01Approach to the Critical Patient/attcp53

Immediate priorities

›Limb threat screen

›Open injury suspicion

›Visible bone

›Wound near midfoot with bleeding or fat globules

›Neurovascular compromise

›Dorsalis pedis pulse abnormal

›Posterior tibial pulse abnormal

›Compartment syndrome concern

›Pain out of proportion

›Pain with passive toe motion

›Skin threat

›Tenting

›Blanching

›Associated injury screen

›Lisfranc instability concern

›Plantar ecchymosis

›Inability to bear weight

›Polytrauma red flags

›High energy mechanism

›Multiple painful regions

Analgesia and monitoring

›Pain control plan

›Acetaminophen PO 1000 mg

›Maximum 4000 mg per 24 hours

›Maximum 3000 mg per 24 hours in frail older adult or liver risk

›Ibuprofen PO 400 mg

›Repeat every 6 to 8 hours as needed

02History/hx36

Mechanism and timeline

›Injury context

›Mechanism pattern

›Direct blow to dorsum

›Axial load on plantarflexed foot

›Energy level

›Low energy twist or trip

›High energy motor vehicle collision or fall from height

›Time since injury

›Immediate swelling

›Delayed swelling

›Weight bearing ability

›Unable to bear weight

›Able to bear weight with pain

Symptoms and red flags

›Symptom map

›Midfoot pain location

›Medial midfoot

›Dorsal midfoot

›Swelling and bruising

›Plantar ecchymosis

›Dorsal ecchymosis

›Neurovascular symptoms

›Numbness or tingling

›Cold foot sensation

›Escalation triggers

›Rapidly increasing pain

›Increasing tightness

03Physical Exam/exam32

Inspection and palpation

›Local findings

›Swelling distribution

›Dorsal midfoot swelling

›Plantar swelling

›Ecchymosis

›Plantar ecchymosis sign for Lisfranc concern

›Dorsal bruising

›Skin integrity

›Abrasions or lacerations

›Fracture blisters

›Point tenderness

›Cuneiform region tenderness

›Tarsometatarsal joint tenderness

Neurovascular and function

›Distal status

›Pulses

›Dorsalis pedis pulse

›Posterior tibial pulse

›Sensation domains

›Deep peroneal nerve

›Tibial nerve plantar sensation

›Motor screening

›Great toe extension

›Toe flexion

›Compartment assessment

›Pain with passive toe extension

›Firm compartments

04Differential Diagnosis/ddx27

Midfoot trauma differentials

›Fracture patterns and co injuries

›Lisfranc injury with fracture or ligament disruption

›ICD 10 S93.324 sprain of tarsometatarsal joint of left foot

›ICD 10 S93.323 sprain of tarsometatarsal joint of right foot

›Navicular fracture

›ICD 10 S92.25 fracture of navicular bone of foot

›Tenderness at navicular

›Cuboid fracture

›ICD 10 S92.21 fracture of cuboid

›Lateral midfoot tenderness

›Metatarsal base fracture

›ICD 10 S92.3 fracture of metatarsal bone

›Base of 2nd metatarsal pain

›Non fracture mimics

›Midfoot sprain

›Pain with normal imaging

›Stable weight bearing views

›Tendon injury

›Tibialis posterior tendinopathy

›Peroneal tendon injury

Complications to consider

›Limb threatening and time sensitive

›Compartment syndrome of foot

›Progressive pain

›Pain with passive toe motion

›Open fracture infection risk

›Contaminated wound

05Laboratory Tests/lt20

Routine ED labs

›Labs usually not required

›Isolated closed cuneiform fracture without surgery plan

›Normal vital signs

Targeted labs when indicated

›Operative or admission pathway

›Complete blood count for anemia or infection concern

›Hemoglobin baseline

›White blood cell count trend context

›Electrolytes and creatinine for perioperative planning

›Renal function for NSAID safety

›Renal function for contrast planning

›Coagulation studies for anticoagulant use or major bleeding concern

›INR for warfarin

›aPTT when heparin exposure concern

›Open fracture pathway

›Type and screen if significant bleeding or planned OR

›Transfusion planning

›Crossmatch readiness

›Serum lactate if shock concern

›Trend with resuscitation

›Alternative causes of elevation

06Diagnostic Tests/dt42

Scoring Systems

›Decision rules and classifications

›Ottawa foot rules

›Midfoot pain zone

›Navicular tenderness

›Base of 5th metatarsal tenderness

›Inability to bear weight for 4 steps

›Lisfranc classification

›Hardcastle Myerson patterns

›Management link

›Stable nondisplaced injuries

›Unstable fracture dislocation injuries

Radiographs

›Plain film strategy

›Initial views

›Foot AP

›Foot oblique

›Foot lateral

›Lisfranc suspicion additions

›Weight bearing comparison views when feasible

›Repeat weight bearing radiographs at 10 to 14 days if high suspicion and initial films negative

›Alignment checks

›2nd metatarsal base alignment with intermediate cuneiform

›1st to 2nd metatarsal interval widening

›Post immobilization imaging

›After reduction if dislocation present

›Before ED discharge for documentation

07Disposition/dispo23

Criteria and follow up

›Discharge with immobilization

›Closed fracture

›Intact neurovascular exam

›Pain controlled with oral medications

›Stable pattern suspected

›No displacement on imaging

›No Lisfranc instability features

›Follow up timing

›Orthopedics or fracture clinic in 5 to 10 days

›Earlier if significant swelling or skin threat

›Admission or transfer triggers

›Open fracture

›IV antibiotics required

›Operative debridement pathway

›Neurovascular compromise

›Diminished pulses

›Progressive neurologic deficit

›Suspected unstable Lisfranc injury

›Diastasis or malalignment on imaging

›Plantar ecchymosis with inability to bear weight and high suspicion

›Compartment syndrome concern

›Escalate to emergent surgical evaluation

›Avoid discharge

08Treatment/t88

Immediate life-saving interventions

›Threat mitigation

›Constriction removal

›Remove rings and tight footwear

›Remove constrictive wraps

›Limb ischemia pathway

›Immediate orthopedics and vascular consultation

›Emergent transfer if no surgical capability

›Open fracture bundle

›Antibiotics and tetanus pathway

›Sterile dressing with saline moistened gauze

Immobilization and Splinting

›Immobilization selection

›Bulky Jones splint for acute swelling

›Posterior short leg slab

›Extra padding over malleoli and dorsum

›Posterior short leg plus stirrup

›Additional inversion eversion control

›Swelling phase alternative to cast

›CAM walker boot

›Low swelling injuries

›Stable nondisplaced patterns

›Immobilization principles

›Non weight bearing default when instability possible

›Crutches or walker

›Knee scooter option

›Elevation strategy

›Foot above heart level

›Frequent elevation in first 48 to 72 hours

›Recheck after splint

›Pain trajectory

›Pulses and sensation

Reduction

›Reduction indications

›Fracture dislocation

›Gross deformity

›Skin tenting

›Neurovascular compromise

›Pulseless foot

›Progressive paresthesia

›Analgesia and anesthesia options

›Nonopioid base

›Acetaminophen PO 1000 mg

›Ibuprofen PO 400 mg

›Opioid for severe pain

›Fentanyl IV 25 to 50 mcg

›Repeat every 5 minutes to effect

›Procedural sedation when required

›Ketamine IV 1 mg per kg

›Additional 0.25 to 0.5 mg per kg as needed

›Continuous monitoring with airway readiness

›Propofol IV 0.5 to 1 mg per kg

›Additional 0.25 to 0.5 mg per kg every 1 to 3 minutes as needed

›Hypotension and apnea risk mitigation

›Technique principles

›Longitudinal traction and countertraction

›Restore length

›Gentle sustained force

›Reverse mechanism when clear

›Plantarflexion or dorsiflexion correction

›Abduction or adduction correction

›Failed reduction pathway

›Persistent deformity

›Urgent orthopedics

Open fracture medications and timing

›Antibiotics

›First line

›Cefazolin IV 2 g

›Repeat every 8 hours while awaiting definitive care per protocol

›Severe beta lactam allergy

›Clindamycin IV 900 mg

›Repeat every 8 hours while awaiting definitive care per protocol

›Heavy contamination

›Gentamicin IV 5 to 7 mg per kg once daily per local protocol

›Metronidazole IV 500 mg for farm contamination concern

›Tetanus prophylaxis

›Tdap

›If immunization unknown or not up to date

›If last booster more than 5 years with dirty wound

›Tetanus immune globulin

›Unimmunized or uncertain with dirty wound

›Immunocompromised with dirty wound

DVT prophylaxis when relevant

›Risk assessment for lower limb immobilization

›High risk factors

›Prior VTE

›Active cancer

›Prolonged non weight bearing

›More than 4 to 6 weeks expected

›Limited mobility baseline

›Local protocol alignment

›Pharmacologic prophylaxis selection per service

›Contraindications documentation

09Special Populations/sp30

Pregnancy

›Pregnancy modifications

›Imaging considerations

›Radiographs with shielding when appropriate

›CT only if results change management

›Analgesia considerations

›Acetaminophen preferred

›NSAID avoidance in later pregnancy per obstetric guidance

›Consultation triggers

›Abdominal trauma concern

›Decreased fetal movement concern

Geriatric

›Older adult considerations

›Fragility fracture context

›Osteoporosis assessment pathway

›Falls risk evaluation

›Higher complication risk

›Skin breakdown under splint

›Deconditioning with non weight bearing

›Medication risk

›NSAID renal risk

›Opioid delirium risk

Pediatrics

›Pediatric considerations

›Physeal injury possibility

›Salter Harris classification use for associated injuries

›Gentle reduction technique if needed

›Non accidental trauma context

10Background/b34

Epidemiology

›Frequency and context

›Relative rarity

›Often associated with other midfoot injuries

›Frequently under recognized when subtle

›Mechanism distribution

›Axial load on plantarflexed foot association with Lisfranc spectrum

›Direct blow association with dorsal fractures

›Risk groups

›Athletes with midfoot stress patterns

›Polytrauma patients with high energy injuries

Pathophysiology

›Anatomy and injury patterns

›Cuneiform roles

›Medial cuneiform with first ray stability

›Intermediate cuneiform with second ray keystone

›Injury mechanism mapping

›Compression and shear with axial load

›Rotational force with tarsometatarsal disruption

›Complication mechanisms

›Post traumatic midfoot arthritis from articular injury

›Chronic instability from Lisfranc ligament disruption

Therapeutic Considerations

›Nonoperative rationale

›Stable nondisplaced fractures

›Immobilization and non weight bearing about 6 weeks

›Transition to protected weight bearing in boot 2 to 6 weeks until pain free

›Instability surveillance

11Patient Discharge Instructions/pdi23

Copy discharge instructions

›Home care and restrictions

›Non weight bearing on injured foot

›Crutches or walker use

›Avoid driving until cleared if right foot involved

›Elevation and swelling control

›Elevate above heart as much as possible for 48 to 72 hours

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

›Splint or boot care

›Keep clean and dry

›Do not insert objects inside for itching

›Pain plan

›Acetaminophen and ibuprofen alternating if safe

›Opioid only if severe pain and prescribed

›Return to ED now

›Increasing pain not controlled with medication

›New numbness or tingling

›Toes cold pale or blue

›Increasing tightness or severe pain with toe movement

›Splint too tight or worsening swelling

›Fever or drainage from wound

›Follow up plan

›Orthopedics or fracture clinic appointment

›Imaging follow up if instructed

12References/r28

Evidence based sources

›Imaging and decision rules

›Ottawa ankle and foot rules summary

›Foot radiographs indications for midfoot pain with navicular tenderness or inability to bear weight

›Validated clinical decision rule for reducing unnecessary radiographs

›British Orthopaedic Foot and Ankle Society hyperbook

›Weight bearing radiographs and repeat imaging for subtle Lisfranc instability

›CT for subtle injury and preoperative planning

›Midfoot and Lisfranc management literature

›Lisfranc complex injuries review

›CT utility for nondisplaced fractures and subtle subluxation

›Conservative treatment for stable injuries with immobilization and non weight bearing about 6 weeks

›Management of midfoot fractures and dislocations review

›Nonoperative protocol of 6 weeks non weight bearing then 2 to 6 weeks protected weight bearing until pain free

›Surgical consideration when fracture line propagates or instability present

›Specialty society patient education

›AAOS OrthoInfo Lisfranc injury overview

›CT role for defining extent and surgical planning

›Operative consideration for unstable injuries

›Medical coding references

›ICD 10 fracture of lateral cuneiform

›S92.22 category

›Laterality and encounter extensions in subcodes

›ICD 10 fracture of intermediate cuneiform

›S92.23 category

›Example displaced initial encounter code S92.231A

›ICD 10 fracture of medial cuneiform

›S92.24 category

Evidence & Review

Evidence & Review