01Approach to the Critical Patient/attcp40

Immediate priorities

›Limb threat screen

›Open fracture concern

›Wound near lateral midfoot

›Visible bone or deep contamination

›Neurovascular compromise

›Dorsalis pedis pulse abnormal

›Posterior tibial pulse abnormal

›Compartment syndrome concern

›Pain out of proportion

›Pain with passive toe stretch

›Skin threat

›Tenting or blanching over cuboid

›Rapidly expanding swelling

›Immediate consult triggers

›If open fracture, immediate orthopedics

›IV antibiotics within 60 minutes (Class I)

›Tetanus prophylaxis pathway

›If pulseless or cool foot, immediate vascular and orthopedics

›Emergent reduction of gross deformity if present

›CTA lower extremity if persistent perfusion concern

›If suspected Lisfranc instability, urgent orthopedics

›Stress views or CT planning

›Strict non weight bearing

Initial stabilization and monitoring

›Analgesia and immobilization first pass

›Pain control plan

›Acetaminophen PO 1000 mg q6-8h

02History/hx36

Mechanism and risk mapping

›Injury context

›Mechanism pattern

›Axial load to plantarflexed foot

›Crush injury to lateral midfoot

›Time since injury

›<6 hours

›>6 hours

›Ambulation after injury

›Unable to bear weight

›Able with limp

›Associated injury clues

›Lisfranc pattern clues

›Midfoot plantar ecchymosis

›Pain with midfoot torsion

›Lateral column injury clues

›Lateral midfoot pain maximum

›Pain with forefoot abduction

›Patient factors

›Anticoagulants or bleeding risk

›DOAC use

›Warfarin use

›Bone health risk

›Osteoporosis

›Chronic glucocorticoids

›Diabetes or neuropathy

›Reduced pain perception risk

›Skin breakdown risk

03Physical Exam/exam61

Focused foot and ankle exam

›Inspection

›Swelling distribution

›Lateral midfoot swelling

›Diffuse midfoot swelling

›Ecchymosis pattern

›Lateral dorsal ecchymosis

›Plantar ecchymosis

›Skin integrity

›Laceration near cuboid

›Fracture blister presence

›Palpation

›Point tenderness

›Cuboid dorsal lateral tenderness

›Calcaneocuboid joint tenderness

›Midfoot and hindfoot survey

›Base of 5th metatarsal tenderness

›Navicular tenderness

›Range of motion and stress maneuvers

›Pain provocation

›Pain with forefoot abduction

›Pain with midfoot torsion

›Peroneal tendon region

›Tenderness along peroneal tendons

›Pain with resisted eversion

Neurovascular and compartments

›Vascular

›Dorsalis pedis pulse quality

04Differential Diagnosis/ddx35

Traumatic midfoot pain differentials

›Fracture patterns

›Cuboid fracture (ICD-10 S92.21)

›Avulsion pattern

›Comminuted crush pattern

›5th metatarsal base fracture (ICD-10 S92.35)

›Tuberosity avulsion

›Jones pattern

›Navicular fracture (ICD-10 S92.25)

›Tuberosity avulsion

›Body fracture

›Calcaneus fracture (ICD-10 S92.0)

›Lateral wall pain

›Heel ecchymosis

›Dislocation and instability

›Calcaneocuboid subluxation or dislocation (SNOMED CT concept)

›Gross lateral midfoot deformity

›Locked midfoot pain

›Lisfranc injury (ICD-10 S93.32)

›Plantar ecchymosis

›Midfoot widening on imaging

›Soft tissue mimics

›Peroneal tendon injury

›Pain with resisted eversion

›Tenderness posterior to lateral malleolus

›Midfoot sprain

›Diffuse tenderness

›Stable imaging

05Laboratory Tests/lt24

Minimal labs for isolated closed injury

›Baseline labs not routinely needed

›No planned sedation or surgery

›No anticoagulant concern

Labs when escalation pathway

›Open fracture or operative planning

›CBC for baseline and anemia

›Hemoglobin for bleeding concern

›WBC for infection baseline

›Basic metabolic panel for renal function

›Creatinine for contrast planning

›Electrolytes for perioperative safety

›Coagulation studies when anticoagulants

›INR for warfarin

›Anti Xa level per local protocol for DOAC

›Crush injury or prolonged entrapment

›Creatine kinase for rhabdomyolysis risk

›Trend for severity

›Renal injury risk linkage

›Urinalysis for heme without RBC

›Myoglobinuria clue

›Escalation to IV fluids pathway

Interpretation and pitfalls

›Inflammatory markers

›CRP and ESR not fracture diagnostic

›Use only when infection concern

›False positives after trauma

06Diagnostic Tests/dt70

Scoring Systems

›Classification and decision anchors

›AO OTA midfoot classification concepts

›Articular involvement marker

›Comminution marker

›Gustilo Anderson open fracture

›Type I

›Wound <1 cm

›Minimal contamination

›Type II

›Wound 1-10 cm

›Moderate soft tissue injury

›Type III

›High energy mechanism

›Extensive soft tissue injury

›Management implications

›Antibiotics urgency (Class I)

›Emergent irrigation and debridement timing

Radiographs

›Initial imaging set

›Foot series

›AP view

›Lateral view

›Oblique view

›Ankle series if pain extends proximally

›Mortise view

›Lateral view

›Weight bearing views if Lisfranc concern and tolerated

07Disposition/dispo37

Discharge versus admission

›Discharge criteria

›Closed fracture

›No open wound

›No gross contamination

›Neurovascularly intact

›Pulses present

›Sensation intact or baseline

›Pain controlled with oral regimen

›Able to sleep

›Breakthrough plan in place

›Safe mobility plan

›Crutches or walker trained

›Strict non weight bearing feasible

›Admission or transfer criteria

›Open fracture

›Antibiotics and tetanus started

›Urgent operative pathway

›Displaced intra articular fracture suspected

›CT obtained or arranged urgently

›Orthopedics involved

›Midfoot instability concern

›Lisfranc concern

›Calcaneocuboid dislocation concern

›Compartment syndrome concern

›Serial exams required

›Compartment pressure pathway per local protocol

08Treatment/t121

Immediate life-saving interventions

›Life threats uncommon in isolated cuboid fracture

›Hemorrhage shock evaluation only if polytrauma

›Limb ischemia pathway if vascular compromise

›Open fracture immediate actions

›If open, initiate antibiotics within 60 minutes (Class I)

›Cefazolin IV 2 g q8h

›If severe cephalosporin allergy, clindamycin IV 900 mg q8h

›If gross contamination, broaden per local protocol

›Add gram negative coverage per open fracture pathway

›Add anaerobe coverage for soil contamination per local protocol

›Tetanus prophylaxis

›Tdap if immunization unknown or not up to date

›TIG if high risk wound and unimmunized

Immobilization and Splinting

›Splint choice

›Posterior short leg splint

›Neutral ankle position

›Foot slight dorsiflexion as tolerated

›Posterior short leg plus stirrup for added control

›Significant swelling

›Pain with inversion eversion

›Immobilization principles

›Swelling phase

›Avoid circumferential cast first 5-7 days

›Frequent neurovascular checks

›Position and padding

›Extra padding over lateral malleolus and cuboid region

›Edge flaring to reduce skin pressure

›Post application checks

›Motor function toes

›Great toe extension

›Toe flexion

›Sensation

›Dorsum and plantar surfaces

›First web space

›Perfusion

›Cap refill

›Distal pulses

Reduction

›Reduction indications

›Calcaneocuboid dislocation or gross subluxation

›Visible deformity

›Neurovascular compromise

›Threatened skin from bony prominence

›Skin blanching

›Tenting

›Analgesia and anesthesia options

›Non opioid baseline

›Acetaminophen PO 1000 mg

›Ibuprofen PO 400-600 mg

›Opioid for severe pain

›Morphine IV 0.05-0.1 mg/kg

›Hydromorphone IV 0.01-0.015 mg/kg

›Regional anesthesia

›Ankle block approach

›Posterior tibial nerve block

›Deep peroneal nerve block

›Superficial peroneal nerve block

›Sural nerve block

›Procedural sedation when needed

›Monitoring requirements

›Continuous pulse oximetry

›Continuous ECG

›Capnography when available (ACEP Level B)

›Medication options

›Ketamine IV 1 mg/kg

›Additional 0.25-0.5 mg/kg PRN q5-10 min

›Propofol IV 0.5-1 mg/kg

›Additional 0.25-0.5 mg/kg PRN q2-3 min

›Technique principles

›Traction and countertraction

›Forefoot traction

›Hindfoot stabilization

›Reverse deforming force

›If forefoot abducted, gentle adduction

›If lateral subluxation, medial translation

›Gentle sustained pressure

›Avoid repeated forceful attempts

›Stop if increasing neurovascular compromise

›Post reduction requirements

›Immediate neurovascular reassessment

›Pulses and cap refill

›Sensation change

›Post reduction imaging

›Foot series confirmation

›Joint congruity confirmation

›Immobilization in stable position

›Posterior short leg plus stirrup if unstable

›Strict non weight bearing

›Failed reduction pathway

›If irreducible, urgent orthopedics

›CT for interposed fragments

›OR reduction planning

›If persistent neurovascular deficit, emergent escalation

›CTA consideration

›Vascular consultation

Open fracture medications and timing

›Antibiotic pathway summary

›Timing target

›Within 60 minutes of recognition (Class I)

›Document time given

›First line closed chain context

›Cefazolin IV 2 g q8h

›Duration per ortho plan

›Allergy alternative

›Clindamycin IV 900 mg q8h

›Vancomycin per local MRSA protocol when indicated

›Tetanus pathway summary

›Clean minor wound

›Tdap if >10 years since last dose

›No TIG if immunized

›Dirty or high risk wound

›Tdap if >5 years since last dose

›TIG if incomplete immunization

DVT prophylaxis when relevant

›Risk stratification

›Lower limb immobilization with additional risk factors

›Prior VTE

›Active cancer

›Surgical pathway planned

›Ortho protocol driven

›Shared decision documentation

›Contraindication screen

›Active bleeding

›Severe thrombocytopenia

09Special Populations/sp42

Pregnancy

›Imaging modifications

›Radiographs acceptable with shielding

›Use lowest reasonable exposure

›Document shared decision

›CT only when management changing and needed

›Discuss risk benefit

›Prefer alternative imaging when sufficient

›Analgesia considerations

›Acetaminophen preferred

›Avoid exceeding 3-4 g per day

›Liver disease caution

›NSAID avoidance in later pregnancy

›Third trimester ductal constriction risk

›Coordinate with obstetrics when uncertainty

Geriatric

›Fragility context

›Low energy mechanism flags

›Ground level fall

›Baseline gait instability

›Osteoporosis evaluation pathway

›Calcium and vitamin D counseling

›PCP follow up for bone health

›Mobility and safety

›Higher admission threshold

›Unsafe non weight bearing at home

›Limited support system

›Delirium risk with opioids

10Background/b39

Epidemiology

›Occurrence context

›Rare compared with other foot fractures

›Often missed on initial evaluation

›Higher prevalence with high energy trauma

›Common co injuries

›Lisfranc injuries

›Calcaneus fractures

Pathophysiology

›Anatomic role

›Lateral column keystone

›Maintains lateral foot length

›Supports calcaneocuboid joint congruity

›Injury mechanisms

›Crush compression causing comminution

›Avulsion from ligamentous attachments

›Deformity consequence

›Lateral column shortening

›Forefoot abduction deformity

›Altered gait mechanics

›Articular depression

›Calcaneocuboid arthritis risk

›Chronic lateral midfoot pain risk

Therapeutic Considerations

›Nonoperative rationale

›Nondisplaced extra articular patterns

›Immobilization supports healing

›Protects lateral column length

11Patient Discharge Instructions/pdi25

copy discharge instructions

›Discharge instructions

›Diagnosis explanation

›Cuboid fracture or suspected cuboid fracture

›Risk of worsening if weight bearing early

›Immobilization care

›Keep splint clean and dry

›Do not insert objects under splint

›Swelling control

›Elevation above heart as much as possible first 48-72 hours

›Ice 15-20 minutes at a time with skin protection

›Activity restrictions

›Non weight bearing on injured foot

›Crutches or walker use until cleared

›Pain plan

›Acetaminophen as directed

›Ibuprofen as directed if safe

›Return to ED now

›Increasing pain not relieved by meds

›New numbness or tingling

›Toes pale blue or cold

›Splint feels too tight

›Wound drainage fever or worsening redness

›Follow up plan

›Orthopedics appointment in 5-7 days or sooner if instructed

›Repeat imaging if pain persists or swelling changes

12References/r13

Clinical guidelines and evidence sources

›Reference set

›BOAST guideline for open fractures antibiotic timing within 60 minutes

›Class I recommendation framing

›IV antibiotic early administration emphasis

›AAOS and orthopedic trauma consensus on open fracture management

›Early antibiotics and tetanus prophylaxis

›Operative irrigation and debridement pathway

›ACEP clinical policy and procedural sedation guidance

›Capnography during moderate to deep sedation (ACEP Level B)

›Monitoring standards for ED sedation

›Standard orthopedic texts for midfoot fracture management

›Indications for CT in complex midfoot fractures

›Operative indications for articular displacement and lateral column shortening

Evidence & Review

Evidence & Review