1. Marie Bamer

2.  Those fractures involving the great toe or any of the lesser toes, metatarsals, or sesamoid bones.

3.  Phalangeal  Metatarsal  Sesamoid

4.  Phalangeal Fractures: can involve the neck, shaft, or base of the bone  MOI:Results from a direct trauma or avulsion mechanism * fx of 1 st from being hit with an axe

5.  Metatarsal Fractures: Fx of a metatarsal  MOI: fractures of the 1 st - 4 th usually result in direct trauma. 2 nd -5 th may occur as result of a twisting injury * Jones Fx- proximal 5 th metatarsal shaft

6.  Sesamoid Fractures: splitting or fragmentation of one or both of the two small bones contained within the tendon of the flexor hallicus longus  MOI: often secondary to the impact of the foot on a hard surface while toes are dorsiflexed. *A) Comminuted fx B) Post-op resection of bone

7. Orthopaedic Objectives  Anatomical alignment of the great toe, phalanx, metatarsal and sesamoid is essential in weight bearing and load distribution on the foot.  Alignment of the 2 nd - 5 th metatarsals is important to minimize problematic gait and painful fitting of shoes  Forefoot stability is important to maintain stable and pain-free gait

8. Rehabilitation Objectives  Range of Motion-restore and maintain all ROM  Muscle Strength- improve and restore strength of extensors, flexors, invertors, and evertors in foot  Functional Goals- normalize gait to pre- injury pattern

9.  Lesser Phalanx Fx: 4 to 6 weeks  2 nd, 3 rd and 4 th Metatarsal Fx: 4 to 6 weeks  5 th Metatarsal Fx ( Jones Fx): 6 to 8 weeks  Great Toe Phalanx Fx: 4 to 6 weeks  1 st Metatarsal Fx: 6 to 8 weeks  Sesamoid Fx: 4 to 8 weeks

10.  Lesser Phalanx Fx: 2 to 6 weeks  2 nd, 3 rd and 4 th Metatarsal Fx: 4 to 6 weeks  5 th Metatarsal Fx (Jones): 4 to 6 weeks (acute), 6 to 10 for delayed union, nonunion, or stress fx  Great Toe Phalanx Fx: 4 to 6 weeks  1 st Metatarsal Fx: 4 to 6 weeks  Sesamoid Fx: 8 to 12 weeks, possibly longer after sesamoidectomy

11. Lesser Phalanx Fx  Splints or Buddy Taping  Open Reduction and Percutaneous Pinning K –wires and short leg cast for 2-3 weeks *distal phalanx of 5 th

12. 2 nd, 3 rd, 4 th Metatarsal Fx  Cast-short leg walking *if undisplaced or minimally displaced  Closed Reduction and Percutaneous Pinning *closed, displaced or angulated fx- NWB cast for 2-3 weeks  Open Reduction and Internal Fixation *open, displaced- NWB cast for 2-3 weeks * 2 nd MT

13. 5 th Metatarsal Fx (Jones)  Cast/Splint Acute avulsion=walking boot if displacement is less than 2 mm Jones of proximal end= NWB cast  Open Reduction and Internal Fixation Avulsion of greater than 2 mm= tension-band wire or lag screw Delayed or non-union require intramedullary screw NWB cast approx 6 weeks

14. Great Toe Phalanx Fx  Cast- NWB extended to toes  Closed Reduction and Percutaneous Pinning or Open Reduction and Internal Fixation

15. 1 st Metatarsal Fx  Cast  Open Reduction and Internal Fixation

16. Sesamoid Fx  Cast/ Splint  Sesamoidectomy

17. Day of injury to 1 week  Stability of fx site: None  Stage of Bone Healing: Inflammatory phase  Radiograph: No callus * NWB, check cap refill, no deformities, radiograph,

18. Two Weeks  Stability of fx site: None to minimal  Stage of bone healing: Begins reparative phase  Radiograph: No change or early callus

19. Four to Six Weeks  Stability of fx site: Bridging callus and fx usually stable (acute fx)  Stage of bone healing: reparative phase  Radiograph: Bridging callus visible

20. Six to Eight Weeks  Stability of fx site: Fx stable with bridging callus  Stage of bone healing: reparative phase  Radiograph: Bridging callus visible w/ increased ridgidity. Fx line less distinct

21. Eight to Twelve Weeks  Stability of fx site: Stable  Stage of bone healing: Remodeling Phase  Radiograph: abundant callus

22.  Age – elderly at higher risks for joint stiffness  Articular Involvement- any fx in forefoot requires anatomic reduction  Location  Open Fractures- all must be treated aggressively with irrigation, debridement, and intravenous antibiotics