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Updated: Jun 2 2022

Metatarsal Fractures

Images fx - xray_moved.jpg mt fracture.jpg
  • summary
    • Metatarsal fractures are among the most common injuries of the foot that may occur due to trauma or repetitive microstress. 
    • Diagnosis is made with plain radiographs of the foot.
    • Treatment may be nonoperative or operative depending on the specific metatarsal involved, number of metatarsals involved, and fracture displacement.
  • Epidemiology
    • Incidence
      • 5th metatarsal most commonly fractured in adults
      • 1st metatarsal most commonly fractured in children less than 4 years old
      • 3rd metatarsal fractures rarely occur in isolation
        • 68% associated with fracture of 2nd or 4th metatarsal
    • Demographics
      • peak incidence between 2nd and 5th decade of life
  • Etiology
    • 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
  • 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
          • restore alignment to allow for normal force transmission across metatarsal heads
          • 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
  • Prognosis
    • Majority of isolated metatarsal fractures heal with conservative management
    • Malunion may lead to transfer metatarsalgia
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