In an earlier blog (http://tinyurl.

com/285eurj ), I discussed the common lateral foot and ankle pain syndromes in the
foot. I recently stumbled on a great case, which is applicable to that theme.
Stress fractures are common in the foot and they most often affect the metatarsal bones. The distal second
metatarsal neck is the most common site of a stress fracture in the foot. Stress fractures of the third or fourth
metatarsals are less frequent. I think we can all agree that stress fractures of the first and fifth metatarsal bones are
relatively rare.
I had a 67-year-old woman patient see me recently with pain on both feet with the right foot worse than the left. She
complained of pain for about a year on and off. She had previous treatment by another podiatrist who told her that
she had bone spurs on the top of her feet. She had one cortisone injection but it did not help much.
Her examination was remarkable for pain with palpation of the dorsal bony prominence of the tarsometatarsal joints.
There was also generalized tenderness over the base of the fourth and fifth metatarsal bases. Bilateral X-rays
revealed an old stress fracture of the left second metatarsal. Mild to moderate degenerative joint disease of the
tarsometatarsal joints was present. There was an underlying metatarsus adductus.
At the patient’s first office visit, my working diagnosis was osteoarthritis of the tarsometatarsal joints with exostosis
and lateral stress syndrome of the foot secondary to metatarsus adductus. I call this condition metatarsal periostitis.
Her treatment included shoe gear modification to avoid flimsy shoes, which increase stress to the foot. I
recommended a stiff soled athletic shoe and alternating her lacing pattern to avoid pressure to the dorsal exostosis. I
prescribed diclofenac 75 mg BID PC #60. She initiated an icing protocol TID x 15 minutes. I instructed her to follow
up in three weeks.
On her return visit, she was not getting better and, in fact, stated that she was worse. She tried wearing better shoes
and she even went to an orthotist to have a pair of orthotics made but these did not help either. Upon re-examination
of the patient, it seemed as if the pain was more on the lateral side of the right foot.
At this point, I dispensed a fracture boot to immobilize the foot and advised her to wear it during all weightbearing
activities. I gave her a prescription for diclofenac patches (the oral medication caused gastrointestinal upset) and
hydrocodone (Vicodin, Abbott Laboratories). She was to follow up in two weeks.
On her following visit, she was approximately 80 percent better. Repeat X-rays revealed a stress fracture of the fifth
metatarsal, which was now quite obvious.
What I find very interesting about this case is that I have always believed in the theory that a Jones fracture was a
"stress fracture in the making." Since most Jones fractures that we see in practice are a result of an injury (foot
plantarflexed with an inversion torque), it is hard to prove the stress fracture theory. I think this is a perfect case in
point to illustrate this.
This patient also has a metatarsus adductus. You will see lateral foot and ankle pathology over and over again in the
pes cavus and/or metatarsus adductus foot type.

http://www.podiatrytoday.com/blogged/case-study-illustrates-challenge-diagnosing-emerging-stress-
fracture

Case study

A 29-year-old male had spent 6 months training for a marathon by running approximately 45 miles/wk. He
mentioned to one of his fellow runners that he had recently noticed a mild ache in his right groin. On the advice
of his friend, the man took a few days off from running, and the pain resolved without further treatment. While
running in the marathon the following week, he developed the same ache, which not only persisted but also
increased so greatly that he had to cease running at mile 14. He was driven home by a friend; upon arrival at
his house, he was unable to bear weight on the right leg. At his friend's insistence, the man traveled to an
emergency department, where he was seen by a physician. No films were obtained at that time, because the
patient had a full, painless range of motion; he was instructed to take ibuprofen and was sent home without a
walking aid.

The following day, the patient went to his primary care physician and obtained a referral to a physiotherapist.
Following 3 weeks of therapy, he was still unable to comfortably bear weight. He returned to the emergency
department one night the following week because his pain had persisted. The patient was told to ice the groin
and was given a prescription for a cyclooxygenase-2 (COX-2) inhibitor, but he did not receive a radiograph.
The patient continued his physiotherapy for an additional 3 weeks without improvement of his symptoms, at
which time his primary care physician referred him to a local orthopedic surgeon.
Upon physical examination, the patient had approximately 1.5 cm of shortening on the affected side, with
severely limited range of motion at the hip. A radiograph confirmed a basicervical fracture of the femoral neck,
with a neck-shaft angle of 90°. An MRI suggested the development of a fibrous nonunion.

The patient was taken to the operating room for open reduction and internal fixation. A subtrochanteric
osteotomy for correction of the varus deformity of the femoral neck also was contemplated, but gentle traction
restored enough neck-shaft angle to permit placement of a dynamic hip screw (DHS). Six months
postoperatively, the fracture was thought to be sufficiently healed to allow unprotected weightbearing. At 8
months postoperatively, the patient had resumed low-impact activities, such as cycling and swimming. After
more than 3 years, he had resumed recreational running without difficulty.

This case is classic in its presentation. A young male distance athlete with insidious onset of hip pain, which
was likely a stress fracture of the femoral neck, went undiagnosed despite several visits to the doctor. Only
after obtaining appropriate imaging studies was the truly serious nature of the patient's symptoms revealed.

Indications

In 1965, Devas instituted a classification scheme for fatigue fractures, based on prognosis and radiographic
appearance.15 His system split stress fractures into compression and transverse (tension) types. Compression
fractures are the less serious of the 2 and are seen most frequently in younger adults. These fractures are
considered stable and may be treated with several days of rest followed by a period of protected weightbearing.
Nonoperative management of these fractures necessitates frequent radiographs because late displacement, a
potentially catastrophic complication, has been reported in the literature.

In select instances, if athletes with a known compression-type fracture continue to participate in strenuous
activities, the lesion may progress to the level of the superior femoral neck and become a complete and, in the
worst instance, displaced femoral neck fracture. Situations in which a physician may elect to prophylactically
treat a compression-type fracture expectantly include those in which patients experience metabolic bone
processes that weaken the femoral neck's structural properties.

Transverse fractures, by contrast, are more commonly seen in the elderly population and carry a 10-15%
possibility of displacement, with subsequent avascular necrosis (AVN) of the femoral head. A displaced femoral
neck is one of the few true orthopedic emergencies, owing to the disastrous outcomes associated with AVN.
Transverse fractures appear on an internally rotated anteroposterior (AP) radiograph as a crack at the superior
femoral neck. One can see sclerosis of the underlying bone, along with cortical deficiency. Over a period of
days to weeks, these fractures may become complete, and callus formation may become evident over time.

Surgical treatment is warranted for all stress fractures that have progressed to a transverse fracture of the
femoral neck. The question then becomes which treatment procedure is more beneficial to the patient. The
orthopedist may choose either internal fixation or arthroplasty. The decision-making process should include
consideration of the patient's bone quality, life expectancy, physiologic status, and overall activity level.
However, the main factor in deciding which type of repair to undertake should be the likelihood of revision
surgery being needed in the future for a failed arthroplasty. For most younger individuals in otherwise good
health, this means internal fixation of the fracture is warranted.

Indications for hemiarthroplasty include such factors as pathologic bone, rheumatoid arthritis, renal failure or
other chronic illness, and limited lifespan.
In the elderly population, osteoporosis becomes increasingly prevalent, resulting in decreased bone fatigue
strength. When bone fails under physiologic loads in this population, it may be termed an insufficiency fracture.
The differentiation between stress and insufficiency fractures lies in the bone's capacity to resist fracture under
physiologic strains.

Relevant Anatomy

Vascular

The femoral head derives its blood supply from 3 terminal arterial branches. The lateral epiphyseal artery (an
ascending branch off of the medical femoral circumflex artery of the profunda femoris) is the predominant
source of blood flow, and its distribution to the head is largely skewed toward the subchondral bone of the
femoral articular cartilage. Two accessory arteries supply the remaining 10% of femoral head circulation. These
minor arteries are the inferior metaphyseal artery (the ascending branch of the lateral femoral circumflex artery)
and the medial epiphyseal artery of the ligamentum teres. The latter vessel originates from the obturator artery.
The vascular anatomy of the femoral neck is especially important because fractures of this region can have
devastating effects on the already tenuous blood supply to this area. The severity of the vascular disruption
generally correlates with the degree of displacement of the fracture.

Bone

By midadolescence, the femoral epiphysis is usually closed, providing a reasonable anatomic picture of the
femoral head and neck. The neck-shaft angle, which is approximately 130°, is relatively constant between the
sexes. Femoral anteversion is estimated at 10.4° and remains unchanged even after skeletal maturity is
reached. A fairly large synovial membrane encloses the femoral head and a good portion of the anterior
femoral neck. The greater trochanter, a large, posteriorly located, bony prominence, serves as the major
attachment for the external rotators; it also provides a definitive surgical landmark for the insertion of numerous
femoral internal-fixation devices.

Contraindications

In general, nondisplaced, compression-type femoral neck fractures are relative contraindications to surgery. In
contrast, tension-type stress fractures demand surgical treatment because they have a high propensity for
fracture displacement. Contraindications to surgical fixation of a tension-type femoral neck fracture are few
because this is one of the few true orthopedic surgical emergencies. If a displaced femoral neck fracture
occurs, the very real possibility of disruption of blood supply to the femoral head makes surgery necessary.
Absolute contraindications include a medically unstable patient who would be unable to tolerate the stress of
surgery and anesthesia. If initial operative fixation is not obtained and osteonecrosis ensues, the patient, when
stabilized, will require a hemiarthroplasty as definitive treatment.

http://emedicine.medscape.com/article/1246691-overview
 Shaun's Fractured Fibula/ Compound Ankle
dislocation playing Baseball (WARNING- Graphic
Fracture Image)
by Shaun
(St. Petersburg, Fl)

Tibia protruding: Compound Ankle dislocation

On May 31, 2009, I was playing a baseball game on my summer team here in sunny Florida. On
this day, I was playing 3rd base. Next thing I know, I find myself chasing a pop foul ball toward
the fence in foul territory and it was right then, that my left foot fell into a hole left by a fence
post causing my fibula to fracture and a compound dislocation of my ankle/tibia. I went to the
ER immediately where I had emergency surgey within a couple of hours. The surgeon repaired 2
or 3 torn ligaments and set my ankle and tibia back into place.

The Dr's main concern I believe, was infection from the compound dislocation, in which my tibia
broke the skin. During the 1st surgery, the Dr determined that the swelling was to severe to
repair the fractured fibula and he decided to wait 48hrs to go back in and asess the swelling.
The swelling was still too severe, so I did not have my 3rd and final surgery until 2 weeks after
the incident. I did wear a External Fixator for the weeks leading up to the last surgery, which
was really weird and uncomfortable if you have never been through something like this.
Today, July 26th, I am all fixed and on the road to recovery. I wore a hard cast for 2 weeks after
the 3rd surgery, before the Dr put me into a AirCast/Boot. I am non-weight bearing for 12
weeks total, and I have 7 weeks out of the 12 remaining. The crutches are HELL. I am going into
my 4th full week of physical therapy, which I am doing 3 times a week. Because of the non-
weight bearing, the therapist are only able to do Range of Motion excercises, which is extremely
painful but well worth it. I am able to move up and down, but side to side is still very stiff.

http://www.sports-injury-info.com/shauns-fractured-fibula-compound-ankle-dislocation-playing-
baseball-warning-graphic-fracture-image.html