The prognosis of fractures of the tarsal bones is not favorable, even though the lesion has been recognized at the time of injury. Even in the most favorable cases there is some limitation of lateral motion. The outlook is better in those cases of fracture of the os calcis in which there is a large heel fragment, than if the fracture is comminuted. The most frequent sequel is stiffness of the ankle-joint and traumatic pes valgus. Infection is frequent in compound fractures.
Treatment. This does not differ from that of a Pott’s fracture until the greater part of the swelling has disappeared. The skin of the foot and lower portion of the leg should be thoroughly cleansed and covered with gauze. This is necessary on account of the possibility of necrosis of the skin of the heel, and the danger of infection of the bruised soft tissues around the heel.
The foot should be placed in a well-padded box or in a posterior splint of the Volkman type. Ice bags should be applied over the sides of the heel.
After from eight to ten days, a circular plaster cast can be applied, extending from the toes to the knee. An anesthetic should be given during the application of the cast, the foot being held flexed at right angles and sheet wadding freely used around the ankle. The cast should be worn for seven weeks. At the end of this time the patient is gradually permitted to step upon the injured foot. Passive and active motion are also now employed.
Fractures of the neck of the astragalus, with rotation of the posterior fragment, are usually followed by great limitation of the movements of the ankle joint. This condition might be greatly improved by an open operation.
Fractures of the Metatarsal Bones. These are usually due to direct violence, as occurs when a heavy weight falls upon the dorsum of the foot. Another example of direct violence is a fracture following a crushing injury, as in being run over.
In indirect violence, such as follows dancing, jumping, or sudden twists of the foot, the fifth metatarsal bone is the one most often involved. There is but little tendency to displacement except when several bones are broken at the same time, and then it is toward the dorsum of the foot.
The diagnosis in fractures produced by direct violence is made from the following: presence of severe localized pain; swelling; and, not infrequently, crepitus and abnormal mobility. In those fractures due to indirect violence (second, third and fifth metatarsals), there is pain when the patient endeavors to put pressure upon the toes or tries to invert the foot. The usual signs of fracture are absent. A skiagraph should be made in every case.
Fracture of the metatarsal bones is liable to be followed by traumatic flat foot, on account of the sinking of the arch, or painful large calluses forming on the sole of the foot may interfere with walking.