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Chapter 198  Metatarsal Fractures 8

Chapter 198  Metatarsal Fractures

Scott Van Aman and M. Truitt Cooper

● Palpation
ICD-9 CODE ● Determine the area of maximum tenderness.
825.25 Metatarsal Fracture ● Careful sensory and vascular examinations
● Palpate the hindfoot and ankle to rule out addi-
tional injuries.
● Range of motion
Key Concepts
● Must range toes; pain out of proportion to what
● Most metatarsal fractures may be treated nonopera- would be expected on passive extension of toes,
tively with excellent results. in conjunction with massive swelling, may indicate
● The fifth metatarsal is most commonly fractured, compartment syndrome
usually by an avulsion of the base as the result of a ● Ankle range of motion
twisting injury.
● The goal of treatment is to maintain alignment of all
five metatarsals to preserve longitudinal and trans-
verse arches of the foot and normal weight-bearing ● Radiographs: weight-bearing (if possible) anteropos-
distribution under the metatarsal heads. terior, lateral, and 45-degree oblique views
● The first and fifth metatarsals are most important ● Usually sufficient to diagnose fracture
for weight bearing, and malalignment is poorly ● Check alignment of second metatarsal base with
tolerated. middle cuneiform to rule out Lisfranc joint injury.
● The history is important to rule out a previous stress ● Occasionally, a nondisplaced fracture will not
fracture. appear for more than 2 weeks on plain
● High-risk fractures include the proximal fifth metatar- radiographs.
sal, first metatarsal shaft, proximal second metatarsal ● Advanced imaging
(Lisfranc joint injury), and multiple fractures of the ● Computed tomography scan only indicated for
middle metatarsals. complex intra-articular fractures
● Magnetic resonance imaging and bone scan rarely
indicated for acute injuries; more commonly used
with stress fractures
● Multiple injury mechanisms include falls, direct crush
injuries, and indirect twisting injuries of the leg with
Differential Diagnosis
the forefoot fixed. Avulsion fractures of the base of
the fifth metatarsal may result from the supination ● Lisfranc joint injury: pain located at tarsometatarsal
mechanism. joint, exacerbated by pronating/supinating forefoot;
● Severe trauma may lead to multiple fractures. may see fracture at base of second metatarsal
● Swelling, pain, and ecchymosis ● Tendon rupture/avulsion: pain located over tendon
● Usually able to bear some weight, except in cases of insertion or tendon proper; weakness to resistance
severe trauma testing
● Stress fracture: prodromal pain present
● Charcot’s arthropathy: patients with neuropathy (any
Physical Examination
type); erythema of foot that decreases with elevation
● Observation
● Gait
● Swelling, ecchymosis
● Deformity, including rotation and angulation of ● At diagnosis
toes ● Dependent on the metatarsal involved, location
● Check for open wounds. (head, neck, shaft, base), and displacement 829
8 Section 8  The Ankle and Foot

Figure 198-1  A, Anteroposterior radiograph of the foot displays a

fracture of the fifth metatarsal at the junction of the diaphysis and
A metaphysis. B, Postoperative radiograph shows a healed fracture
treated with an intramedullary screw.

Treatment is primarily symptomatic and includes
When to Refer
compressive wrapping with a hard-soled shoe and
weight bearing as tolerated for 5 to 6 weeks. ● Several fracture patterns require referral for surgical
● If necessary, a fracture boot may be applied to consideration.
further immobilize the foot. ● Displaced fractures of the first or fifth metatarsal;
● Close follow-up is recommended with early repeat may lead to abnormal loading patterns
radiographs to check for changes in alignment. ● Fractures of the proximal fifth metatarsal (with the
● Avulsions of the fifth metatarsal base should be exception of small avulsions); high risk of non-
treated with a walking cast or fracture boot with union; frequently treated with intramedullary screw
restricted weight bearing until the foot is com- fixation (Fig. 198-1)
pletely pain free. ● Multiple metatarsal shaft or neck fractures: treated
● Later with percutaneous wires or plate and screw
● Rarely, metatarsal fractures go on to symptomatic constructs
malunion or nonunion, and surgical osteotomy, ● Possible Lisfranc joint injury: fixed with screws or
bone grafting, and internal fixation may be fusion of the tarsometatarsal joints depending on
beneficial. the extent of injury
Chapter 198  Metatarsal Fractures 8
● Intra-articular fractures of the proximal or distal first bearing on the affected limb to allow for proper
metatarsal; may lead to posttraumatic arthritis; healing.
fixation frequently includes plate and screw
Considerations in Special Populations
Prognosis ● Diabetic patients require longer periods of treatment
due to delayed healing, even in young patients.
● Generally good, especially for isolated mid–metatarsal
● Fractures may precipitate Charcot’s arthropathy.
shaft fractures
● Malalignment is poorly tolerated as altered weight
● Appropriate management of neck fractures, as well as
bearing predisposes the patient to the develop-
first and fifth metatarsal fractures, should also lead to
ment of skin ulceration.
a good outcome.
● High-level athletes/dancers may benefit from surgical
● Although good outcomes can be anticipated for fifth
metatarsal base avulsion fractures, it may be several
● Patients with previous or recurrent stress fractures
months before a return to preinjury activity level
may also benefit from surgical fixation.
● Intra-articular fractures may lead to posttraumatic
● Missed Lisfranc joint injuries may lead to devastating Suggested Reading
arthritic collapse of the arch of the foot. ●● Egol K, Walsh M, Rosenblatt K, et al: Avulsion fractures of the
fifth metatarsal base: A prospective outcome study. Foot Ankle
Int 2007;28:581–583.
●● Fetzer GB, Wright RW: Metatarsal shaft fractures and fractures of
● Patients should be counseled on the risks associated the proximal fifth metatarsal. Clin Sports Med 2006;25:139–150.
with certain fractures as discussed previously. ●● Jones R: Fracture of the base of the fifth metatarsal bone by
● Surgical risks include bleeding, infection, superficial indirect violence. Ann Surg 1902;35:697–700.
nerve injury, and hardware irritation. ●● Kell IP, Glisson RR, Fink C, et al: Intramedullary screw fixation of
Jones fractures. Foot Ankle Int 2001;22:585–589.
●● Petrisor BA, Ekrol I, Court-Brown C: The epidemiology of
Patient Instructions metatarsal fractures. Foot Ankle Int 2006;27:172–174.

● Patients should be counseled on the nature of their ●● Reese K, Litsky A, Kaeding C, et al: Cannulated screw fixation of
Jones fractures. A clinical and biomechanical study. Am J Sports
Med 2004;32:1736–1742.
● They should be instructed in the importance of ice and
●● Sanders RW, Papp S: Fractures of the midfoot and forefoot. In
elevation in the acute period in an effort to reduce Coughlin MJ, Mann RA, Saltzman CL (eds): Surgery of the Foot
swelling. and Ankle, 8th ed. Mosby: Philadelphia, 2007, p 2199.
● For most fractures other than isolated mid-metatarsal
●● Schenck RC, Heckman JD: Fractures and dislocations of the
shaft fractures, patients should be instructed in appro- forefoot: Operative and non-operative treatment. J Am Acad
priate crutch use and the importance of non-weight Orthop Surg 1995;3:70–78.