Metatarsal Fractures

Author: Brian Weatherford

Topic updated on 03/06/13 6:23am

Introduction

Metatarsal fractures are among the most common injuries of the foot
- goals of treatment include:
  - maintenance of transverse and longitudinal arch of forefoot
  - restore alignment to allow for normal force transmission across metatarsal heads
Epidemiology
- 5th metatarsal most commonly fractured
- peak incidence between 2nd and 5th decade of life
- 3rd metatarsal fractures rarely occur in isolation
  - 68% associated with fracture of 2nd or 4th metatarsal
Mechanism
- direct crush injury
  - may have significant associated soft tissue injury
- indirect mechanism (most common)
  - occurs with forefoot fixed and hindfoot or leg rotating
Associated conditions
- Lisfranc injury
  - Lisfranc equivalent injuries seen with multiple proximal metatarsal fractures
- stress fracture
  - consider metabolic evaluation for fragility fracture
  - look for associated foot deformity
  - seen at base of 2nd metatarsal in ballet dancers
    - may have history of amenorrhea
Prognosis
- majority of isolated metatarsal fractures heal with conservative management
- malunion may lead to transfer metatarsalgia

Anatomy

Osteology
- shape and function similar to metacarpals of the hand
- first metatarsal has plantar crista that articulates with sesamoids
  - widest and shortest
  - bears 30-50% of weight during gait
- second metatarsal is longest
  - most common location of stress fracture
Muscles
- muscular balance between extrinsic and intrinsic muscles
- extrinsics include
  - Extensor digitorum longus (EDL)
  - Flexor digitorum longus (FDL)
- intrinsics include
  - Interossei
  - Lumbricals
- see Layers of the Plantar Foot
Ligaments
- Metatarsals have dense proximal and distal ligamentous attachments
- 2nd-5th metatarsal have distal intermetatarsal ligaments that maintain length and alignment with isolated fractures
  - implicated in formation of interdigital (Morton's) neuromas
  - multiple metatarsal fractures lose the stability of intermetatarsal ligaments leading to increased displacement
Blood supply
- dorsal and plantar metatarsal arteries
Biomechanics
- see Foot and Ankle Biomechanics

Classification

Classification of metatarsal fractures is descriptive and should include
- location
- fracture pattern
- displacement
- angulation
- articular involvement

Presentation

History
- look for antecedent pain when suspicious for stress fracture
Symptoms
- pain, inability to bear weight
Physical Exam
- inspection
  - foot alignment (neutral, cavovarus, planovalgus)
  - focal areas or diffuse areas of tenderness
  - careful soft tissue evaluation with crush or high-energy injuries
- motion
  - evaluate for overlapping or malrotation with motion
- neurovascular
  - semmes weinstein monofilament testing if suspicious for peripheral neuropathy

Imaging

Radiographs
- recommended views
  - required
    - AP, lateral and oblique views of the foot
  - optional
    - contralateral foot views
    - stress or weight bearing radiographs
CT
- not routinely obtained
- may be of use in periarticular injuries or to rule out Lisfranc injury
MRI or bone scan
- useful in detection of occult or stress fractures

Treatment

Nonoperative
- stiff soled shoe or walking boot with weight bearing as tolerated
  - indications
    - first metatarsal
      - non-displaced fractures
    - second through fourth (central) metatarsals
      - isolated fractures
      - non-displaced or minimally displaced fractures
    - stress fractures
      - second metatarsal most common
      - look for metabolic bone disease
      - evaluate for cavovarus foot with recurrent stress fractures
Operative
- percutaneous vs open reduction and fixation
  - indications
    - open fractures
    - first metatarsal
      any displacement
      
      no intermetatarsal ligament support
      
      30-50% of weight bearing with gait
    - central metatarsals
      - sagittal plane deformity more than 10 degrees
      - >4mm translation
      - multiple fractures
  - techniques
    - antegrade or retrograde pinning
    - lag screws or mini fragment plates in length unstable fracture patterns
    - maintain proper length to minimize risk of transfer metatarsalgia
  - outcomes
    - limited information available in literature

Complications

Malunion
- may lead to transfer metatarsalgia or plantar keratosis
- treat with osteotomy to correct deformity

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Qbank (3 Questions)

TAG

(OBQ09.156) A 55 year-old woman comes to you with 2 months of right foot pain. She is active in ballet and her pain is exacerbated with push-off and en pointe maneuvers. Radiograph, bone scan, and MRI are found in Figures A-C, respectively. Your next step in management should consist of: Topic

Review Topic

FIGURES: A

1. Percutaneous biopsy and referral to an orthopaedic oncologist
2. Walker boot application and evaluation for metabolic bone disease
3. Referral to an orthopaedic oncologist for limb salvage procedure
4. Internal fixation of the fracture and evaluation for metabolic bone disease
5. Metatarsal-cuneiform fusion of the Lisfranc joint

PREFERRED RESPONSE ▶

DISCUSSION: Stress fracture of the second metatarsal is classically described in amenorrheal dancers. However, this patient is of an age that a fragility fracture should be considered. Metatarsal stress fractures can be successfully treated with a short-leg cast, low walking boot, or hard-soled shoe with arch support. MRI is a useful screening tool, but CT better visualizes bone when the fracture is visible on plain radiographs. The reference by Bogoch et al created a multidisciplinary team to enroll a cohort of patients at risk for osteoporosis. They found that >95% of patients were appropriately diagnosed, treated, or referred for osteoporosis care with use of this team.

REFERENCES:

1. Bogoch ER, Elliot-Gibson V, Beaton DE, Jamal SA, Josse RG, Murray TM. Effective initiation of osteoporosis diagnosis and treatment for patients with a fragility fracture in an orthopaedic environment. J Bone Joint Surg Am. 2006 Jan;88(1):25-34 PMID:16391246 (Link to Abstract)

2. Fischgrund JS (ed): Orthopaedic Knowledge Update 9. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2008, pp 189-196

Question Authors:

Michael Hughes MD,

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TAG

(OBQ05.209) A 19-year-old cross country runner complains of 3 months of foot pain with running. Based on the radiographs shown in Figure A, what is the most appropriate next step in treatment? Topic

Review Topic

FIGURES: A

1. open reduction, internal fixation
2. excisional biopsy
3. continue running with a molded orthotic
4. protected weightbearing with crutches, with slow return to running
5. percutaneous Kirschner wire fixation

PREFERRED RESPONSE ▶

DISCUSSION: The radiographs show a diaphyseal stress fracture of the 3rd metatarsal with obvious callus formation and good alignment of the bone. These are coined a march fracture and occur in the 2nd, 3rd and 4th metatarsals, with 2nd being the most common. The cited reference indicates that a technium99 bone scan is the most useful diagnostic imaging modality, although CT and MRI can also be used. Treatment of this consists of 4-6 weeks of rest with gradual return in activity to pre-injury activity level. The other treatments are not appropriate for this scenario.

Illustration A shows the periosteal reaction usually seen with these injuries.

Illustrations: A

REFERENCES:

1. Brodsky, JW Stress Fractures of the foot and ankle, in Orthopaedic Sports Medicine Principles and Practice, 2003, 2391

Question Authors:

Ben Taylor MD, Ben Taylor MD, John Badylak MD,

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(OBQ05.226) A 26-year-old professional ballet dancer presents with insidious onset of right midfoot pain which began 6 months ago. She has no history of ankle or foot trauma, and medical history is significant only for delayed menarche. Radiographs are shown in Figure A. What is the most likely diagnosis? Topic

Review Topic

FIGURES: A

1. Lisfranc joint injury
2. Cuneiform stress fracture
3. Second metatarsal base stress fracture
4. Plantar fascia strain
5. First metatarsal base stress fracture

PREFERRED RESPONSE ▶

DISCUSSION: Stress fractures in ballet dancers occur most frequently at the second metatarsal base. The radiograph shown in Figures A demonstrates a chronic stress reaction at the base of the second metatarsal typical of these injuries when delayed on presentation. MRI, shown in Illustration A and B, can be obtained to help confirm the diagnosis.

O'Malley et al identified 51 professional dancers (64 fractures) who sustained a stress fracture at the base of the second metatarsal. Delayed menarche was common in those affected, and the usual location of the fracture was at the proximal metaphyseal-diaphyseal junction of the second metatarsal. Treatment consisted of a short leg walking cast for 6 patients, and a wooden shoe and symptomatic treatment for the remainder. The patients returned to performance at an average of 6.2 weeks following diagnosis, with 14% reporting continued pain with dancing. No patients required bone grafting for persistent symptoms.

This patient went on to develop a nonunion of her stress fracture requiring fixation, which is shown in Illustration C.

Illustrations: A

REFERENCES:

1. O'Malley MJ, Hamilton WG, Munyak J, DeFranco MJ. Stress fractures at the base of the second metatarsal in ballet dancers. Foot Ankle Int. 1996 Feb;17(2):89-94. PMID:8919407 (Link to Abstract)

Question Authors:

Joshua Blomberg MD, Ben Taylor MD, Dave Marcu MD,

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Groups

ABOS II: Metatarsal Fractures

General - Oral Boards Review

7/29/2011

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Evidence & References Show References

Level of Evidence 2 (Prospective Cohort Study)

Bogoch ER, Elliot-Gibson V, Beaton DE, Jamal SA, Josse RG, Murray TM. Effective initiation of osteoporosis diagnosis and treatment for patients with a fragility fracture in an orthopaedic environment. J Bone Joint Surg Am. 2006 Jan;88(1):25-34 PMID:16391246 (Link to Abstract)

Textbooks

Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Fischgrund JS (ed): Orthopaedic Knowledge Update 9. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2008, pp 189-196

Undefined

Brodsky, JW Stress Fractures of the foot and ankle, in Orthopaedic Sports Medicine Principles and Practice, 2003, 2391
O'Malley MJ, Hamilton WG, Munyak J, DeFranco MJ. Stress fractures at the base of the second metatarsal in ballet dancers. Foot Ankle Int. 1996 Feb;17(2):89-94. PMID:8919407 (Link to Abstract)

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Metatarsal Fractures

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