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A midfoot fracture is a break in one or all of the bones in the midfoot (navicular, cuboid, and 3 cuneiforms). The bones and ligaments of the midfoot form a rigid structure. When injuries occur, the force is transmitted across the rows of bones. Fractures of the bones in the midfoot usually are not isolated injuries; there are often multiple fractures or fracture-dislocations.
Navicular fractures are classified as dorsal avulsion fractures, tuberosity fractures, nondisplaced body fractures, displaced body fractures, or osteochondral fractures. Fifty percent of all navicular fractures are dorsal avulsion fractures (Ho). Avulsion fractures occur when a fragment of bone is torn away from the main mass of bone.
Cuboid fractures can occur in isolation but are more often seen in conjunction with other fractures. Cuboid fractures are classified as avulsion (most occur on the lateral side) or body fractures (may be simple, stress, comminuted, crush, or fracture/dislocation).
Cuneiform fractures are classified as avulsion fractures, body fractures, or fracture-dislocations. Of the three cuneiform bones, the medial cuneiform bone is the most commonly injured.
Injuries to the tarsometatarsal joint complex (Lisfranc's fracture or Lisfranc fracture dislocation) occur at the articulation between the midfoot (3 cuneiform bones and the cuboid) and the forefoot (5 metatarsals). These injuries are most commonly seen following motor vehicle accidents but also may be seen following falls, crush injuries, and low energy mechanisms (e.g., soccer and football).
Stress fractures also may occur in the midfoot. They are often precipitated by abrupt increases in training intensity.
Incidence and Prevalence: Approximately 10% of all fractures occur in the bones of the foot (Silbergleit). Fractures of the midfoot, a relatively stable area, are rare, but among them, navicular fractures are the most common (Ho). Navicular stress fractures are usually sports-related and account for up to 35% of all stress fractures in athletes (Ameres). The incidence of Lisfranc's fracture-dislocation is approximately 1 per 55,000 persons per year (Trevino). |
Source: Medical Disability Advisor
| History: The individual usually reports marked pain and swelling (edema) and limited ability to move the foot and bear weight. There may be open wounds or severe soft tissue damage if the fracture results from a crushing injury. Physical exam: Localized pain, edema, and possible deformity may be noted. Attention must be paid to skin integrity and neurovascular status. The exam must rule out dislocations of the metatarsal bones because they are commonly associated injuries. Tests: Anterior-posterior (AP), lateral, and oblique x-rays with comparison views from the other (contralateral) foot often are necessary. Midfoot fractures are often difficult to detect due to overlapping bone outlines and associated dislocations. CT and MRI scans may be needed to confirm the diagnosis. Technetium bone scanning is a useful study to detect navicular stress fractures. |
Source: Medical Disability Advisor
| Depending on the type of fracture, treatment may range from a weight-bearing fracture brace or cast until the individual is asymptomatic (approximately 3 to 6 weeks) to open reduction, internal fixation (ORIF) followed by a non-weight bearing cast or brace until the bones have healed. Unstable, comminuted, or displaced fractures that cannot be simply returned to their normal anatomical alignment (reduced) are treated surgically, as are fracture-dislocations. |
Source: Medical Disability Advisor
| The outcome depends on the severity of the fracture, associated injuries, the treatment required, and the development of complications. Nondisplaced fractures generally have an excellent prognosis with appropriate treatment. Open fractures generally have the worst outcomes; they are usually associated with crush injuries. In fractures severe enough to require surgery, healing times are difficult to quantify. A severe crush injury could take a year to heal and even then the result may be poor. |
Source: Medical Disability Advisor
| Note on research and authorship The duration of treatment for a midfoot fracture is related to the location and type of fracture and the length of immobilization. The main focus of rehabilitation should emphasize restoring full range of motion, strength, proprioception, and endurance while maintaining independence in all activities of daily living (Bucholz). Resumption of pre-injury status is the goal with consideration of any residual deficit of the foot or ankle. Protocols for rehabilitation must be based upon stability of the fracture and fracture management (operative, nonoperative).
The goal of rehabilitation is to return the full function with a painless foot. Modalities such as cold may be beneficial for controlling pain and edema (Salter). This type of fracture typically may not impede activities of daily living, but it may interfere with the individual's ability to work due to pain and restricted weight bearing. Gait training using appropriate assistive devices will help the individual walk and move about independently; weight bearing should progress as indicated by the treating physician. When indicated, the physical therapist progresses the range of motion and proprioceptive and strengthening exercises until a normal gait and full function is evident. The individual may be instructed in home exercises to be performed in conjunction with supervised rehabilitation. Orthotics may be indicated in some cases to protect the foot, relieve discomfort and promote a functional gait pattern.
If the fracture required surgery, the treating physician will dictate the rehabilitation protocol.
Bone healing may occur within 6 to 12 weeks, but bone strength and the ability of the bone to sustain a heavy load may take up to several years to return (Chapman). Once healing has occurred, the individual may resume full activities of daily living. It is important to instruct the individual not to overload the fracture site until the bone has regained its full strength. The resumption of heavy work and sports should be guided by the treating physician. |
| FREQUENCY OF REHABILITATION VISITS | | Nonsurgical ‡ | |
| Physical Therapist | | Up to 15 visits within 6 weeks | | | | | | | | Surgical | |
| Physical Therapist | | Up to 12 visits within 6 weeks | |
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| ‡ Note on Nonsurgical Guidelines: Rehabilitation may not begin until tissue healing, about 6 to 8 weeks after the fracture. |
| The table above represents a range of the usual acceptable number of visits for uncomplicated cases. It provides a framework based on the duration of tissue healing time and standard clinical practice. |
Source: Medical Disability Advisor
| Compartment syndrome is the most dangerous acute complication of midfoot fractures. Long-term complications include infection, degenerative arthritis, nonunion or instability, and gait disturbances. |
Source: Medical Disability Advisor
| Weight bearing may be restricted for several weeks. This will affect the individual's ability to climb stairs and ladders, stand for even short periods, or walk short distances. Crutches, canes, walkers, or wheelchairs may be required. Stooping and squatting should be restricted until the individual has regained full range of motion through stretching and physical therapy. Safety issues concerning working in a confined space, with limited dexterity, and with a limited ability to ambulate should be reviewed. Company policy on medication usage should be reviewed to determine if pain medication use is compatible with job safety and function. Frequent rest periods that allow the individual to elevate the lower extremity may be necessary. Temporary work restrictions may be necessary due to casts or other special footwear requirements.
Risk of recurrence, especially for stress fractures, can be lessened with a gradual increase in activity level following recovery. Shock absorbing inserts in footwear may be helpful in reducing the incidence of midfoot stress fractures in military recruits (Amere). |
Source: Medical Disability Advisor
| If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case. Regarding diagnosis:
- Has diagnosis been confirmed by x-ray, CT scan, MRI scan, or bone scan?
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Is Lisfranc tarsal-metatarsal fracture-dislocation present but unrecognized?
Regarding treatment:
- Was individual’s fractured foot placed in a cast or brace?
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Was surgical intervention necessary?
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Is individual active in physical therapy?
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Is individual compliant with weight-bearing restrictions?
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Has individual experienced any complications related to fracture or treatment?
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Has rehabilitative therapy been prescribed? Is individual compliant?
Regarding prognosis:
- If symptoms persist past expected recovery, have imaging studies been repeated to rule out nonunion or malunion?
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Does individual have an underlying condition, such as diabetes, peripheral vascular disease, obesity, or other condition that may affect recovery?
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Are other complications present?
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Is individual following prescribed rehabilitative therapy?
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Has individual resumed weight-bearing too soon?
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Source: Medical Disability Advisor
| Bucholz, Robert, and James D. Heckman. Rockwood and Green's Fractures in Adults. 5th ed. Philadelphia: Lippincott, Williams & Wilkins, 2002.Chapman, Michael W. Chapman's Orthopaedic Surgery. Philadelphia: Lippincott, Williams & Wilkins, 2001. Coris, E. E., and J. A. Lombardo. "Tarsal Navicular Stress Fractures." American Family Physician 67 1 (2003): 85-90. MD Consult. 1 Jan. 2003. Elsevier, Inc. 26 Oct. 2004 <http://home.mdconsult.com/das/journal/view/41945434-2/N/12614482?sid=281490667&source=MI>. Ho, Kendall, et al. "Ankle and Foot." Rosen's Emergency Medicine: Concepts and Clinical Practice. Ed. J. A. Marx. 6th ed. Philadelphia: Mosby Elsevier, 2006. Salter, Robert, ed. Textbook of Disorders and Injuries of the Musculoskeletal System. 3rd ed. Philadelphia: Lippincott, Williams & Wilkins, 1999. Sherman, Andrew L., et al., eds. "Navicular Fracture." eMedicine. Eds. Andrew L. Sherman, et al. 11 Feb. 2008. Medscape. 6 Mar. 2009 <http://emedicine.medscape.com/article/825060-overview>. Silbergleit, Robert. "Fracture, Foot." eMedicine. Eds. Francis Counselman, et al. 6 Dec. 2009. Medscape. 6 Mar. 2009 <http://emedicine.medscape.com/article/825060-overview>. Trevino, Saul G., et al. "Lisfranc Fracture Dislocation." eMedicine. Eds. James K. DeOrio, et al. 16 Jun. 2008. Medscape. 6 Mar. 2009 <http://emedicine.medscape.com/article/1236228-overview>. |
Source: Medical Disability Advisor
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