What are fractures?
Foot and ankle fractures, or breaks in the bone, come in many different varieties: ankle fracture, heel bone fracture, metatarsal fracture, 5th metatarsal fracture, pilon fracture, Lisfranc fracture and snowboarder’s fracture, to name just a few.
Overusing the bones can cause stress fractures and these occur frequently in runners or others pursuing sports involving repetitive strain.
What causes ankle fractures?
An ankle fracture is characterised by a break in one or more of the three ankle bones: the tibia, fibula and talus. The two ankle joints: the ankle joint (the point at which the tibia, fibula and talus meet) and the syndesmosis joint (located between the tibia and fibula) may also be affected. Ankle fractures are a familiar injury which can result in instability, if not treated properly, leading to the probability of further problems.
The reason for the frequency of ankle fractures is that the ankle bears your entire bodyweight and endures additional strain when running, jumping or participating in sport.
Ankle fracture
The reason for the frequency of ankle fractures is that the ankle bears your entire bodyweight and endures additional strain when running, jumping or participating in sport.
An ankle fracture can be signified by a cracking sound at the time of the injury, swelling, intense pain, bruising, tenderness, a bone protruding from the fracture (known as a compound or open injury) and an inability to place any weight on your ankle. The ankle can also look deformed and the shock of the injury may initiate a bout of nausea and dizziness.
Your consultant will invite you to discuss your symptoms when you meet and will advise you on the best treatment for you. X-rays may be organised to identify the extent of the injury and, in more involved cases, a CT or MRI scan may be required.
The kind of fracture you have will dictate your treatment. A dislocated ankle may need to undergo a realignment procedure (reduction) to avoid issues relating to the supply of blood to the foot, and nerve damage. A badly broken ankle, or open ankle, may require ankle fusion surgery to realign and repair the bones.
In the majority of cases, the ankle is placed in a cast or splint for approximately six weeks and crutches are often used to avoid putting weight on the joint. Your consultant may also recommend a personalised rehabilitation programme of physiotherapy.
Heel bone (Calcaneum) fracture
The heel bone or calcaneus, lying below the ankle joint, is the biggest tarsal bone. Along with the talus, it makes up the subtalar joint which enables the lateral movement in the hindfoot, essential for balance, particularly on bumpy terrain.
A relatively uncommon injury, a heel bone fracture or calcaneal fracture, can be caused by a fall from height, landing on your feet, as experienced in a fall from a ladder or from twisting your ankle. If the heel takes the full impact of your bodyweight, it can become wider and shorter.
Pain, swelling, bruising, and being unable to place weight on your heel to walk are common symptoms.
At your initial consultation, you will talk through your symptoms with your consultant, who will outline the most appropriate treatment for you. X-rays and CT scans may also be organised for further investigation of your condition.
The type of fracture you have will determine your treatment. A twisted ankle can, for instance, lead to a minor crack in the bone, however being in a car accident can cause the heel bone to shatter, otherwise known as a comminuted fracture. The talus bone can be forced into the heel bone when you land on your feet from a fall. The greater the impact, the greater the probability that the heel bone will be damaged.
Should no displacement of bones occur, it may be possible to take the non-surgical treatment route by wearing a cast, brace or splint and avoiding putting weight on the foot for approximately eight weeks.
It may be necessary for your consultant to perform surgery to realign displaced bones, repair your fracture to try to ensure that long-term issues such as pain and arthritis do not occur. Your consultant may also recommend a personalised rehabilitation programme of physiotherapy.
Metatarsal fracture
Each foot contains five metatarsal bones, linking your ankle to your toes, assisting balance when walking or standing and supporting the foot when you move. Metatarsal bone fractures occur frequently and are especially common for footballers.
A fracture is either described as ‘open’, if the skin is broken and the bones protrude, or ‘displaced’ in cases of bone misalignment.
Impact to the foot, such as something heavy landing on the foot, a fall or sporting injury where the foot is stepped on or kicked, can all cause fractures. A sharp twist to the foot can also lead to a fracture. Over-intensive use of the bones can result in stress fractures, an injury runners often complain of.
A ‘crack’ may be heard when the injury occurs. Pain and tenderness will be in evidence, along with bruising and swelling. Placing weight on the foot may be problematic and movement restricted. On occasion, the pain will decrease after an hour or two.
At your first appointment your consultant will discuss your symptoms with you and advise you on the most suitable treatment. X-rays and CT scans to further investigate your condition may be organised.
Your treatment is dependent on the extent of injury, the type of bone affected and whether the fracture is open, or the bone has been displaced. Should the fracture be neither open nor displaced, taking painkillers (under your doctor’s direction), lifting your foot higher than your heart and the regular application of an ice pack may be all that is required for it to heal. Your consultant may suggest that you wear a supportive dressing or plaster cast.
However, it may be that your consultant needs to perform realignment surgery on the displaced bones, repair the fracture and prevent long-term issues such as pain and arthritis. Your consultant may also recommend a personalised rehabilitation programme of physiotherapy for you.
5th metatarsal fracture
The 5th metatarsal bone is connected to the little toe on the foot’s outer edge.
The 5th metatarsal bone is the metatarsal most commonly fractured. Fracturing can occur during sport, gymnastic exercise or dancing, if the foot is twisted, or rolls inwards, which can also lead to ankle sprain. These fractures can be subdivided into:
Avulsion fracture: this is often accompanied by an ankle sprain and occurs at the bottom of the 5th metatarsal and normally doesn’t result in bone displacement.
The Jones fracture affects the joint lower down and the usual cause is stress across the bone while the heel is not in contact with the ground; this point suffers from below average blood supply to the bone which can hinder healing.
The spiral or oblique shaft fracture occurs closer to the toe, often as a result of impact to the foot or stresses on the bone; this sort of injury frequently causes bone displacement and dancers and gymnasts are among the chief sufferers.
Stress fractures, caused by overuse.
Bruising, swelling and pain are typical symptoms. A cracking sound may be heard as the bone breaks. Placing weight on the foot can be problematic, however, walking with a limp may be possible. Getting medical advice as soon as you can is advisable to check for other injuries, like ankle sprain or Lisfranc injury.
You will be able to discuss your symptoms at your initial appointment with your consultant, who will guide you to the best treatment for your condition and, in addition, may organise X-rays to reinforce or check his diagnosis.
The type of fracture, where it is located, and if it is open (skin is broken) or displaced (bones misaligned), will dictate your treatment. Most 5th metatarsal fractures can, however, be treated non-surgically through a special walking boot being worn and the use of crutches to reduce the weight carried by the foot.
You may be instructed to lift your foot above the level of your heart when possible, to get plenty of rest and to take anti-inflammatory painkillers. Full recovery normally takes up to 12 weeks, but on the plus side, most people can usually return to their chosen sport without long-term issues. However, it could be that your consultant recommends bone realignment surgery to improve the long-term prospects by repairing any damage.
Pilon fracture
A pilon fracture affects the shinbone or tibia, together with the weight-bearing surface of the ankle joint. Often, the fibula is also broken. The word ‘pilon’ is French for ‘pestle’, the utensil used when crushing, because the bone is frequently crushed or fragmented in a pilon fracture.
A pilon fracture often occurs after impact from incidents such as a car accident or a fall from height. It happens more frequently in sports like skiing. Typical of this injury are several fractures, including ‘open’ fractures in which the skin is open, and displacements of the bones, and also injury to neighbouring skin, tendons and muscle.
Pain, swelling, bruising, deformity and being unable to place weight on the injured ankle are all common symptoms.
Your consultant will discuss your symptoms with you at your initial meeting and guide you as to the most appropriate treatment. X-rays and CT scans may also be organised to help clarify initial diagnosis.
In cases where the bones aren’t displaced, the non-surgical route will normally be an option. This involves wearing a splint or cast and undergoing a tailored rehabilitation plan of physiotherapy.
Should your fracture be open, or if the bones are displaced, then surgery to repair and realign the bones may be necessary.
Lisfranc fracture
A Lisfranc or midfoot injury occurs when the midfoot bones are broken, or the ligaments that support the midfoot are torn. Sometimes, a Lisfranc injury can be wrongly diagnosed as an ankle sprain. The midfoot’s job is to add stability to the foot, support the arch and facilitate the transfer of energy from the calves to the forefoot when walking. If this area is damaged, it can lead to arthritis and flat foot.
These injuries are usually the result of a twisting fall which can break or displace the bones and cause damage to the surrounding cartilage. Football players are prone to this injury, which often occurs when a player trips over the top of a foot that is flexed downwards. Falls from height can also cause Lisfranc injuries, and these falls can also result in joint fractures and dislocation.
Common symptoms are bruising, pain and swelling on both the top and bottom of the foot, together with pain that worsens on standing or walking.
Having discussed your symptoms with your consultant when you meet for the first time, he will then take you through your treatment options and perhaps arrange CT and MRI scans and X-rays to aid accurate diagnosis.
Surgery is the usual treatment for a Lisfranc fracture. It may be necessary to realign and fix bones in place, depending on the extent of your injury. Post-operatively, it will be necessary to avoid putting weight on the foot completely, while wearing a cast or boot, followed by a programme of physiotherapy.
Snowboarder’s fracture
This type of injury occurs when the lateral process of the talus on the outside of the ankle, just above the heel, is fractured. It often occurs the toes are dorsiflexed (brought towards the shin), leading to the talus being locked in place by the surrounding bones. With the foot in this position, and if the ankle is rolled outwards with too much force, the bone will fracture. Sometimes this injury is mistakenly diagnosed as an ankle sprain that hasn’t responded to treatment, despite the apparently normal appearance of your X-rays.
This kind of fracture occurs, as its name would suggest, more frequently when, while snowboarding or skiing, the ankle is sprained. Twisting and forcing the ankle up and outwards, often when landing after a jump, is one of the main causes.
Symptoms include pain, bruising and swelling on the bony area that protrudes from the outside of the ankle, known as the lateral malleolus of the fibula. It can be misdiagnosed an ankle sprain that hasn’t responded to treatment.
Long-term issues are best avoided by seeking early diagnosis. Should the joint continue to be used, loose bone fragments caused by the injury can accumulate, causing long-term joint damage, notably arthritis. The first step will be to discuss your symptoms with your consultant, who will advise you on the appropriate treatment for your condition and may request that X-rays and a CT scan are done to inform his diagnosis.
Surgery is not a given for the treatment of a snowboarder’s fracture. If no loose bone fragments are revealed by the CT scan, you will normally be put in a cast and advised to avoid putting weight on the injured ankle for six weeks.
Should the CT scan show that there are loose fragments of bone, your consultant will normally recommend surgery for their removal and then resolve any bone displacement. Post-surgery, you’ll wear a removable plaster cast and be directed not to place weight on the ankle for six weeks before starting a programme of rehabilitation physiotherapy.
Stress fractures
Stress fractures are one of the most frequent sports injuries, with women suffering from them more often than men. These injuries are small cracks in the bone, triggered by overuse. Fractures occur when fatigued muscles can no longer absorb the shock of an impact created by a repeated movement. Stress fractures often happen in bones that bear the heaviest load, such as the second and third metatarsals in the foot, which are not only thinner than the first metatarsal but also take the brunt of the impact when running or walking. Stress fractures can also affect the heel (calcaneus), the outer bone of the lower leg and ankle or fibula, the talus (in the ankle joint) and the navicular, which is located on top of the midfoot.
Dancers often have stress fractures in the navicular or metatarsal bones. Walkers and runners are more likely to suffer stress fractures in their metatarsal and calcaneal bones.
Stress fractures in the heel area may be related to tibial and femoral neck stress fractures. These fractures higher up the leg are to be treated with extreme caution because, if they turn into a complete fracture or the bones misalign, it can lead to an aggressive form of arthritis. Should the bone in your femoral head die, a total hip replacement will be necessary.
Stress fractures can be caused over a period of time. New bone is always developing to supersede older bone. However, overintense repeated activity will break down the older bone too quickly, before new bone has the chance to grow and therefore bones weaken and are more prone to fracturing. Causes of stress fractures include:
- Raising the intensity level of an activity too suddenly, especially on hard surfaces
- Not wearing the correct footwear or using the right equipment when playing sport
- Greater activity, for example, participating in sport more often
- Adopting an abnormal foot posture or movement
- Suffering from osteoporosis or a hormone deficiency affecting your bones’ density
- Women experiencing irregular periods are at greater risk, due to reduced oestrogen, which normally helps to strengthen bones
- Running, jumping, or dancing or other high impact sports can make injury more likely
Pain when exercising, which dissipates when you are at rest, is the most common symptom.
Once you have discussed your symptoms with your consultant, he will advise you on the best treatment for you. In order to confirm the diagnosis, he may also organise X-rays and an MRI scan.
You will be advised to refrain from the activity that led to the fracture and to get plenty of rest for approximately eight weeks to allow healing to take place. After this, there will be regular MRI scans to check progress. If you were to continue your normal pattern of activity, without resting, it is likely to result in further stress fractures which may be more resistant to treatment. Your consultant may also advise you to wear shoe inserts or braces to help the fracture heal.
Surgery can be offered to sportspeople wanting a quick return to action, particularly those with a fracture on the inside of the tibia (medial malleolus fracture) or a 5th metatarsal fracture.
Not overdoing things after your treatment is key to avoiding further stress fractures. A staged return to training, without putting too much stress on your bones, is the best option.
To help you avoid future stress fractures, your consultant may suggest that you adjust your training goals and avoid overexerting yourself. As a rule, the level of your training intensity should go up by no more than 10% per week. Varying your training routine is an excellent idea as is ensuring you use the correct equipment, and particularly, the right footwear, for your sport.
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