STAVE FRACTURE OF THE FIRST METATARSAL BY M. B. COOPERMAN, M.D. OF PHILADELPHIA, PA. INSTRUCTOR IN ORTHOPEDICS IN THE UNIVERSITY OF PENNSYLVANIA GRADUATE SHOOL STAVE fractures of the metatarsal are rare. No mention of this type of fracture is made by Cotton, Scudder, Stimson, Moorehead, DaCosta or Keene. A stave of the metacarpal bone, on the other , is fairly common, that of the being called Bennett's fracture. A stave of the thumb usually results from violent force applied to the distal end of the extended thumb. It is a fracture of the proximal end of the metacarpal, oblique or longitudinal and into the with the . There is, usually, a backward dislocation of the first metacarpal bone. The case to be described is a stave at the base of the first metatarsal bone, and into the articulation with the internal cuneiform. J. H. G., colored, aged thirty-five years, employed as a laborer in a warehouse, pulling a four-wheeled truck. When loaded, this truck requires two men to move it, one in the rear pushing it and one in front pulling by means of a handle. In going down a slight decline in the warehouse, one of the wheels of the truck struck the back of the elevated heel of the right . The ankle-joint was severely wrenched. He had to stop work immediately because of pain in the ankle-joint and foot. The patient was seen about a half hour after the accident and the following was noted: The injured foot showed a third degree of pes planus. The opposite foot; examined for com- parison, also showed this deformity. The astragalo-scaphoid joint of the affected foot bulged inward and downward. The inner border of foot was markedly convex. The ankle-joint, on its anterior and lateral aspect, was swollen. The movements of the foot were pain- ful, especially plantar flexion, abduction and eversion. Palpation revealed an area of pain and tenderness on the inner border of the base of the first metatarsal bone and at the insertion of the tibialis- anticus tendon. There was considerable pain and tenderness to pressure beneath the internal , indicating a sprain of the internal lateral ligament. No crepitus was elicited. The X-ray showed an oblique fracture of the base of the first metatarsal. The mechanism in the production of this fracture differs from that of the thumb, in that the violence is transmitted through a series of bones (the mid-tarsum), finally spending its force upon the principal pillar of the fore-foot, the strong first metatarsal. The fracture produced is there- fore due to indirect force. When the impact of the violence is received upon the back of the heel, the foot is in plantar flexion and weight is momentarily borne upon 215 M. B. COOPERMAN the anterior metatarsal arch and . There is a sprain of the capsular ligament of the ankle-joint at its attachment to the anterior margin of the lower anterior border of the and perhaps also the margin of attachment to the astragalus. There is also some strain put upon the lateral ligaments. The violence is diffused forward, downward, inward and upward. There is an anterior subluxation of the astragalus. The head of this bone is forced down- ward and i nward upon the scaphoid, carrying the latter with it. The strong inferior calcaneo- scaphoid ligament being relaxed in this case, owing to the defor- mity, does not resist the strain. The internal cuneiform bone re- ceives this violence, and it in turn is jammed against the base of the first metatarsal bone. The lat- ter, being the last bone in the line of force, does not move ante- riorly because it rests on the ground. Dislocation backward does not occur; and inward dis- placement is restricted by the peroneus-longus muscle which is inserted into the inferior surface of the base. The first metatarsal bone, caught between these forces, will fracture at the base. An accurate diagnosis of _ these cases cannot be made un- less the X-ray is employed. The symptomatology of this type of iS rather severe because FIG. I.-Stave fracture of base of first metatarsal bone. inj1uryir of the extensiverathersveirinjbaeury to the capsule and the lateral ligaments of the ankle-joint. The treatment of a stave fracture of the first metatarsal is to supinate and adduct the foot at right angles to the leg and immediate immobiliza- tion in this position by means of plaster of Paris for about two weeks, followed later on by baking, massage, passive and active movements. Weight may be borne about the end of a month.

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