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Joe Biden's Fractured Foot

— A closer look at the President-elect's recent slip

MedpageToday
Two photos of Joe Biden with his dog Major

President-elect Joe Biden and his transition team are hard at work so that they can "hit the ground running" when he is sworn in on January 20th. But in a literal sense, this will be more difficult to do as Biden has injured his foot.

In late November, Biden slipped and twisted his ankle while playing with his German shepherd, Major (who will be the first rescue dog to live in the White House). According to Biden's personal physician, Kevin O'Connor, DO, "Initial x-rays did not show any obvious fracture, but his clinical exam warranted more detailed imaging." A CT scan was performed and "showed hairline (small) fractures of President-elect Biden's lateral and intermediate cuneiform bones, which are in the mid-foot. It is anticipated that he will likely require a walking boot for several weeks."

Foot Fractures

A brief review of the bones of the foot:

There are 26 bones in the foot, which consist of three main groups:

  • 7 tarsal bones
  • 5 metatarsal bones
  • 14 phalanges

The foot is often divided into three main sections:

  • Hindfoot: includes the tarsal bones, the talus and the calcaneus (heel)
  • Midfoot: includes the remainder of the tarsal bones
  • Forefoot: contains the metatarsals and the phalanges

The Bones of the Midfoot

The cuboid is located on the lateral side of the foot, in front of the calcaneus, and behind the 4th and 5th metatarsal bones. It has five articular surfaces that contribute to the intrinsic movement of the foot. An articular surface is any surface of a skeletal formation (bone, cartilage) that makes normal direct contact with another skeletal structure as part of a synovial joint. The cuboid provides a groove for the peroneus longus muscle tendon as it reaches to insert in the first metatarsal and medial cuneiform bones. The only muscle to attach to the cuboid is the tibialis posterior.

The navicular bone is located medially in the midfoot, with the talus behind it and the 3 cuneiform bones in front of it. It is boat-shaped and forms the uppermost portion of the medial longitudinal arch of the foot and acts as a keystone of the arch. It has six articular surfaces.

The three cuneiforms are named for their locations: medial, middle, and lateral. The medial and lateral cuneiforms project further forward than the middle cuneiform, which creates a recess for the base of the second metatarsal where it articulates with the middle cuneiform. This configuration creates a keystone effect and contributes to the stability of the midfoot.

The Lisfranc joint complex is the point at which the metatarsal bones and the tarsal bones connect. It is named after French surgeon Jacques Lisfranc de St. Martin, who served in the Napoleonic army in the 1800s. The Lisfranc ligament runs between these bones and is important for maintaining proper alignment and strength of the joint.

Foot Fractures

A 2020 study by looked at the population-based incidence and epidemiology of almost 6,000 foot fractures. They calculated that the incidence of foot fracture is 142.3/100,000/year. The forefoot is the most common site with 123.9/100,000, followed by the hindfoot with 13.7/100,000, and the midfoot at 6.5/100,000/year. The peak incidence of foot fracture is in the age group 10-19 years and is the same in both genders. Low energy trauma was the most common mode of injury, occurring in 98.7%.

Midfoot Fractures

As mentioned, midfoot fractures are the least common location for foot fractures. Unfortunately, they may be missed, especially when associated with other injuries. If so, they may receive inadequate treatment, leading to a high rate of mid- and long-term morbidity. However, recognized isolated fractures of the midfoot typically have an outcome with minimal functional impairment.

A Lisfranc injury occurs if the bones of the midfoot are broken or ligaments that support the midfoot are torn. The cartilage of the midfoot joints may be damaged with this type of injury. The severity can range from simple -- treated with standard RICE therapy -- to complex, which may require surgical repair.

The symptoms of a Lisfranc injury include pain and swelling of the top of the foot. The pain worsens with standing, walking, or attempting to push off with the affected foot. There may be bruising on the top or bottom of the foot, with bruising on the bottom being highly suggestive of a Lisfranc injury.

Hairline (Stress) Fractures

Hairline fractures, also known as stress fractures, are small cracks or severe bruising in a bone. They can occur acutely, although they are more commonly associated with repetitive movement. The weight-bearing bones of the foot and lower leg are most vulnerable to stress fractures due to the repetitive forces placed on them by walking, running, or jumping. The most common locations of stress fractures are the second and third metatarsals (the area of greatest impact on your foot when you walk or run). Other common sites include the calcaneus (heel), fibula, talus, and navicular.

According to , "Stress fractures account for about 20% of all sports medicine injuries, and runners who average more than 25 miles a week are considered high risk. [In addition] due to the repetitive nature of military training, stress fractures are common in members of the military."

The most common cause of stress fractures is a sudden increase in physical activity. It could be an increase in frequency, duration, or intensity. This is true for both athletes and non-athletes. Conditions that decrease bone strength or density, such as osteoporosis, long-term medications, or lack of vitamin D can increase the risk of stress fractures.

Symptoms of a stress fracture in the foot include pain that decreases with rest and increases with daily activity. Swelling may be present on the top of the foot with tenderness to touch at the site of the fracture. Bruising may also be present.

Treatment of stress fractures includes:

  • RICE protocol (rest, ice, compression, elevation)
  • Modifying activity for 6-8 weeks
  • Protective footwear (stiff-soled shoe or short-leg walking boot or cast)
  • Occasionally, stress fractures need surgical intervention to heal properly. This is usually done by internal fixation using pins, screws, or plates to hold to bone together during the healing process.

Osteoporosis in Men

Although many think of osteoporosis as a "women's disease," the NIH Osteoporosis and Related Bone Diseases National Resource Center that it poses a threat to millions of men in the United States.

Osteoporosis is called a "silent disease" because it progresses without symptoms until a fracture occurs. It develops less often in men than in women because men have larger skeletons, their bone loss starts later and progresses more slowly, and they have no period of rapid hormonal change and bone loss. However, in the past few years, the problem of osteoporosis in men has been recognized as an important public health issue, particularly in light of estimates that the number of men above the age of 70 will continue to increase as life expectancy continues to rise.

Bone is constantly changing -- that is, old bone is removed and replaced by new bone. During childhood, more bone is produced than removed, so the skeleton grows in both size and strength. For most people, bone mass peaks during the third decade of life. By this age, men typically have accumulated more bone mass than women. After this point, the amount of bone in the skeleton typically begins to decline slowly as removal of old bone exceeds formation of new bone.

Men in their fifties do not experience the rapid loss of bone mass that women do in the years following menopause. By age 65 or 70, however, men and women lose bone mass at the same rate, and the absorption of calcium -- an essential nutrient for bone health throughout life -- decreases in both sexes. Excessive bone loss causes bone to become fragile and more likely to fracture.

Fractures resulting from osteoporosis most commonly occur in the hip, spine, and wrist, and can be permanently disabling. Hip fractures are especially dangerous. Perhaps because such fractures tend to occur at older ages in men than in women, men who sustain hip fractures are more likely than women to die from complications.

There are two main types of osteoporosis: primary and secondary. In cases of primary osteoporosis, either the condition is caused by age-related bone loss (sometimes called senile osteoporosis) or the cause is unknown (idiopathic osteoporosis). The term idiopathic osteoporosis is typically used only for men younger than 70 years old; in older men, age-related bone loss is assumed to be the cause.

The majority of men with osteoporosis have at least one (sometimes more than one) secondary cause. In cases of secondary osteoporosis, the loss of bone mass is caused by certain lifestyle behaviors, diseases, or medications. Some of the most common causes of secondary osteoporosis in men are exposure to glucocorticoid medications, hypogonadism (low levels of testosterone), alcohol abuse, smoking, gastrointestinal disease, hypercalciuria, and immobilization.

Michele R. Berman, MD, and Mark S. Boguski, MD, PhD, are a wife and husband team of physicians who have trained and taught at some of the top medical schools in the country, including Harvard, Johns Hopkins, and Washington University in St. Louis. Their mission is both a journalistic and educational one: to report on common diseases affecting uncommon people and summarize the evidence-based medicine behind the headlines.