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Metatarsal Stress Fracture

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Other Names

  • 5th metatarsal stress fracture
  • Zone 3 metatarsal stress fracture
  • Metatarsal shaft fracture
  • Metatarsal base fracture
  • March fractures

Background

History

  • First described as 'March fracture' by Prussian military physician Breithaupt in 1855 (need citation)

Epidemiology

  • Prevalence
    • In a study of 320 athletes, metatarsals represented 8.8% of stress fractures[1]
    • 2nd and 3rd metatarsal represent 80-90% of metatarsal stress fractures (need citation)
    • 10% - 20% of stress fractures in athletes[2][3]
    • 23% of stress fractures in military recruits[4]

Pathophysiology

Location

  • General
    • Occur most commonly in 2nd, 3rd
    • 2nd metatarsal: non-proximal more common than proximal
    • Low risk for progression: 2nd to 4th metatarsal shaft
    • High risk for progression: proximal 5th metatarsal, proximal 2nd metatarsal
  • Metatarsal shaft
    • Distal 2nd metatarsal stress fractures are most common[5]
  • Metatarsal base
  • Proximal fifth metatarsal (zone 3)
    • "High risk" of progression to full cortical break or non-union[6]

Mechanism

  • Second metatarsal
    • Second metatarsal assumes the highest bending strain, sheer force during running and walking[7]
    • Because of fixed base, proximal hinged metatarsophalangeal joints create a bending moment at the proximal diaphysis during the stance phase of gait
    • Relatively long second metatarsal, excessively mobile first ray increase this force even further
  • Metatarsal base
    • In ballet dancers, most at risk en pointe position due to the locking of the second metatarsal base and cuneiforms in extreme plantar flexion[8]
  • Proximal fifth metatarsal (zone 3)
    • Due to repetitive adduction force with the ankle in plantarflexion

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

  • See: Risk Factors for Stress Fractures
  • Sports
    • Sports that involve running, jumping
    • Runners
    • Ballet Dancers[9]
    • Pronated foot, poor ankle plantarflexion shifts center of gravity to the metatarsal shaft, creating more force at the base
    • Basketball
    • Soccer
    • Tennis[10]
  • Occupation
    • Military recruits
  • Intrinsic
    • Pronated foot
    • Poor ankle plantarflexion
    • Pes Cavus
    • Restricted ankle eversion

Differential Diagnosis


Clinical Features

  • History
    • History consistent with stress injury (increased training volume, intensity, duration, etc)
    • Patients report gradual onset of forefoot pain, worse with weight bearing
    • About half of rugby players have lateral foot pain prior prior to diagnosis of 5th metatarsal stress fracture[11]
  • Physical Exam: Physical Exam Foot And Ankle
    • Swelling may be present
    • Point tenderness over affected metatarsal(s)
    • Trouble walking
    • Pain with passive inversion may suggest 5th metatarsal
  • Special Tests

Evaluation

Radiographs

  • Standard Radiographs Foot
    • Strongly consider imaging ankle as well
  • Stress fracture
    • Sensitivity as low as 10% early, between 30 and 70% at follow up (need citation)
    • If concern remains can repeat imaging in 10-14 days
    • Up to 50% of stress fractures are never observed on plain films (need citation)
    • Look for reabsoption gap around fracture site

MRI

  • Gold standard for diagnosis
  • Can help differentiation between stress reaction, stress fracture and other soft tissue disease

Bone Scintography

  • Sensitive, but not specific
  • Does not give any anatomic resolution

Ultrasound

  • Small case control study by Banal et al using MRI as gold standard[12]
    • Sensitivity: 83%
    • Specificity: 76%
    • PPD: 59%
    • NPD: 92%
    • LR+: 3.45
    • LR-: 0.22

Classification

Torg Radiographic Classification for 5th Metatarsal

  • Type I
    • Narrow fracture line without intramedullary sclerosis
    • Acute
  • Type II
    • Widened fracture line with intramedullary sclerosis
    • Delayed Union
  • Type III
    • Widened intramedullary canal with no callus
    • Nonunion

Management

Nonoperative

  • Indications
    • Most 2nd - 4th metatarsal fractures
    • Nondisplaced 5th metatarsal (Torg type I)
  • Activity modification
    • For at least 6-8 weeks
    • Gradual return to sport when asymptomatic
  • Immobilization
  • Orthosis
    • Custom orthotics
    • Semicustom orthotics
  • Weight bearing status
    • Most patients will do well with a brief period of non weight bearing or partial weight bearing
    • Followed by weight bearing in protective equipment
    • 5th Metatarsal: Non weight bearing for 6-8 weeks
  • External Shockwave Therapy
    • Good results, with relatively short rest period and return to dancing among 18 dancers[9]
  • Low-intensity Ultrasound
    • One patient with good results, relatively short period of rest, return to dance[9]
  • Medications to consider when appropriate

Operative

  • Reduction Indications
    • If greater than 3 or 4 mm displacement, or angulation > 10°
  • Indications
    • Avascular necrosis
    • Non-union
    • 5th metatarsal with delayed or nonunion (Torg type II, III)
    • In elite athletes, can consider for nondisplaced 5th metatarsal (Torg type I)
  • Technique
    • Open reduction, internal fixation

Rehab and Return to Play

Rehabilitation

  • Progression to weight bearing
  • Wean out of walking boot/ immobilization

Return to Play/ Work

  • Cross Training
    • Alter G treadmill with progressive weight bearing
    • Consider swimming, cycling
  • Return to play is slow, progressive
    • No more than 10% increase in intensity or duration weekly
    • If any return of pain, rest for a week and take a step down in progression

Complications and Prognosis

Prognosis

  • Needs to be updated

Complications


See Also


References

  1. Matheson GO, Clement DB, McKenzie DC, Taunton JE, Lloyd-Smith DR, Macintyre JG. Stress fractures in athletes: a study of 320 cases. Am J Sports Med. 1987;15:46-58
  2. McBryde A M. Stress fractures in athletes. J Sports Med1975;3:212–17
  3. McBryde A M. Stress fractures in runners. Clin Sports Med1985;4:737–52
  4. Milgrom C, Giladi M, Stein M, et al. Stress fractures in military recruits. A prospective study showing an unusually high incidence. J Bone Joint Surg [Br] 1985;67:732–5.
  5. Brockwell J, Yeung Y, Griffith JF. Stress fractures of the foot and ankle. Sports Med Arthrosc Rev. 2009;17:149-159
  6. Boden BP, Osbahr DC. High-risk stress fractures: evaluation and treatment. J Am Acad Orthop Surg. 2000;8:344-353
  7. Gross TS, Bunch RP. A mechanical model of metatarsal stress fracture during distance running. Am J Sports Med. 1989;17:669-674
  8. O’Malley MJ, Hamilton WG, Munyak J, DeFranco MJ. Stress fractures at the base of the second metatarsal in ballet dancers. Foot Ankle Int. 1996;17:89-94
  9. 9.0 9.1 9.2 Albisetti W, Perugia D, De Bartolomeo O, Tagliabue L, Camerucci E, Calori GM. Stress fractures of the base of the metatarsal bones in young trainee ballet dancers. Int Orthop. 2010;34:51-55
  10. Balius, Ramon, et al. "Stress fractures of the metacarpal bones in adolescent tennis players: a case series." The American journal of sports medicine 38.6 (2010): 1215-1220.
  11. Eckstrand J, van Dijk CN. Fifth metatarsal fractures among male professional footballers: a potential career-ending disease. Br J Sports Med. 2013;47(12):754-758.
  12. Banal F, Gandjbakhch F, Foltz V, et al. Sensitivity and specificity of ultrasonography in early diagnosis of metatarsal bone stress fractures: a pilot study of 37 patients. J Rheumatol 2009; 36:1715–1719.
  13. Chuckpaiwong B, Cook C, Nunley JA. Stress fractures of the second metatarsal base occur in nondancers. Clin Orthop Relat Res. 2007;461:197-202
  14. Wright RW, Fischer DA, Shively RA, Heidt RS, Nuber GW. Refracture of proximal fifth metatarsal (Jones) fracture after intramedullary screw fixation in athletes. Am J Sports Med. 2000;28:732-736
Created by:
John Kiel on 31 October 2021 13:39:30
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Last edited:
4 October 2022 12:37:00
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