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Approach to the Critical Patient
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
Maximum 2400 mg per 24 hours
Hydromorphone PO 1 mg
Repeat every 4 to 6 hours as needed
Avoid in opioid naive if pain controlled with nonopioids
Procedural sedation trigger
Fracture dislocation requiring reduction
Severe pain preventing immobilization
Monitoring and documentation
Pre immobilization neurovascular exam
Dorsalis pedis and posterior tibial pulses
Sensation
Post immobilization neurovascular exam
Pain trend
Capillary refill
Open fracture pathway
Open fracture actions
Antibiotics within 1 hour target
Cefazolin IV 2 g
Clindamycin IV 900 mg for severe beta lactam allergy
Heavy contamination consideration
Add gentamicin IV 5 to 7 mg per kg once daily per local protocol
Add metronidazole IV 500 mg if farm or fecal contamination concern
Tetanus prophylaxis
Tdap if immunization unknown or not up to date
Tetanus immune globulin if unimmunized or uncertain with dirty wound
Urgent orthopedics and transfer triggers
Gross contamination
Vascular compromise
History
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
Patient factors
Baseline and risks
Prior foot surgery or hardware
Midfoot fusion history
Prior Lisfranc injury
Bone health risk
Osteoporosis
Chronic glucocorticoid use
Bleeding risk
Anticoagulants
Antiplatelet agents
Physical Exam
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
PITFALLS
Missed instability risk
Normal non weight bearing radiographs despite Lisfranc injury
Plantar ecchymosis as instability clue
Examination limitations
Pain limiting stress maneuvers
Swelling obscuring deformity
Differential Diagnosis
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
Delayed antibiotics
Laboratory Tests
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
Diagnostic Tests
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
MRI
Soft tissue and occult pathways
Lisfranc ligament injury detection
High suspicion with normal radiographs
Persistent plantar ecchymosis and midfoot pain
Occult fracture or stress injury
Persistent focal tenderness with negative radiographs
Return to sport planning in athletes
CT
Cross sectional imaging indications
Subtle fracture detection
Nondisplaced fractures not seen on radiographs
Minimal subluxation concern
Intra articular extension assessment
Joint surface step off concern
Surgical planning
High energy injury mapping
Multiple midfoot fractures
Polytrauma with foot swelling
Disposition
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
Treatment
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
Special Populations
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
Inconsistent history with injury pattern
Delay in presentation
Immobilization selection
Splint for swelling phase
Cast decision with orthopedics
Background
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
Repeat weight bearing imaging to detect delayed diastasis
Persistent pain trigger for advanced imaging
Operative rationale
Displacement or joint incongruity
Anatomic alignment to reduce arthritis risk
Stabilization for Lisfranc instability
Urgency drivers
Skin compromise
Neurovascular compromise
Patient Discharge Instructions
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
References
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
Example displaced initial encounter codes S92.241A and S92.242A
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.