The Foot & Ankle Online Guide for Primary Care & Primary Treating Physicians

Injury Guidelines & Education—Fractures, Sprains, Achilles Ruptures

Surgical and nonsurgical injury treatment is a very important component of orthopedic care. Timing and acuity can be somewhat unclear, so we have developed the helpful chart below to try to help facilitate patient care and orthopedic referrals. Our office will make our very best effort to facilitate scheduling acute fractures and injuries.

Foot Fractures:
Fractures: Many fractures do not need surgery, but those that do need to be fixed within the first 1 – 2 weeks before the bone starts to soften and remodel. Because of this, I would like to see fractures as soon as possible during the first week. This allows me to repair the fracture more promptly, which gets your patient back to work in a timelier manner. When a fracture is seen on a delayed basis, 3 – 4 weeks, there is often nothing that can be done to change the outcome.
  Management & Monitoring: When to Refer:
Toe (Phalanx) Fractures: Usually, these do not need to be seen by an orthopedic surgeon. Exception: Visible deformity, significant joint involvement, or an open fracture.
Metatarsal Fracture: Many are treated nonoperatively. Follow-up X-rays at 6 – 8 weeks are often read as not healing. If a patient is feeling better and clinically looks better 6 – 8 weeks after an injury, the X-ray may be lagging compared to the actual healing. Exception: Fifth metatarsal base fractures, very angulated fractures, and fractures involving the metatarsal bases.
Tarsometatarsal (Lisfranc) Injuries:   Always need to be seen by an orthopedic surgeon and often require surgery. Any displacement on X-ray or significant plantar foot bruising is cause for concern. A CT or MRI may be helpful to work this up, but this should not delay a referral.
Navicular Fractures: Dorsal avulsion fractures where there is a small fleck of bone are a variant of a sprain and do not need to be seen acutely. Exception: Any fracture into the navicular body should be seen acutely.
Calcaneus Fractures:   Please refer immediately. Many of these injuries require surgery.
Ankle Fractures:
  Management & Monitoring: When to Refer:
Tiny Malleolar Avulsion Fractures: These are a variant of a sprain and can be treated like a sprain. They do not need an orthopedic referral unless they are not improving.  
Malleolar Fractures:   These may or may not need surgery, but surgery can often be performed within the first week after the injury. Please refer immediately.
Pilon/Plafond/Comminuted Fractures:   These almost always require surgery. Please refer immediately.
Ankle Sprains:
  Management & Monitoring: When to Refer:
  A sprain is a ligament tear. Most ankle sprains involve the lateral part of the ankle. A lateral ankle sprain (anterior talofibular and calcaneofibular ligaments) with normal X-rays or with a tiny avulsion fracture can be treated with early mobilization, weight-bearing with a brace, and a functional ankle rehabilitation program (PT). Waiting until swelling has resolved before initiating PT or weight-bearing typically results in a stiffer, more painful ankle that takes longer to return to work. Every ankle sprain is sore for six or more months. Exception: If there is lack of improvement at three months post injury or if there are mechanical symptoms such as catching, locking, or giving way, please order an MRI of the ankle prior to the referral. Note that MRI reports may have ominous sounding words like “complete rupture of the anterior talofibular ligament,” but a sprain is a ligament tear and complete or incomplete are not really useful terminology.
Achilles Ruptures:
When to Refer:
Achilles ruptures often do not need an MRI for diagnosis. If a patient is tender at the Achilles and has a palpable gap, please refer immediately. Delayed presentation produces poorer results.
Gastrocnemius Tears/Strains:
Management & Monitoring:
Tears of the medial head of the gastrocnemius are nonsurgical injuries. If the tenderness is at the medial calf, there is no tenderness at the Achilles, and there is normal resting tension of the ankle, this can be treated with early weight-bearing and PT.

Our Foot & Ankle Specialist

Francis E. Glaser, M.D.

Francis E. Glaser, M.D.
Board-certified, fellowship-trained orthopedic surgeon specializing in disorders of the foot and ankle

If you have questions about these injuries or if there is anything that we can do to improve the referral process, we value your input.

To refer one of your patients to Dr. Glaser, please call (559) 256-5200 or visit our online referral form.