Updated: 6/7/2021

Metatarsal Fractures

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Cases
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  • 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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(SBQ12FA.87) A 26-year-old female presents to the office with complaints of right foot pain worse with activity. She states that she has always been a runner to stay healthy, but recently increased her miles per day as she prepares for her marathon. Weight-bearing radiographs were obtained and are unremarkable. Physical examination demonstrates minimal swelling and diffuse tenderness over the second metatarsal. What would be the next best step?

QID: 3894
1

Non-weight bearing and placement into a cast and re-evaluate in 3-4 weeks

20%

(275/1375)

2

Technetium 99 Bone Scan

2%

(28/1375)

3

CT of the foot

2%

(34/1375)

4

Limit miles per day and re-evaluate in 2-3 weeks

23%

(319/1375)

5

MRI of the foot

52%

(712/1375)

L 5 D

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(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:

QID: 2969
FIGURES:
1

Percutaneous biopsy and referral to an orthopaedic oncologist

3%

(65/2534)

2

Walker boot application and evaluation for metabolic bone disease

88%

(2222/2534)

3

Referral to an orthopaedic oncologist for limb salvage procedure

1%

(21/2534)

4

Internal fixation of the fracture and evaluation for metabolic bone disease

5%

(135/2534)

5

Metatarsal-cuneiform fusion of the Lisfranc joint

3%

(83/2534)

L 1 B

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(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?

QID: 1095
FIGURES:
1

open reduction, internal fixation

2%

(33/2143)

2

excisional biopsy

6%

(127/2143)

3

continue running with a molded orthotic

2%

(35/2143)

4

protected weightbearing with crutches, with slow return to running

90%

(1931/2143)

5

percutaneous Kirschner wire fixation

0%

(7/2143)

L 1 B

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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?

QID: 1112
FIGURES:
1

Lisfranc joint injury

7%

(151/2198)

2

Cuneiform stress fracture

9%

(194/2198)

3

Second metatarsal base stress fracture

77%

(1693/2198)

4

Plantar fascia strain

1%

(32/2198)

5

First metatarsal base stress fracture

5%

(117/2198)

L 2 D

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CASES (2)
EXPERT COMMENTS (6)
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