Updated: 10/6/2016

Metatarsal Fractures

Topic
Review Topic
0
0
Questions
7
0
0
Evidence
7
0
0
Cases
1
https://upload.orthobullets.com/topic/7032/images/March fx - xray_moved.jpg
https://upload.orthobullets.com/topic/7032/images/metarsals.jpg
https://upload.orthobullets.com/topic/7032/images/first metatarsal.jpg
https://upload.orthobullets.com/topic/7032/images/metatarsal-fracture-222x300.jpg
https://upload.orthobullets.com/topic/7032/images/first mt fracture.jpg
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
 

Please rate topic.

Average 4.4 of 31 Ratings

Thank you for rating! Please vote below and help us build the most advanced adaptive learning platform in medicine

The complexity of this topic is appropriate for?
How important is this topic for board examinations?
How important is this topic for clinical practice?
Questions (7)
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK

You have 100% on this question.
Just skip this one for now.

(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:
1

Percutaneous biopsy and referral to an orthopaedic oncologist

2%

(46/2140)

2

Walker boot application and evaluation for metabolic bone disease

89%

(1907/2140)

3

Referral to an orthopaedic oncologist for limb salvage procedure

1%

(16/2140)

4

Internal fixation of the fracture and evaluation for metabolic bone disease

5%

(105/2140)

5

Metatarsal-cuneiform fusion of the Lisfranc joint

3%

(61/2140)

L 1

Select Answer to see Preferred Response

SUBMIT RESPONSE 2

You have 100% on this question.
Just skip this one for now.

(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:
1

buddy taping of the great toe to the second toe for 3 weeks and use of a hard-soled shoe.

2%

(4/219)

2

buddy taping of the great toe to the second toe for 3 weeks and application of a short leg cast.

1%

(2/219)

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.

8%

(18/219)

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.

27%

(60/219)

5

irrigation and open reduction, with or without fixation, and a short course of antibiotics.

59%

(129/219)

N/A

Select Answer to see Preferred Response

SUBMIT RESPONSE 5

You have 100% on this question.
Just skip this one for now.

(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:
1

open reduction, internal fixation

1%

(28/1900)

2

excisional biopsy

6%

(116/1900)

3

continue running with a molded orthotic

2%

(31/1900)

4

protected weightbearing with crutches, with slow return to running

90%

(1707/1900)

5

percutaneous Kirschner wire fixation

0%

(7/1900)

L 1

Select Answer to see Preferred Response

SUBMIT RESPONSE 4

You have 100% on this question.
Just skip this one for now.

(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:
1

Lisfranc joint injury

7%

(124/1873)

2

Cuneiform stress fracture

9%

(165/1873)

3

Second metatarsal base stress fracture

77%

(1446/1873)

4

Plantar fascia strain

1%

(26/1873)

5

First metatarsal base stress fracture

5%

(103/1873)

L 2

Select Answer to see Preferred Response

SUBMIT RESPONSE 3
ARTICLES (12)
CASES (1)
Topic COMMENTS (4)
Private Note