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 in adults 1st metatarsal most commonly fractured in children less than 4 years old 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
QUESTIONS 1 of 7 1 2 3 4 5 6 7 Previous Next This is an AAOS Self assessment question. Orthobullets was not involved into the editorial process, and does not have the ability to alter. If you prefer to hide SAE questions on topics simply turn them off in your Content Settings (SAE07PE.78) Figures 35a through 35c show the clinical photograph and radiographs of a 15-year-old boy who stubbed his toe 1 day ago while walking barefoot in the yard. Management should consist of Review Topic QID: 6138 FIGURES: A B C 1 buddy taping of the great toe to the second toe for 3 weeks and use of a hard-soled shoe. 2% (1/61) 2 buddy taping of the great toe to the second toe for 3 weeks and application of a short leg cast. 2% (1/61) 3 buddy taping of the great toe to the second toe for 3 weeks, use of a hard-soled shoe, and a short course of antibiotics. 16% (10/61) 4 nail removal in the emergency department, buddy taping of the great toe to the second toe for 3 weeks, and use of a hard-soled shoe. 21% (13/61) 5 irrigation and open reduction, with or without fixation, and a short course of antibiotics. 51% (31/61) N/A Select Answer to see Preferred Response PREFERRED RESPONSE 5 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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. A radiograph, bone scan, and MRI are found in Figures A-C, respectively. Your next step in management should consist of: Review Topic QID: 2969 FIGURES: A B C 1 Percutaneous biopsy and referral to an orthopaedic oncologist 2% (45/2062) 2 Walker boot application and evaluation for metabolic bone disease 89% (1839/2062) 3 Referral to an orthopaedic oncologist for limb salvage procedure 1% (14/2062) 4 Internal fixation of the fracture and evaluation for metabolic bone disease 5% (99/2062) 5 Metatarsal-cuneiform fusion of the Lisfranc joint 3% (60/2062) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 2 (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? Review Topic QID: 1095 FIGURES: A 1 open reduction, internal fixation 1% (25/1743) 2 excisional biopsy 6% (106/1743) 3 continue running with a molded orthotic 2% (30/1743) 4 protected weightbearing with crutches, with slow return to running 90% (1566/1743) 5 percutaneous Kirschner wire fixation 0% (7/1743) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 4 (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? Review Topic QID: 1112 FIGURES: A 1 Lisfranc joint injury 6% (113/1745) 2 Cuneiform stress fracture 9% (154/1745) 3 Second metatarsal base stress fracture 77% (1350/1745) 4 Plantar fascia strain 1% (24/1745) 5 First metatarsal base stress fracture 6% (97/1745) ML 2 Select Answer to see Preferred Response PREFERRED RESPONSE 3