidiously [7]. Radiographic findings for calcaneal stress fractures are absent or subtle in the early stage [7], necessitating a high index of suspicion for orthopaedic surgeons to correctly diagnose these injuries [7]. Fatigue fracture of the tarsal navicular had not been previously reported in man at the time of the 1970 study [10]. Treatment of difficult stress fractures should be individualized to the patient, activity, anatomical site, and severity [19].

Anterior Process Calcaneus Specifics: Early excision of anterior-process calcaneus fracture fragments is usually not necessary or advisable [4]. Correct initial diagnosis and treatment are important for anterior-process calcaneus fractures, particularly if the fracture fragment is large [4]. Computed tomography diagnostics should be performed if there is any clinical suspicion of anterior process calcaneus fractures [38].

Hindfoot Process and Tubercle Injuries: Nonsurgical management is frequently successful for acute hindfoot process and tubercle fractures [5]. Late surgical intervention can substantially improve pain and function in untreated chronic hindfoot process and tubercle injuries [5].

Lisfranc and Ankle Complex: A high level of suspicion, recognition of clinical signs, and appropriate radiographic studies are needed for correct diagnosis of Lisfranc joint injuries to avoid late sequelae of posttraumatic arthritis [17]. Posterior malleolar ankle fractures (PMAFs) are three separate entities based on fracture morphology [21]. Different posterior malleolar ankle fracture types have different predictors of outcome [21]. Analysis of imaging features and evaluation of diagnostic methods for tibial shaft fractures with concomitant posterior malleolar fractures can provide imaging basics for developing accurate treatment options [8].

Compartment Syndrome and Polytrauma: Polytrauma and associated fractures increase suspicion for acute compartment syndrome in tibial shaft fractures [18]. Radiographic signs of significant displacement were not correlated with acute compartment syndrome development in tibial shaft fractures [18]. Almost two thirds of pelvic fractures are complicated by a wide variety of other fractures and injuries to soft tissues [22].

Associated Soft Tissue Findings: Bone bruise is frequent in patients with knee injuries without radiographically detectable fractures [35]. Bone bruise resolves in most cases 4–12 months after the injury [35]. Further research is needed to elucidate the relationship of the anteroposterior Garden Index with other fracture characteristics and to enhance its criterion and construct validity for assessing displacement severity in Garden III femoral neck fractures [40].

Investigations

Plain radiography: While essential for initial assessment, plain radiographs may fail to visualize injuries in 56% of children presenting with hemarthrosis and occult intra-articular knee injuries [27]. For hook of hamate fractures, standard radiographs demonstrate only 53% to 90% sensitivity [58]. In calcaneal stress fractures, radiographic findings are often absent or subtle in the early stages, necessitating a high index of suspicion despite insidious clinical symptoms [7]. Similarly, correct diagnosis of Lisfranc joint injury requires appropriate radiographic studies alongside a high level of clinical suspicion to avoid late posttraumatic arthritis [17]. In tibial shaft fractures, radiographic signs of significant displacement were not correlated with the development of acute compartment syndrome, though polytrauma and associated fractures increase clinical suspicion for this condition [18].

MRI: Magnetic resonance imaging is recommended for the liberal detection of knee injuries in patients with high-energy traumatic ipsilateral hip dislocation that are not discoverable by history and physical examination alone [47]. MRI-based examination is useful for all symptomatic elderly patients whose plain radiographic findings reveal isolated greater trochanter fractures [41]. Clinicians should consider advanced imaging to rule out occult fracture in athletes with significant capsular distention or those who do not respond to nonoperative management after a suspected ankle sprain [59].

CT: Advanced imaging techniques, including CT and three-dimensional reconstructions, augment information obtained from plain radiographs to guide treatment decisions for acetabular fractures [62]. CT offers 94% specificity and 97% accuracy for hook of hamate fractures, significantly outperforming standard radiographs [58]. Preoperative use of computed tomography may be justified for posterior malleolar fractures of the ankle due to the great variation in fracture configurations [29]. Computerized tomography allows prediction of outcomes for calcaneal fractures, indicating that Type-I fractures do well with closed treatment, Type-II fractures have a lower success rate, and all Type-III fractures have poor results after closed treatment [26]. Furthermore, analysis of imaging features and the diagnostic value of various methods can provide imaging basics for developing accurate treatment options for concomitant posterior malleolar fractures in tibial shaft fractures [8].

Other Considerations: Accurate identification of partial avulsion patterns in pediatric humeral medial epicondyle injuries and their underlying pathology is important for understanding natural history and treatment outcomes [3].

Treatment

Non-Operative

Nonsurgical management is frequently successful for acute process and tubercle fractures of the hindfoot [5], as well as for acute zone 1 proximal fifth metatarsal fractures where union rates are similar to surgical options [49]. Conservative approaches are also appropriate for acute fractures of medial and lateral great toe sesamoids in athletes [12], avulsion fractures of the calcaneal tuberosity in children [15], and tarsal navicular stress fractures, which should be managed with non-weightbearing immobilization as the standard of care [45]. For distal femoral fractures in children, conservative management remains a valid alternative to surgery [6], while closed treatment is effective for Type-I acute intra-articular calcaneus fractures [26]. However, conservative treatment is generally not appropriate for Jones fractures in the athletic population, as immobilization does not guarantee healing [51].

Operative

Indications: Surgical intervention is indicated for primary treatment of type II snowboarder's talus fractures to improve outcomes and reduce sequelae [11], and for chronic process and tubercle fractures of the hindfoot where late surgery substantially improves pain and function [5]. Operative management is preferred for fifth metatarsal base fractures (Jones fractures) to reduce non-union rates, shorten union duration, and accelerate return to activity and sport compared to non-operative care [53]. Intra-medullary screw fixation is more likely to achieve successful union for all types of Jones fractures than non-operative treatments [57]. Surgery is also considered for fractures of the proximal shaft of the fifth metatarsal when symptomatic delayed union or non-union occurs, often requiring bone grafts [30]. Indications for surgical management of calcaneus fractures remain controversial and depend on fracture pattern, patient demographics, and surgeon experience [24].

Surgical Approach / Technique: For open fractures of the tibia in children, a specific technique is preferred over external fixation due to potential complications associated with the latter [28]. Preoperative computed tomography is justified for posterior malleolar fractures of the ankle due to great variation in fracture configurations [29]. Computerized tomography allows prediction of which acute intra-articular calcaneus fractures will do well with closed treatment, guiding the decision to operate on Type-II and Type-III fractures which have lower success rates or poor results with closed management [26].

Implant Selection: Evidence supports operative interventions for fifth metatarsal base fractures, which demonstrate beneficial effects in reducing visual analog scale scores and increasing American orthopedic foot & ankle scale scores compared to non-operative interventions [53].

Other Considerations: Treatment of cuboid fractures is described in the literature [1]. In type B lateral malleolus fractures, bone fragments indicating higher trauma do not predict clinical outcomes [2]. Early excision of fragments in anterior-process calcaneus fractures is usually not necessary or advisable, though correct initial diagnosis and treatment are critical if the fragment is large [4]. Long-term outcomes for distal tibial pilon fractures are related to the severity of bone and soft-tissue injury, with more severe fractures having poorer outcomes, as well as the quality of the reduction [9]. Fractures of the tibia, ankle, and foot are common in children and adolescents, with management ranging from nonsurgical immobilization to surgical intervention based on fracture stability, displacement, and patient age [14]. Calcaneus fractures remain challenging to manage due to high complication rates and poor outcomes regardless of treatment modality [16]. Difficult stress fractures should be treated individually based on the patient, activity, anatomical site, and severity [19]. A trial is likely to provide level-I evidence on the effectiveness of cB + cBMA in the operative treatment of fifth metatarsal stress fractures [43].

Complications

Other Considerations: Management outcomes vary significantly by fracture type and patient demographics. In type B lateral malleolus fractures, bone fragments indicating higher trauma do not predict clinical outcomes [2]. Accurate identification of partial avulsion patterns in pediatric humeral medial epicondyle injuries is likely important for understanding their natural history and treatment outcomes [3]. Early excision of the fragment in anterior-process calcaneus fractures is usually not necessary or advisable [4], and nonsurgical management is frequently successful for acute process and tubercle fractures of the hindfoot [5]; however, late surgical intervention can substantially improve pain and function in untreated chronic process and tubercle fractures of the hindfoot [5]. Conservative and surgical management are valid alternatives for distal femoral fractures in children, with the choice depending on fracture type [6]. Clinical symptoms of calcaneal stress fractures appear insidiously, and radiographic findings are absent or subtle in the early stage [7]. Long-term outcomes of distal tibial pilon fractures are related to the severity of bone and soft-tissue injury and the quality of reduction, with more severe injuries having a poorer outcome [9]. Fatigue fractures of the tarsal navicular have not been previously reported in man [10]. Acute fractures of medial and lateral great toe sesamoids in athletes healed uneventfully after non-surgical treatment [12]. Closed or open treatment of avulsion fractures of the calcaneal tuberosity in children led to excellent results, with apparent healing by eight weeks and no occurrence of skin necrosis or functional loss [15]. Calcaneus fractures remain challenging to manage because of high complication rates and poor outcomes regardless of treatment modality [16]. Significant loss to follow-up could be expected in the longer term for symptomatic treatment or cast immobilization of avulsion fractures of the base of the fifth metatarsal [20]. Outcomes of calcaneal interlocking nail treatment showed good function, suggesting it could be an alternative method for minimally invasive fixation [23]. Talar fractures typically result from high-energy trauma with concomitant lower extremity injuries, leading to fair to poor long-term functional outcomes [25]. Fifty-six percent of children with hemarthrosis had no visible injury on plain radiographs [27]. Comminution and open fractures of the talar neck were associated with an increased risk of osteonecrosis [52], and functional outcomes were worse in patients with comminuted talar neck fractures [52]. In postmenopausal women, a history of wrist or spine fracture is a significant risk factor for subsequent hip fracture [63], with spine fractures conferring a higher relative risk (2.20) for subsequent hip fracture than wrist fractures (1.53) [63]. Evaluation of coxa vara in childhood should include a search for family history, trauma, infection, and associated skeletal abnormalities [65].

Recovery

Light activity (weeks): Return to desk work and light activities of daily living is feasible within eight weeks for specific pediatric avulsion fractures of the calcaneal tuberosity, which demonstrate apparent healing by this timeframe [15]. Conversely, early return to play at eight weeks or less following fixation of fifth metatarsal stress fractures carries a risk of delayed union in up to 24% of patients [73].

Full activity (months): Patients with type II snowboarder's talus fractures treated primarily with surgery can regain pre-injury sports activity levels [11]. While early return to play at eight weeks or less does not increase the risk of long-term non-union or prevent athletes from continuing to play following fifth metatarsal stress fracture fixation, the timing of reduction is critical for hip dislocations and femoral head fractures to minimize osteonecrosis risk [72, 73]. For distal femoral fractures in children, management choices between conservative and surgical approaches depend on fracture type, influencing the timeline for full functional return [6].

Complete recovery / outcome plateau (months): Functional outcomes for intra-articular ankle fractures stabilize at 12 months, a period where increased inflammatory cytokine levels do not affect the final result [46]. Long-term outcomes for distal tibial pilon fractures are determined by the severity of bone and soft-tissue injury and reduction quality, with severe injuries resulting in poorer outcomes [9]. Talar fractures, typically resulting from high-energy trauma, often lead to fair to poor long-term functional outcomes [25].

Rehabilitation protocol: Management for fractures of the tibia, ankle, and foot ranges from nonsurgical immobilization to surgical intervention based on fracture stability, displacement, and patient age [14]. Closed or open treatment of avulsion fractures of the calcaneal tuberosity in children resulted in no skin necrosis or functional loss [15]. Symptomatic treatment or cast immobilization for avulsion fractures of the base of the fifth metatarsal is associated with significant loss to follow-up [20]. For acute medial and lateral great toe sesamoid fractures in athletes, non-surgical treatment led to uneventful healing [12].

Functional milestones: Nonsurgical management is frequently successful for acute hindfoot process and tubercle fractures [5]. Late surgical intervention substantially improves pain and function in untreated chronic hindfoot process and tubercle fractures [5]. The calcaneal interlocking nail system demonstrates good function as an alternative for minimally invasive calcaneal fracture fixation [23]. Fractures of the proximal shaft of the fifth metatarsal heal slowly, often requiring bone grafts for symptomatic delayed union or non-union [30]. Three distinct fracture patterns exist in the proximal fifth metatarsal, each with unique mechanisms, locations, treatment options, and prognoses regarding delayed union and non-union [74].

Other Considerations: The choice between conservative and surgical management for distal femoral fractures in children depends on factors related to the fracture type [6]. Management of tibia, ankle, and foot fractures in children and adolescents varies by fracture stability, displacement, and patient age [14].

Key Evidence

  • [L4] The treatment of these fractures is described. (10.1302/0301-620x.98b7.36639)
  • [L4] In type B fractures, bone fragments indicating higher trauma do not predict clinical outcomes, thereby supporting personalised surgical planning. (10.1186/s13018-024-05424-1)
  • [L4] Accurate identification of these injury patterns and their underlying pathology is likely important for understanding the natural history of these injuries and the outcomes of different treatment strategies. (10.1177/03635465241310407)
  • [L4] Early excision of the fragment is usually not necessary or advisable; correct initial diagnosis and treatment are important, particularly if the fracture fragment is large. (10.2106/00004623-198264040-00006)
  • [L5] Nonsurgical management is frequently successful for acute fractures, while late surgical intervention can substantially improve pain and function in untreated chronic injuries. (10.5435/00124635-200512000-00002)
  • [L5] Conservative and surgical management are valid alternatives for the treatment of these fractures, with the choice depending on factors related to the fracture type. (10.1530/eor-21-0110)
  • [L4] Because clinical symptoms of the fracture appear insidiously and radiographic findings are absent or subtle in the early stage, a high index of suspicion is needed for orthopaedic surgeons to make the correct diagnosis. (10.2106/jbjs.l.01472)
  • [L3] An analysis of the imaging features of such fractures and evaluation of the diagnostic value of various methods can provide imaging basics for the development of accurate and appropriate treatment options. (10.1186/s12891-018-1982-1)
  • [L4] This type of fracture has not been previously reported in man. (10.2106/00004623-197052020-00023)
  • [L2] In type II fractures, primary surgical treatment has led to achieving better outcomes, reducing sequelae, and allowing patients to regain the same sports activity level as before injury. (10.1177/0363546504271001)
  • [L4] The fractures healed uneventfully after non-surgical treatment. (10.1007/s00167-003-0472-6)
  • [L4] Closed or open treatment led to excellent results, with apparent healing of all fractures by eight weeks and with no occurrence of skin necrosis or functional loss. (10.2106/00004623-199510000-00013)
  • [L5] Calcaneus fractures remain challenging injuries to manage because of high complication rates and poor outcomes regardless of treatment modality. (10.5435/jaaos-d-24-00567)
  • [L5] A high level of suspicion, recognition of clinical signs, and appropriate radiographic studies are needed for correct diagnosis to avoid late sequelae of posttraumatic arthritis. (10.5435/00124635-201012000-00002)
  • [L3] Polytrauma and associated fractures also increase suspicion, while radiographic signs of significant displacement were not correlated with acute compartment syndrome development. (10.1186/s12891-020-3044-8)
  • [L5] Treatment of difficult stress fractures should be individualized to the patient, activity, anatomical site, and severity. (10.1186/s13018-016-0431-9)
  • [L1] Significant loss to follow-up with this injury could be expected in longer term. (10.1302/0301-620x.98b6.36329)
  • [L3] PMAFs are three separate entities based on fracture morphology, with different predictors of outcome for each PMAF type. (10.1302/0301-620x.102b9.bjj-2019-1660.r1)
  • [L4] Almost two thirds of pelvic fractures are complicated by a wide variety of other fractures and injuries to soft tissues. (10.2106/00004623-196547050-00018)
  • [L4] The outcomes of follow-up showed good function, and the system could be an alternative method for minimally invasive calcaneous fracture fixation. (10.1186/s12891-022-05871-z)
  • [L4] Talar fractures typically result from high-energy trauma with concomitant lower extremity injuries, leading to fair to poor long-term functional outcomes. (10.1186/s12891-021-04572-3)
  • [L4] The authors conclude that computerized tomography allows prediction of which fractures will do well with closed treatment; Type-I fractures did well, Type-II fractures had a lower success rate, and all Type-III fractures had poor results after closed treatment. (10.2106/00004623-199173090-00024)
  • [L4] Fifty-six percent of these patients had no visible injury on plain radiographs. (10.1177/0363546514529639)
  • [L4] The authors prefer this technique to external fixation due to potential complications associated with the latter. (10.2106/00004623-199607000-00008)
  • [L4] Because of the great variation in fracture configurations, preoperative use of computed tomography may be justified. (10.2106/jbjs.e.00856)
  • [L4] In contrast, fractures of the proximal shaft heal slowly, often requiring bone grafts for symptomatic delayed union or non-union. (10.2106/00004623-197557060-00010)
  • [L4] Stress fractures of the talus do not seem to seriously damage the foot. (10.1177/0363546506291405)
  • [L4] Hand and foot fractures have many accompanying injuries that require attention during diagnosis and treatment. (10.1186/s12891-024-07407-z)
  • [L4] The proposed classification system is helpful in understanding injury mechanisms and guiding diagnosis, as well as surgical strategies. (10.1302/0301-620x.103b5.bjj-2020-1859.r2)
  • [L3] Bone bruise is frequent in patients with knee injuries without radiographically detectable fractures, and it resolves in most cases 4–12 months after the injury. (10.1007/s00167-001-0272-9)
  • [L4] The revised 2018 AO/OTA classification simplified the previous classification of intracapsular fracture but remain unreliable with only fair interobserver reliability. (10.1186/s12891-022-05007-3)
  • [L4] Missed APC type IIIA fractures are at risk to develop complications, which is why computed tomography diagnostics should be performed if there is any clinical suspicion. (10.1186/s12891-022-05903-8)
  • [L4] Biomechanical factors associated with multiple stress fractures were high longitudinal arch of the foot, leg-length inequality, and excessive forefoot varus. (10.1177/03635465010290030901)
  • [L4] Further research is needed to elucidate its relationship with other fracture characteristics and to enhance its criterion and construct validity. (10.1186/s13018-023-04269-4)
  • [L4] MRI-based examination is useful in all symptomatic elderly patients whose plain radiographic findings reveal isolated GT fractures. (10.1186/s12891-018-2193-5)
  • [L3] The decrease in maximum force in the middle forefoot in patients with a previous stress fracture could have resulted from gait alterations after the fracture. (10.1177/0363546508324967)
  • [L2] This trial will likely provide level-I evidence on the effectiveness of cB + cBMA in the operative treatment of MT-V stress fractures. (10.1186/s12891-015-0649-4)
  • [L4] Different types of the posterior process of the talus may be related to the probability of fracture, and it may be better to consider different treatment strategies for different types of fractures. (10.1186/s13018-022-03345-5)
  • [L1] Non-weightbearing conservative management should be considered the standard of care for tarsal navicular stress fractures. (10.1177/0363546509355408)
  • [L3] Increased inflammatory cytokine levels after fracture did not affect functional outcome at 12 months. (10.1186/s13018-021-02473-8)
  • [L4] The authors recommend the liberal use of magnetic resonance imaging to detect injuries not discoverable by history and physical examination alone. (10.2106/jbjs.d.02306)
  • [L5] Computed tomography is an absolute necessity for comprehensive assessment of calcaneal fracture patterns, accurate classification, and treatment planning. (10.2106/00004623-199072060-00027)
  • [L4] Acute zone 1 fractures are preferably treated conservatively as similar union rates were found after both conservative and surgical management. (10.1007/s00167-020-06072-8)
  • [L4] It does not affect the stability of the ankle joint and is conducive to the recovery of ankle function. (10.1186/s13018-023-04253-y)
  • [L4] Conservative treatment is not appropriate for Jones fractures in the athletic population as immobilization does not guarantee healing. (10.1007/s001670050183)
  • [L3] Comminution and open fractures were associated with an increased risk of osteonecrosis, and functional outcomes were worse in patients with comminuted fractures. (10.2106/00004623-200408000-00003)
  • [L1] The systematic review and meta-analysis recommend the use of operative interventions for managing the fifth metatarsal's base fracture, demonstrating beneficial effects compared to non-operative interventions for reducing the rate of non-union, duration of union, duration of return to activity, duration of return to sport, and visual analog scale scores, while increasing the American orthopedic foot & ankle scale score. (10.1371/journal.pone.0237151)
  • [L4] Hallux valgus deformity and its severity were positively associated with the magnitude of the anteroposterior postural sway. (10.1186/s12891-021-04385-4)
  • [L3] In addition, high medial longitudinal arch may contribute to increased load on the lateral side of the foot. (10.1177/0363546519893365)
  • [L4] Although intramedullary screw fixation of Jones fractures has advantages over nonoperative treatment in a select group of patients, the risk for postoperative complications exists. (10.1177/03635465020300012301)
  • [L4] Although supported by mostly level 4 evidence, intra-medullary screw fixation is more likely to lead to successful union of all types of Jones fractures compared to non-operative treatments. (10.1007/s00167-012-2138-8)
  • [L5] Standard radiographs provide between 53% and 90% sensitivity, while CT offers 94% specificity and 97% accuracy. (10.1016/j.jhsa.2013.06.004)
  • [L4] Clinicians should consider advanced imaging to rule out occult fracture in athletes with significant capsular distention or those who do not respond to nonoperative management after a suspected ankle sprain. (10.1177/0363546508324965)
  • [L5] Advanced imaging techniques, including CT and three-dimensional reconstructions, augment the information obtained from plain radiographs to guide treatment decisions. (10.5435/jaaos-d-15-00666)
  • [L1] In postmenopausal women, a history of wrist or spine fracture is a significant risk factor for subsequent hip fracture, with spine fractures conferring a higher relative risk (2.20) than wrist fractures (1.53). (10.2106/00004623-200310000-00011)
  • [L5] Evaluation should include a search for family history, trauma, infection, and associated skeletal abnormalities to classify coxa vara and select optimal treatment. (10.5435/00124635-199803000-00003)
  • [L4] The shape of the talus and calcaneus and the architecture within the calcaneus, especially the arrangement of the trabeculae, are essential factors for calcaneal fractures. (10.1186/s13018-022-02930-y)
  • [L3] This study could not identify parameters such as the BMI, the shape of the first metatarsal head or the amputation level as risk factors for the development of either hallux valgus deformity or ulcer occurrence after second toe amputation. (10.1186/s13018-023-03577-z)
  • [L4] The majority of patients sustaining Jones fractures have evidence of varus hindfoot alignment, which may be a predisposing factor to developing the fracture or refracture. (10.1177/0363546508314401)
  • [L3] The demonstrated alteration of the rollover process with an increased forefoot loading may help to explain the incidence of stress fractures of the metatarsals under fatiguing loading conditions. (10.1177/0363546504265191)
  • [L4] The hallux valgus could be an integral part of the causes of stress fractures of the proximal phalanx of the great toe. (10.1177/0363546503258780)
  • [L4] Early return to play (8 weeks or less) may result in delayed union in up to 24% of patients, but this does not increase the risk of long-term non-union or prevent athletes from continuing to play. (10.1007/s00167-018-5104-2)
  • [L5] There are three distinct fracture patterns in the proximal fifth metatarsal, each having its own mechanism of injury, location, treatment options, and prognosis regarding delayed union and nonunion. (10.5435/00124635-200009000-00007)

See Also

References

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[2] Morphological and clinical study of lateral malleolus fractures based on fracture mapping: a retrospective study. Journal of Orthopaedic Surgery and Research. 2024. DOI: 10.1186/s13018-024-05424-1

[3] Partial Avulsion Patterns in the Pediatric Humeral Medial Epicondyle. The American Journal of Sports Medicine. 2025. DOI: 10.1177/03635465241310407

[4] Surgical excision for anterior-process fractures of the calcaneus.. The Journal of Bone & Joint Surgery. 1982. DOI: 10.2106/00004623-198264040-00006

[5] Process and Tubercle Fractures of the Hindfoot. Journal of the American Academy of Orthopaedic Surgeons. 2005. DOI: 10.5435/00124635-200512000-00002

[6] Distal femoral fractures in children. EFORT Open Reviews. 2022. DOI: 10.1530/eor-21-0110

[7] Calcaneal Stress Fracture: An Adverse Event Following Total Hip and Total Knee Arthroplasty. Journal of Bone and Joint Surgery. 2014. DOI: 10.2106/jbjs.l.01472

[8] Pre-operative radiographic findings predicting concomitant posterior malleolar fractures in tibial shaft fractures: a comparative retrospective study. BMC Musculoskeletal Disorders. 2018. DOI: 10.1186/s12891-018-1982-1

[9] Chapter 44 Distal Tibial Pilon Fractures. 2021.

[10] Fatigue Fracture of the Tarsal Navicular. The Journal of Bone & Joint Surgery. 1970. DOI: 10.2106/00004623-197052020-00023

[11] Snowboarder's Talus Fracture. The American Journal of Sports Medicine. 2005. DOI: 10.1177/0363546504271001

[12] Acute fractures of medial and lateral great toe sesamoids in an athlete. Knee Surgery, Sports Traumatology, Arthroscopy. 2004. DOI: 10.1007/s00167-003-0472-6

[13] Chapter 46 Foot Fractures and Dislocations. 2021.

[14] Chapter 45 Tibia, Ankle, and Foot Fractures. 2020.

[15] Avulsion fracture of the tuberosity of the calcaneus in children. A report of four cases and review of the literature.. The Journal of Bone & Joint Surgery. 1995. DOI: 10.2106/00004623-199510000-00013

[16] Calcaneus Fractures: A Review of Management, Treatment, and Recent Advances. Journal of the American Academy of Orthopaedic Surgeons. 2025. DOI: 10.5435/jaaos-d-24-00567

[17] Treatment of Lisfranc Joint Injury: Current Concepts. Journal of the American Academy of Orthopaedic Surgeons. 2010. DOI: 10.5435/00124635-201012000-00002

[18] Clinical and radiographic predictors of acute compartment syndrome in the treatment of tibial shaft fractures: a retrospective cohort study. BMC Musculoskeletal Disorders. 2020. DOI: 10.1186/s12891-020-3044-8

[19] Taking a holistic approach to managing difficult stress fractures. Journal of Orthopaedic Surgery and Research. 2016. DOI: 10.1186/s13018-016-0431-9

[20] Symptomatic treatment or cast immobilisation for avulsion fractures of the base of the fifth metatarsal. The Bone & Joint Journal. 2016. DOI: 10.1302/0301-620x.98b6.36329

[21] Posterior malleolar ankle fractures. The Bone & Joint Journal. 2020. DOI: 10.1302/0301-620x.102b9.bjj-2019-1660.r1

[22] Complications Associated with Fractures of the Pelvis. The Journal of Bone & Joint Surgery. 1965. DOI: 10.2106/00004623-196547050-00018

[23] Calcaneous interlocking nail treatment for calcaneous fracture: a multiple center retrospective study. BMC Musculoskeletal Disorders. 2022. DOI: 10.1186/s12891-022-05871-z

[24] Chapter 45 Calcaneus Fractures. 2021.

[25] Patient reported outcome of 33 operatively treated talar fractures. BMC Musculoskeletal Disorders. 2021. DOI: 10.1186/s12891-021-04572-3

[26] Computerized tomography scanning of acute intra-articular fractures of the calcaneus. A new classification system.. The Journal of Bone & Joint Surgery. 1991. DOI: 10.2106/00004623-199173090-00024

[27] Occult Intra-articular Knee Injuries in Children With Hemarthrosis. The American Journal of Sports Medicine. 2014. DOI: 10.1177/0363546514529639

[28] Open Fracture of the Tibia in Children. The Journal of Bone & Joint Surgery*. 1996. DOI: 10.2106/00004623-199607000-00008

[29] Pathoanatomy of Posterior Malleolar Fractures of the Ankle. The Journal of Bone & Joint Surgery. 2006. DOI: 10.2106/jbjs.e.00856

[30] Fractures and anatomical variations of the proximal portion of the fifth metatarsal. The Journal of Bone & Joint Surgery. 1975. DOI: 10.2106/00004623-197557060-00010

[31] Outcomes of Stress Fractures of the Talus. The American Journal of Sports Medicine. 2006. DOI: 10.1177/0363546506291405

[32] Clinical analysis of 1301 children with hand and foot fractures and growth plate injuries. BMC Musculoskeletal Disorders. 2024. DOI: 10.1186/s12891-024-07407-z

[33] Characteristics and classification of medial malleolar fractures. The Bone & Joint Journal. 2021. DOI: 10.1302/0301-620x.103b5.bjj-2020-1859.r2

[35] Bone bruise in the acutely injured knee. Knee Surgery, Sports Traumatology, Arthroscopy. 2002. DOI: 10.1007/s00167-001-0272-9

[37] Femoral neck fracture: the reliability of radiologic classifications. BMC Musculoskeletal Disorders. 2022. DOI: 10.1186/s12891-022-05007-3

[38] Introduction of a modified Degan classification to specify treatment algorithms in fractures of the anterior process of the calcaneus. BMC Musculoskeletal Disorders. 2022. DOI: 10.1186/s12891-022-05903-8

[39] Risk Factors for Recurrent Stress Fractures in Athletes. The American Journal of Sports Medicine. 2001. DOI: 10.1177/03635465010290030901

[40] Exploring the displacement characteristics of Garden III femoral neck fractures and the reliability, validity, and value of the anteroposterior Garden Index in assessing displacement severity. Journal of Orthopaedic Surgery and Research. 2023. DOI: 10.1186/s13018-023-04269-4

[41] Diagnostic strategy for elderly patients with isolated greater trochanter fractures on plain radiographs. BMC Musculoskeletal Disorders. 2018. DOI: 10.1186/s12891-018-2193-5

[42] Plantar Loading Comparisons between Women with a History of Second Metatarsal Stress Fractures and Normal Controls. The American Journal of Sports Medicine. 2008. DOI: 10.1177/0363546508324967

[43] The effect of concentrated bone marrow aspirate in operative treatment of fifth metatarsal stress fractures; a double-blind randomized controlled trial. BMC Musculoskeletal Disorders. 2015. DOI: 10.1186/s12891-015-0649-4

[44] Anatomical observation, classification, fracture and finite element analysis of the posterior process of the Asian adult talus. Journal of Orthopaedic Surgery and Research. 2022. DOI: 10.1186/s13018-022-03345-5

[45] Management of Tarsal Navicular Stress Fractures. The American Journal of Sports Medicine. 2010. DOI: 10.1177/0363546509355408

[46] Association of acute inflammatory cytokines, fracture malreduction, and functional outcome 12 months after intra-articular ankle fracture—a prospective cohort study of 46 patients with ankle fractures. Journal of Orthopaedic Surgery and Research. 2021. DOI: 10.1186/s13018-021-02473-8

[47] Knee Injury in Patients Experiencing a High-Energy Traumatic Ipsilateral Hip Dislocation. The Journal of Bone and Joint Surgery (American). 2005. DOI: 10.2106/jbjs.d.02306

[48] Intra-articular fractures of the calcaneus.. The Journal of Bone & Joint Surgery. 1990. DOI: 10.2106/00004623-199072060-00027

[49] Adequate union rates for the treatment of acute proximal fifth metatarsal fractures. Knee Surgery, Sports Traumatology, Arthroscopy. 2020. DOI: 10.1007/s00167-020-06072-8

[50] Anteromedial cannulated screw fixation for Hawkins II/III talus fractures in children: a retrospective study. Journal of Orthopaedic Surgery and Research. 2023. DOI: 10.1186/s13018-023-04253-y

[51] Fractures of the fifth metatarsal in basketball players. Knee Surgery, Sports Traumatology, Arthroscopy. 1999. DOI: 10.1007/s001670050183

[52] Talar Neck Fractures: Results and Outcomes. The Journal of Bone and Joint Surgery-American Volume. 2004. DOI: 10.2106/00004623-200408000-00003

[53] Comparison of operative and non-operative management of fifth metatarsal base fracture: A meta-analysis. PLOS ONE. 2020. DOI: 10.1371/journal.pone.0237151

[54] Hallux valgus deformity and postural sway: a cross-sectional study. BMC Musculoskeletal Disorders. 2021. DOI: 10.1186/s12891-021-04385-4

[55] Pathoanatomy of the Jones Fracture in Male University Soccer Players. The American Journal of Sports Medicine. 2019. DOI: 10.1177/0363546519893365

[56] Intramedullary Screw Fixation of Jones Fractures. The American Journal of Sports Medicine. 2002. DOI: 10.1177/03635465020300012301

[57] Treatment and return to sport following a Jones fracture of the fifth metatarsal: a systematic review. Knee Surgery, Sports Traumatology, Arthroscopy. 2012. DOI: 10.1007/s00167-012-2138-8

[58] Hook of Hamate Fractures. The Journal of Hand Surgery. 2013. DOI: 10.1016/j.jhsa.2013.06.004

[59] Unusual Presentation of a Talar Neck Fracture in an Intercollegiate Varsity Football Player. The American Journal of Sports Medicine. 2008. DOI: 10.1177/0363546508324965

[62] Radiographic Evaluation of Acetabular Fractures: Review and Update on Methodology. Journal of the American Academy of Orthopaedic Surgeons. 2018. DOI: 10.5435/jaaos-d-15-00666

[63] COLLES FRACTURE, SPINE FRACTURE, AND SUBSEQUENT RISK OF HIP FRACTURE IN MEN AND WOMEN. The Journal of Bone and Joint Surgery-American Volume. 2003. DOI: 10.2106/00004623-200310000-00011

[65] Coxa Vara in Childhood: Evaluation and Management. Journal of the American Academy of Orthopaedic Surgeons. 1998. DOI: 10.5435/00124635-199803000-00003

[67] Calcaneal fracture maps and their determinants. Journal of Orthopaedic Surgery and Research. 2022. DOI: 10.1186/s13018-022-02930-y

[68] Ulcer occurrence on adjacent toes and hallux valgus deformity after amputation of the second toe in diabetic patients. Journal of Orthopaedic Surgery and Research. 2023. DOI: 10.1186/s13018-023-03577-z

[69] The Association of a Varus Hindfoot and Fracture of the Fifth Metatarsal Metaphyseal-Diaphyseal Junction. The American Journal of Sports Medicine. 2008. DOI: 10.1177/0363546508314401

[70] The Influence of Muscle Fatigue on Electromyogram and Plantar Pressure Patterns as an Explanation for the Incidence of Metatarsal Stress Fractures. The American Journal of Sports Medicine. 2004. DOI: 10.1177/0363546504265191

[71] Relationship between Stress Fractures of the Proximal Phalanx of the Great Toe and Hallux Valgus. The American Journal of Sports Medicine. 2004. DOI: 10.1177/0363546503258780

[72] Chapter 98 Hip Dislocations and Femoral Head Fractures. 2019.

[73] Early return to playing professional football following fixation of 5th metatarsal stress fractures may lead to delayed union but does not increase the risk of long-term non-union. Knee Surgery, Sports Traumatology, Arthroscopy. 2018. DOI: 10.1007/s00167-018-5104-2

[74] Treatment Strategies for Acute Fractures and Nonunions of the Proximal Fifth Metatarsal. Journal of the American Academy of Orthopaedic Surgeons. 2000. DOI: 10.5435/00124635-200009000-00007

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