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Metatarsal Fracti]Res METATARSAL FRACTI]RES Bradley D. Castellano, DPM Stepben V. Corey, DPM TbomasJ. Merrill, DPM John A. Rucb, DPM As with many common disorders of the foot, the displaced fractures, stress fractures, joint disloca- area of metatarsal fractures has received only tions, intra-articular fractures, severely comminut- superficial attention in historical and current med- ed and even compound fractures. The sllrgeon ical and surgical discr-rssions. General principles must have a thorough working knowledge of of fracture management have been sparingly these injuries in the specific region and unique applied to the topic in most ofihopedic and podi- anatomy of the forefoot. The full scope of poten- atric texts. The fifth metatarsal, however, has tial injury must be appreciated to avoid misdiag- received some degree of attention uncler the nosis and inappropriate treatment. eponym of the Jones' fracture. The eponym how- The variety of injuries to the metatarsal ever is often misapplied to the common avulsion region can be systematically classified. This type fracture of the fifth metatarsal base. Most refer- of classification can serve the same purpose as ences ciealing with the subject are interesting per- the Lauge-Hansen system in ankle fractures. A sonal experiences with metatarsal fractures and working knowledge of the mechanism of injury is an attempt to introduce a new or re-visited tech- also the key to successful management of many nique for the management of a unique or bizarre of the common injuries through conservative injury. Figura presents a iogical and rather com- methods or closed reduction techniques. plete classification of metatarsal fractures and dis- Complete clinical and radiographic evalua- cusses treatment.l tion are essential stepping stones in the success- State of the art has yet to be described in the ful management of metatarsal fractures. A management of metatarsal fractures. However, detailed description of the clinical appearance of the tools are avallable for a more consistent and the injury may often be the clue to a major injury definitive course of treatment. that may not be ful1y radiographically demon- Diagnosis and treatment of metatarsal frac- strated because of spontaneous reduction. A min- tures is dependent upon: imum of three radiographic views, dorsoplantar, 7, A comprehensive knowledge of metatarsal lateral, and oblique, are essential in the initial fractures, evaluation of any forefoot trauma that may 2. A thorough clinical and radiographic evalua- include metatarsal fractures. tion, and Armed with a ftr11 appreciation of potential 3. A sound working knowledge of the principles injury patterns the surgeon must apply a similar of treatment including: closed reduction tech- advanced level of practice to the techniques of niques bone healing internal fixation. management. Conservative methods or closed The topic of metatarsal fractures can be a reduction techniques do not necessarily fall into comprehensive microcosm of orthopedic trauma. the category of outdated skilis. Indeed, Charnley The variety of injuries can include simple non- presents a scientific basis to the principles and 294 techniques of closed redr-rction in his text The GENERAL CONSIDERATIONS IN Closed Treatment of Common Fractures.2 The sci- METATARSAL FRACTURES entific application of the principles of closed reduction inciude: The general topic of metatarsal fractures is very 1. The mechanism of injury poorly described in general orthopedic and podi- 2. The solt tissue hingc atric literature. Most attention has been focused 3. The closecl reduction technique on specific and definable injuries such as the 4. Maintenance of the reduction via the plaster. Jones' fracture, Lisfranc injury, and ar'.u1sion frac- These basic concepts are extremely impor- tures of the base of the fifth metatarsal. Common tant for effective and consistent results through fractures of the metatarsals are casually described closed methods. as being caused by direct trauma or some form of Open reduction and internal fixation of impaction. \fhile a detailed knowledge of the metatarsal fractures may be more fashionable in mechanism of injury for common fractures may the current surgicai theater. While there are not be essential to successful management, it definitive indications for ORIF, such as intra- does demonstrate the level of minor significance articular fracture and severe non-reducible defor- that common metatarsal fractures have been mity, the indications for ORIF in more common given. injuries remains less distinct. It is through a com- Factors which must be taken into considera- bined appreciation of a more normal functional tion in evaluation of metatarsal fractures include: result and the concepts and skills of rigid internal displacement, angulation deformity, shortening, fixation that a logical approach to the manage- and comminution. The extent of these factors will ment of metatarsal fractures can be devised. play malor roles in determining the most appro- priate form of treatment for each fracture. CIASSIFTCAIION NECK FRACTURES A u,.orking outline for categorizatton of metatarsal fractures can be summarized as follows: The most common fractures at the level of the I. General Fractures metatarsal neck are transverse or shofi oblique in A. Location configuration. Transverse fractures are typically B. Configuration bending fractures caused by direct trauma from a IL Special Categories falling object. One of the most common trans- A. First metatarsal fractures verse fractures at the metatarsal neck, however, is 1. Biomechantcal significance not caused by direct trauma but rather fatigue as 2. Avulsion peroneus longus seen in the typical stress fracture of the lesser B. Fifth Metatarsal Fractures metatarsals. 1. Avulsion Fractures The short oblique fracture at the neck of the 2. Jones'Fractures metatarsal is caused by a bending force applied 3. Oblique Neck Fractures with Butterfly w-ith longitudinal compression as seen in the Fragment "brake foot" follow-ing an automobile accident. C. Intra-artictilar Fractures (inch-rdes frac- Direct pressure is applied through the plantar ture/dislocation) surface of the metatarsal heads forcing the 1. Lisfranc Joint metatarsal head up and back. A similar mecha- 2. Metatarsophalangeal Joint nism can create a short oblique fracture with 3. Metatarsocuneiform/cuboid Joint plantar displacement or angulation of the D. Stress Fractures metatarsal head. This injury can occur with E. Epiphyseal Fractures extreme extension of the digit on the metatarsal F. Open Fractures head and an impaction force causing a violent plantar bending force at the metatarsal neck. Sim- ilar displacement can also occur in either a medi- al or lateral direction depending on the angle of pressure directed against the metatarsai head. 295 MID-SIIAFT FRACTI]RES Fifth Metatarsal Fractures The same mechanical forces can create fracture at The fifth metatarsal is subject to the same type of the mid-shaft level of the metatarsal. Direct general fractures as the other metatarsal seg- impact from a falling object is likely to create a ments. However, two unique fractures to the fifth transverse fracture pattern. Long oblique fractures metatarsal are classically described. of the metatarsal involving the mid-shaft region Auulsion fracture, Avulsion of the styloid can be seen with direct linear impact through the process of the base of the fifth metatarsal is clas- longitudinal axis of the metatarsal. Torsion frac- sically described as a consequence of an inver- tures of the metatarsals are rare. sion injury of the foot and is a direct result of traction from the peroneus brevis tendon. This BASE FRACTURES fracture usually heals with minimal complications. However, significant displacement can occur with Fractures identified at the base of the metatarsals separation of the fracture fragments due to pull of must raise suspicion as "tell tale" signs of more the peroneus brevis tendon and may require sur- major injury. Small obscure fractures such as arr gical intervention for reduction and fixation. avulsion fracture from the base the second of Jones'fracture. The classic Jones' fracture is metatarsal may be suggestive of a more signifi- a transverse fracture at the base of the fifth cant fracture/dislocation of the Lisfranc joint. metatarsal approximately one centimeter distal to Transverse fractures can occur at the metatarsal the metatarsocuboid joint. It has been historically bases without disruption of the tarsometatarsal labeled as a poor healing fracture due to joint. decreased vascularity of the metaphyseal segment of the metatarsal base. However, this concept is SPECIAL CATEGORIES OF Llnsuppofted and more logically explained on the METATARSAL FRACTURES basis of mechanical instability of this unique frac- ture location. The proximal end of the fifth The grouping of special categories serves several metatarsal is securely immobilized by ligamen- purposes. Many special fractures occur only in tous attachment, interlocking joint articulation, specific metatarsals and are caused by unique and insertion of a maior tendon. and well defined mechanisms of injury. Certain The distal segment of the fifth metatarsal, fractures have significant functional or healing unlike the internal metatarsals, is only stabilized significance. Each of the categories will be dis- by intermetatarsal attachments on one side. The cussed briefly as they have been described in distal segment of the fifth metatarsal is subject to detail in other references. motion
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