An open fracture, also called a compound fracture, is a fracture resulting in the bone penetrating through the skin. Open fractures are usually the result of high-energy trauma. These injuries are considered contaminated, but if they are left without treatment for 6 to 8 hours, they are considered infected. Open fractures are considered a medical or surgical emergency, and patients should be admitted for antibiotics, closed reduction/open reduction internal fixation (ORIF), and/or debridement.

A stress fracture is a fracture that develops due to cyclical loading on a bone. These forces are seen in people with overuse and repetitive activities, such as runners and athletes. Ninety-five percent of stress fractures occur in the lower extremity, most notably the neck of the 2nd metatarsal. They may take 14 to 21 days to present radiographically after a bony callus has developed. If x-rays are inconclusive, a three-phase technetium bone scan may be positive as early as 2 to 8 days after onset of symptoms. MRI may show early signs within 1 to 2 weeks, and exposes patient to less radiation.

A greenstick fracture is an incomplete fracture in which the cortex on only one side of the bone is cracked. They are more commonly seen in children due to their soft bones.

Turf toe is a traumatic soft tissue injury of the 1st MPJ caused by forced hyperextension of the joint. Turf toe is more common in sports played on synthetic surfaces, hence the name “turf toe.” Turf toe results in plantar capsular and ligamentous injury, causing dislocation of the joint.

1. Release of extensor expansion

2. Tenotomy/lengthening of extensor digitorum longus/extensor digitorum brevis

3. Transverse MPJ capsulotomy

4. Release of collateral ligaments

5. Plantar plate release—metatarsal (McGlamry) scoop

1. Z-Plasty or V-Y skin plasty

2. Z-Tendon lengthening (for severe cases, transfer tendon to metatarsal head)

3. Release of extensor hood

4. Capsulotomy (dorsally and medially)

5. Plantar plate release (McGlamry elevator)

6. Plantar skin wedge excision

A fractured sesamoid must be distinguished from a bipartite sesamoid, which has an incidence of 20%. The easiest way to make the distinction is to compare current radiographs with previous films, if available. When earlier films are not available, comparing the contralateral foot can be useful. Fractured sesamoids may show irregular jagged edges of separation with interrupted peripheral cortices, longitudinal or oblique division lines, or a bone callus formation.

Ankle sprains occur when the ligaments of the ankle are stretched or torn. There are three main types of ankle sprains: inversion sprains, eversion sprains, and high ankle sprains. Eversion sprains are rare for two reasons: The fibula prevents the foot from everting and the deltoid ligament on the medial ankle is very strong. High ankle sprains are syndesmotic injuries.

Most ankle sprains are inversion sprains, in which the foot inverts and the lateral ligaments are damaged. The position of the foot at the time of an inversion sprain determines which ligaments are damaged. When the foot is plantarflexed at the time of injury, the anterior talofibular (ATF) ligament is damaged. This accounts for 95% of ankle sprains. When the foot is dorsiflexed at the time of injury, the calcaneofibular ligament is most likely damaged. Due to its proximity, rupture of the calcaneofibular ligament may also result in tearing of the peroneal tendon sheath.

A distal tibiofibular syndesmotic injury is also called a high ankle sprain and accounts for 10% of all ankle sprains. The mechanism of injury is eversion, dorsiflexion, and pronation, which forces the talus against the fibula widening the mortise. This results in damage to the ligaments holding the tibia and fibula together. The distal tibiofibular syndesmosis is a fibrous joint connecting the bones just above the ankle joint. The distal tibiofibular syndesmosis is composed of the following four ligaments, listed from anterior to posterior:

Anterior inferior tibiofibular ligament

Tibiofibular interosseous ligament

Inferior transverse tibiofibular ligament

Posterior inferior tibiofibular ligament (PITFL; strongest)

The talar dome is wider anteriorly than posteriorly, and the syndesmosis shows elasticity of 1 to 2 mm when the foot moves from plantarflexion to dorsiflexion. Extreme dorsiflexion can cause separation of the distal tibiofibular articulation and injure the ligamentous structures.

1. Bosworth fracture: Lateral malleolar fracture with posterior displacement of proximal fibula

2. Cotton fracture: Trimalleolar fracture

3. Dupuytren fracture: Pott fracture (bimalleolar fracture)

4. Maisonneuve fracture: Proximal 1/3 fibular fracture (fibular neck), associated with syndesmotic injury. Often involves medial malleolar fracture or rupture of the deltoid ligaments.

5. Tillaux-Chaput fracture: Avulsion fracture of anterior inferior lateral tibia

6. Wagstaffe fracture: Avulsion fracture of anterior inferior medial fibula

7. Volkmann fracture: Posterior malleolar fracture

Calcaneal fractures account for 1% to 2% of all fractures and typically occur as a result of axial loading such as a fall from a height or an MVA. The mechanism of injury is by way of the lateral process of the talus being driven down into the neutral triangle. Twenty percent of calcaneal fractures are associated with a spinal fracture between T12 and L2, L1 being the most common. Lumbar radiographs are, therefore, recommended in all fall/calcaneal injury patients presenting with back pain. Surgical repair should be performed within 5 hours of injury before acute swelling begins. If this window is missed, surgery should be delayed until swelling subsides, usually around 7 to 10 days, but before the 3-week mark when consolidation of the fracture begins. The goal of ORIF is to reestablish height and length to the calcaneus and realign the articular cartilage. These patients should be monitored for compartment syndrome.

Mondor sign is a clinical indicator for a calcaneal fracture. Patients present with ecchymosis extending from the malleoli to the sole of the foot.

Böhler angle is useful in evaluating calcaneal fractures. Normal values range between 20° and 40°; average is around 30° to 35°. Measurements less than 20° are seen in calcaneal fractures. Surgeons should strive to correct Böhler angle following ORIF for optimal outcome.

Gissane angle (critical angle) is useful in evaluating calcaneal fractures. Normal is 120° to 145°; a
fractured calcaneus will cause this angle to increase. Surgeons should strive to correct Gissane angle following ORIF for optimal outcome.