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Metatarsal Fracture
From WikiSM
Other Names
- Met Fracture
- Metatarsal Fracture
- Metatarsal stress fracture
- 1st metatarsal fracture
- Central metatarsal fracture (CMF)
Background
- This page refers to fractures of the 1st to 4th Metatarsals
- Fifth metatarsal fractures are discussed separately
- Metatarsal stress fractures are also discussed separately
History
Epidemiology
- Prevalence
- Incidence
- Approximately 6.7 per 10,000 people[4]
- Demographics
- Among non athletes, the average age is 42 and female
- Among athletes, the average age is 26 and male
- Pediatric considerations[5]
- Under 5: 1st metatarsal is most commonly fractured
- Over 5: 5th metatarsal is most commonly fractured
- Account for 61% of all fractures of the foot[6]
Pathophysiology
- General
- Occur as a result of direct trauma to forefoot
- Central metatarsals include the 2nd, 3rd, and 4th
Etiology
- Generally occur due to low energy trauma
- Fall from standing height
- Twisting injury with a static forefoot
Fracture Patterns
- Location
- 5th metatarsal is most common, followed by 3rd metatarsal[7]
- Contiguous metatarsal fractures occur in 9% of all metatarsal fractures
- 60% of middle metatarsal fractures associated with neighboring metatarsal injury[4]
- 1st metatarsal fractures are the least common, representing only 1.5% of metatarsal fractures
Associated Conditions
Pathaoanatomy
- Metatarsal Bones
- Skeletal component of the foot between the tarsus and the foot phalanges
- Numbered 1 to 5 from medial to lateral
Risk Factors
- Unknown
Differential Diagnosis
- Fractures & Osseous Disease
- Traumatic/ Acute
- Stress Fractures
- Other Osseous
- Dislocations & Subluxations
- Muscle and Tendon Injuries
- Ligament Injuries
- Plantar Fasciopathy (Plantar Fasciitis)
- Turf Toe
- Plantar Plate Tear
- Spring Ligament Injury
- Neuropathies
- Mortons Neuroma
- Tarsal Tunnel Syndrome
- Joggers Foot (Medial Plantar Nerve)
- Baxters Neuropathy (Lateral Plantar Nerve)
- Arthropathies
- Hallux Rigidus (1st MTPJ OA)
- Gout
- Toenail
- Pediatrics
- Fifth Metatarsal Apophysitis (Iselin's Disease)
- Calcaneal Apophysitis (Sever's Disease)
- Freibergs Disease (Avascular Necrosis of the Metatarsal Head)
Clinical Features
- History
- Characterized by pain, swelling and trouble weight bearing
- Deformities are typically absent unless there are more significant injuries present
- Physical Exam: Physical Exam Foot
- Bruising and swelling
- Tenderness to metatarsal
- Pain with axial loading of the forefoot
- Special Tests
Evaluation
Radiographs
- Standard Radiographs Foot
- Should be obtained for all suspected metatarsal injuries
MRI
- Only recommended for occupt fractures, or suspected stress fracture
CT
- Useful to
- Assess the degree of intra-articular involvement, comminution
- Evaluate integrity of lisfranc joint
- Surgical planning when appropriate
Classification
AO-ICI (Integral classification of injuries)
- Type A: extra-articular fractures[8]
- Subdivided into metaphyseal, diaphyseal, and distal metaphyseal fractures
- Type B: intra-articular fracture
- subdivided into proximal partial articular, meta-diaphyseal wedge, and distal partial articular
- Type C: fracture-dislocations
- subdivided into proximal complete articular, meta-diaphyseal communition, and distal complete articular
- Type D: pure metatarsal dislocation or ‘floating metatarsal.’
Management
- Objectives
- Restore the alignment of all metatarsals
- Maintain the arches of the forefoot
- Normal distribution of weight under the head of metatarsals
Nonoperative
1st Metatarsal
- Indications
- Nondisplaced, stable fractures
- Isolated avulsion fractures
- Serial radiographs
- close radiographic monitoring for callous formation
- Immobilization/ Protection
- Consider posterior short leg splint or split cast for first 3-7 days until swelling subsides
- Then place in a Synthetic Cast Shoe (Lopresti slipper) for 3-5 weeks
- Weightbearing status
- Non-weight bearing for at least 3 weeks
- Progression to a walking cast for another 3 weeks
Central Metatarsals
- Indications
- Nondisplaced or minimally displaced
- Nondisplaced or minimally displaced neck fractures
- Less than 10° sagittal angulation, 3 - 4 mm displacement in any plane
- Immobilization/ Protection
- Total immobilization time 3 - 6 weeks
- Short Leg Walking Cast for 2 - 4 weeks
- Can consider a Talus Shoe
- Zenios et al found no difference at 3 months between cast or taping[9]
- Weight bearing status
- Weight bearing as tolerated
Operative
1st Metatarsal
- Indications
- Unstable closed fractures
- Intra-articular fracture
- Open fractures
- Polytrauma
- Technique
- Open reduction, internal fixation
- K-wire fixation
- Plate osteosynthesis
- Reconstruction of the TMTJ, MTPJ
Central Metatarsals
- Indications
- Displacement > 2 mm
- More than 10° sagittal angulation, 3 - 4 mm displacement in any plane
- Displaced metatarsal neck fractures
- Technique
- K-wire fixation
Rehab and Return to Play
Rehabilitation
- Needs to be updated
Return to Play/ Work
- Needs to be updated
Complications and Prognosis
Prognosis
- Patient predictors of poor outcome[10]
- Diabetes Mellitus
- Obesity or overweight
- Female Gender
- Injury predictors of poor outcome
- Open fractures[11]
- Planatarly displaced fracture
Complications
- Acute Compartment Syndrome
- One systematic review estimated the risk at 2.6%[12]
- Metatarsophalangeal Arthrosis
- Especially of the first metatarsal phalangeal joint
- Metatarsalgia
- In up to 56.8% of patients in once study[11]
- Delayed return to sport
- Inability to return to sport
- Delayed Union associated with[13]
- Tobacco Use
- Poor nutrition
- Systemic illnesses,
- Immune compromise
- Systemic review of complications from ORIF of 1st metatarsal[12]
- 3.6% of patients experienced skin problems
- 1.5% developed wound infection
- 0.5% developed Deep Vein Thrombosis
- Complex Regional Pain Syndrome (1.0%)
- Complications from metal implant (16.1%)
- Need for amputation (1.0%)
- Neuroma
- Deep Vein Thrombosis
- Rate is low, estimated below 0.03%[14]
See Also
- Internal
- External
- Sports Medicine Review Foot Pain: https://www.sportsmedreview.com/by-joint/foot/
References
- ↑ Cakir H, Van Vliet-Koppert ST, Van Lieshout EM, De Vries MR, Van Der Elst M, Schepers T. Demographics and outcome of metatarsal fractures. Arch Orthop Trauma Surg. 2011;131:241–5.
- ↑ Vuori JP and AroHT. Lisfranc joint injuries: traumamechanisms and associated injuries. J Trauma 1993; 35: 40–45.
- ↑ Urteaga A and Lynch M. Fractures of the central metatarsals. Clin Podiatry Med Surg 1995; 12: 759–762.
- ↑ 4.0 4.1 Petrisor BA, Ekrol I and Court-Brown C. The epidemiology of metatarsal fractures. Foot Ankle Int 2006; 27: 172–174.
- ↑ Singer G, Cichocki M, Schalamon J, et al. A study of metatarsal fractures in children. J Bone Joint Surg Am 2008; 90: 772–776.
- ↑ Zwipp H, Ranft T. Malunited juvenile fractures in the foot region. Orthopaede. 1991;20(6):374–80.
- ↑ Johnson VS. In: Bateman JE (ed.) Treatment of fractures of the forefoot in industryFoot Science. Philadelphia, PA: WB Saunders, 1976.
- ↑ Zwipp H, Baumgart F, Cronier P, et al. Integral classification of injuries (ICI) to the bones, joints, and ligaments– application to injuries of the foot. Injury 2004; 35: SB3–SB9.
- ↑ Zenios M, Kim WY, Sampath J, Muddu BN. Functional treatment of acute metatarsal fractures. A prospective randomised comparison of management in a cast versus elasticated support bandage. Injury. 2005 Jul;36(7):832–5.
- ↑ Cakir H, Van Vliet-Koppert ST, Van Lieshout EM, et al. Demographics and outcome of metatarsal fractures. Arch Orthop Trauma Surg 2011; 131: 241–245.
- ↑ 11.0 11.1 Sánchez Alepuz E, Vicent Carsi V, Alcántara P, Llabrés AJ. Fractures of the central metatarsal. Foot Ankle Int. 1996;17(4):200–3.
- ↑ 12.0 12.1 Stavlas P, Roberts CS, Xypnitos FN, et al. The role of reduction and internal fixation of Lisfranc fracture dislocations: a systematic review of the literature. Int Orthop 2010; 34: 1083–1091.
- ↑ Murphy GA. Operative treatment of stress fractures of the metatarsals. Oper Tech Sports Med 2006; 14: 239–247.
- ↑ Jameson SS, Augustine A, James P, et al. Venous thromboembolic events following foot and ankle surgery in the English National Health Service. J Bone Joint Surg Br 2011; 93: 490–497.
