Review Question - QID 218223

This patient's clinical presentation and imaging are consistent with a stress fracture of the distal aspect of the second metatarsal. The most appropriate initial treatment is a trial non-operative management with a short walking cast or a fracture boot.

Metatarsal stress fractures are relatively common and are most frequent in the second and third metatarsal, but can also be seen in the fifth metatarsal. High-risk populations include runners, military recruits, ballet dancers, basketball players, or those with a recent increase in activity or training. Metatarsals are loaded perpendicular to their long axis, and the relatively fixed proximal anatomy of the second and third metatarsals makes them particularly prone to diaphyseal stress fracture. Due to its length and overall immobility, the distal second metatarsal shaft remains the most common location for fracture. Further risk factors include a long 2nd metatarsal, hypermobile first ray, and female gender. Metatarsalgia, metatarsophalangeal synovitis, Freiberg’s infarction, and Morton’s neuroma should also be considered in the differential. Radiographs may be negative or show callus formation. MRI can be obtained to confirm the diagnosis in cases of negative radiographs. Initial treatment usually involves immobilization in a short leg walking cast or fracture boot (a hard-soled shoe may also suffice), activity modification, and symptom resolution guides a return to activity (typically over a 6-8wk period).

Boden and Osbahr provide a review on the evaluation and treatment of high-risk stress fractures. They discussed the pathology, clinical evaluation and use of imaging for stress fractures, including stress fractures in the femoral neck, tibia, patella, medial malleolus, talus, navicular, 5th metatarsal, and great toe sesamoid.

Pell et al. provide a review on leg pain in the running athlete, discussing the etiology, presentation, imaging/diagnostic findings, and management of athletes with medial tibial stress syndrome, stress fractures, chronic exertional compartment syndrome, and popliteal artery entrapment. Briefly mentioned are nerve entrapment syndromes, gastrocnemius-soleus muscle strains, tibiofibular synostosis, effort-induced DVT, and muscle herniation. Finally, they offer a nice algorithm for the diagnosis of these potential causes.

Figure A is a T2-weighted MRI image of a left foot demonstrating a distal second metatarsal stress fracture with surrounding edema.

Incorrect Answers:
Answers 1, 3, and 4: Operative intervention should only be considered after a trial of non-operative management fails.
Answer 2: There is no evidence of a soft tissue or bony lesion on the patient’s MRI that would warrant a biopsy. The history and MRI are consistent with a stress fracture.