Injuries to the toes and metatarsals

Surgical Treatment for Isolated Closed Multi-metatarsal Fractures: At Least 2-Year Outcomes in 79 Feet

Multimetatarsal fractures are a particular type possibly associated with worse functional outcomes. Existing studies are scarce, fragmented, and lack control for confounders. This study aimed to explore the functional prognosis of isolated closed extra-articular multimetatarsal fractures and the different outcomes between the plate-screw and K-wire fixation. This retrospective study included 79 patients who underwent surgery for isolated closed extra-articular multimetatarsal fractures from May 2017 to December 2020. We recorded baseline characteristics. The primary outcome measure was Visual Analogue Scale (VAS), American Orthopedic Foot and Ankle Society (AOFAS) score, and Foot and Ankle Outcome Score (FAOS). Exploratory correlation analysis of the variables with VAS, AOFAS score, and FAOS was performed. The differences between the plate-screw group (n = 58) and K-wire group (n = 21) were compared. Seventy-nine patients (79 feet) were included with a follow-up of (47.3 ± 12.7) months (range, 26-70). Full weight bearing time was (11.7±5.3) weeks. VAS was (1.4±1.8) points, AOFAS score was (86.4±13.3) points, and FAOS was (79.0±11.1) points. Complications were observed in 17 cases (21.5%). According to exploratory correlation analysis, VAS was weakly associated with fixation method and gender, AOFAS was weakly associated with fixation method, FAOS was weakly associated with trauma mechanism. When the plate-screw group (n = 58) was compared with the K-wire group (n = 21), we found the former was superior to the latter in terms of full weight bearing time, VAS, AOFAS score, and malunion rate (all p < .05). FAOS was nonsignificant (p = .056). Operative treatment of isolated closed extra-articular multimetatarsal fractures showed good mid-term results. Plate-screw fixation was associated with faster rehabilitation as well as a lower malunion rate. The mid-term follow-up results showed patients with plate-screw fixation had better VAS and AOFAS scores.

Biomechanical comparison of different fixation methods in metatarsal shaft fractures: A cadaver study

BACKGROUND

Various fixation methods are available for the operative treatment of metatarsal shaft fractures: Kirschner wire, Titanium elastic nail, plate, or an intramedullary bone stabilization system within a balloon catheter. The aim of this study was to compare the stability of these techniques.

METHODS

72 metatarsals II to V from fresh frozen human cadaver feet were used. A shaft fracture was performed and fixed with a 1.6-mm Kirschner wire, a 1.5-mm Titanium elastic nail, a locking 6-hole-plate, or an intramedullary bone stabilization system. In a cantilever configuration, the head of the metatarsals was loaded statically (2 mm/min until failure; all groups) or cyclically (0 to 20 N for 1000 cycles with 10 mm/s, after 1000 cycles 2 mm/min until failure; plate and bone stabilization system).

FINDINGS

The mean failure strength for static loading was 17 N for Kirschner wire, 13 N for Titanium elastic nail, 73 N for plate and 34 N for the bone stabilization system (P < .01). For cyclic loading, the mean cycle of failure was 1000 for plate and 961 for the bone stabilization system (P = .76). The mean failure strength after cyclic loading was 73 N for plate and 48 N for the bone stabilization system (P = .03).

INTERPRETATION

Stability differs depending on the fixation method, with a plate showing the greatest stability and Kirschner wire or Titanium elastic nail the least. The stability of the bone stabilization system for fixing metatarsal shaft fractures is intermediate.

Closed Transverse Pinning for Reduction and Fixation of Metatarsal Neck Fractures: Surgical Technique

Most metatarsal neck fractures can be successfully treated non-operatively in a cast boot. Displaced metatarsal neck fractures tend to be less stable and have a propensity for the distal fragment to angulate, secondary to the strong flexor tendons, which often forces the distal fracture fragment in a plantar direction and leads to relative metatarsal shortening. Most literature is focussed on antegrade fixation of metatarsal neck fractures using pre-bent K wires or thin elastic nails. Apart from the technical challenges, this technique is limited when bones are osteoporotic as the pre-bent distal end of the K-wire may penetrate the plantar cortex of the proximal metatarsal and prevent the wire from entering the medullary canal of the metatarsal and advancing to the fracture site. Furthermore, when the medullary canal is narrow especially in Asian patients, it may be difficult to pass a bent K-wire through the isthmus of the metatarsal shaft. We describe an innovative technique of closed transverse wiring of the metatarsal head necks that has a distinct advantage in Asian population with osteoporotic bones. With percutaneous manipulation using digital pressure, closed reduction of fracture fragments of the most displaced fracture is done under fluoroscopic guidance to achieve a satisfactory alignment followed by closed transverse wiring of the metatarsal heads. With this procedure, adjacent fractures remain stable within an acceptable range because of intermetatarsal ligaments connected to the adjacent intact head. Our technique has a relatively short operating time and allows for early motion of the metatarso-phalangeal joint. This is especially useful for those with osteoporosis, narrow canal, soft tissue compromise, intra-operative failure of ante-grade pinning and in scenarios of limited surgical equipment/expertise.

Central metatarsal fractures: a review and current concepts

Central metatarsal fractures (CMF) are common injuries. More frequently fractures are those of the fifth metatarsal, followed by CMF and therefore by the first metatarsal. Third metatarsal is injured most frequently than the others and up to 63% is associated with second or fourth metatarsal fractures and up to 28% with both. Anatomy and metatarsal kinematics merits attention due to its influence on function, injuries and treatment options. Diagnosis is based on the history of trauma and clinical examination, relating with instrumental exams. Fractures with less than 10° of angulation and 3-4 mm of translation in any plane are typically treated conservatively, while operative treatment is generally reserved for fractures out if these values. Intramedullary fixation with K-wires seem to be the most common and valid surgical treatment in simple fractures. Spiral fractures should be treated by interfragmentary screws, which positioning may result difficult due to the adjacent metatarsals. Therefore, an alternative approach is an osteosynthesis with a dorsal plate. Multiple metatarsal fractures often occur in the contiguous bones, so clinicians will also have to carefully inspect metatarsals and adjacent joints such as Lisfranc articulation. The clinical and functional outcomes are often influenced by the pattern of fractures and patient conditions and are reported in the literature up to 39% of poor results.

Initial support with no immobilisation as therapy of choice for fractures of the fifth metatarsal

AIM

To demonstrate the effectiveness of early weight bearing with no immobilisation (functional therapy) applied to fractures of the fifth metatarsal.

MATERIAL AND METHOD

A retrospective case and control observational study was performed among 382 fractures on the fifth metatarsal comparing functional, conservative-orthopaedic and surgical treatments. Fractures were classified according to the settlement on the distal, diaphyseal or proximal part of the bone, the recommended therapy and the treatment performed. Influence of age, profession and characteristics of the injury were considered and results were measured using the parameters incapacity for work and number and intensity of complications.

DISCUSSION

Fractures of the fifth metatarsal are the most common injuries of the foot. Whether conservative or surgical treatment is recommended depends on the sort of fracture, the trend nowadays is to use non-invasive methods.

CONCLUSIONS

Functional treatment for metatarsal fractures provides earlier healing and fewer adverse effects than conventional therapies, and becomes first choice for non-displaced fractures and most displaced fractures of the fifth metatarsal.

Union Rate and Rate of Hardware Removal Following Plate Fixation of Metatarsal Shaft and Neck Fractures

BACKGROUND

There have been very few studies related to the treatment of first, second, third, and fourth (MT) metatarsal shaft and neck fractures. In order to reduce metatarsal fracture malunion, many surgeons have turned from K-wire to plate fixation of these fractures. This study reports the healing rates, final fracture angulation, and need for hardware removal of operatively treated first to fourth MT shaft and neck fractures with plate fixation.

METHODS

A retrospective review was performed on all metatarsal fractures at our institution between 2008 and 2014 to identify all first to fourth MT shaft and neck fractures. Medical records and radiographs were reviewed for evidence of union, sagittal, and coronal fracture angulation (degrees), time to full weight bearing, plate size, fracture location (neck vs shaft), and number of screws on each side of the fracture. Multiple linear regression analysis was used to make calculations of statistical significance.

RESULTS

Forty-five patients with a total of 75 first to fourth MT fractures treated with plate fixation were included in this study. All fractures went on to union and full weight bearing. The average time to union and time to full weight bearing was 10.9 ± 2 weeks and 7.5 ± 1.6 weeks, respectively. The average coronal and sagittal plane angulation was 3.9 and 2.2 degrees, respectively. Fractures located in the neck were found to have higher coronal plane angulation malunion compared with fractures in the shaft ( P = .019). No variable was found to be related to final sagittal plane angulation. No patient had a plate removed, and 26 of 27 of patients did not want to have the plate removed.

CONCLUSION

Metatarsal fractures fixed with plates had high rates of union and low final fracture angulation. No patient included in this study underwent hardware removal.

LEVEL OF EVIDENCE

Level III, comparative study.

Fifth metatarsal fractures and current treatment

Metatarsal fractures are one of the most common injuries of the foot. There has been conflicting literature on management of fifth metatarsal fractures due to inconsistency with respect to classification of these fractures. This article provides a thorough review of fifth metatarsal fractures with examination of relevant literature to describe the management of fifth metatarsal fractures especially the proximal fracture. A description of nonoperative and operative management for fifth metatarsal fractures according to anatomical region is provided.

Do Broken Toes Need Follow-Up in the Fracture Clinic?

Most toe phalangeal fractures can be successfully treated nonoperatively without any residual deformity and are usually clinically asymptomatic. Toe phalangeal fractures are nevertheless common fracture clinic referrals. Our aim was to evaluate the injury characteristics of patients with toe fractures attending a fracture clinic and to understand how current management affects the fracture clinic workload. We retrospectively evaluated all new referrals to a subspecialized foot and ankle fracture clinic during a 12-month period at our institution under the care of 1 consultant. Data were collected regarding patient demographics, fracture type, patient outcome, and the number of clinic appointments attended, cancelled, or not attended. A total of 707 new patients (mean age 39 ± 19 years; 345 males, 362 females) were seen in 47 foot and ankle fracture clinics within the study period. Seventy-four phalangeal fractures were identified in 65 patients. A total of 135 outpatient appointments were scheduled for these patients (initial and follow-up), with 93 (69%) attended, 25 (19%) not attended, and 15 (11%) cancelled and rescheduled at the patient's request. Seventeen patients (13%) failed to attend their first clinic appointment. The results of the present study highlight that 9% of all new patient referrals to a fracture clinic were for toe phalangeal fractures. Only 2 patients required surgery for significant loss of articular congruency or deformity. No patient subsequently developed a symptomatic malunion or required toe surgery during the following 2 years. We believe that undisplaced and stable toe phalangeal fractures do not need to be referred to the fracture clinic. This would result in a reduction of outpatient appointments for toe fractures by 52%.

The Epidemiology of Fifth Metatarsal Fracture

BACKGROUND

A paucity of data exists studying the epidemiology of fifth metatarsal fractures. While a number of studies exist focusing on specific fracture patterns and patient populations, a large comprehensive epidemiologic study on the general public does not.

OBJECTIVE

We reviewed 1275 fifth metatarsal fractures treated at a multicenter orthopaedic practice attempting to classify mechanism of injury and patient demographics as they pertain to specific fracture patterns.

METHODS

Patient demographics were recorded and fractures categorized by location and mechanism of injury. Demographics and mechanism of injury were assessed to determine their predictive value for the type of fracture. Statistical analysis was used to predict whether demographics and mechanism of injury were statistically significant for types of fractures and whether gender and age were positive predictive values for fifth metatarsal fractures.

RESULTS

Twisting injuries were a statistically significant predictor of zone 1 injuries. A significant correlation between gender and fracture location was seen with women sustaining 75% of zone 1 injuries and 84% of dancer's fractures. A positive predictive value existed for age and gender with respect to the incidence of fractures. Males accounted for more fractures among younger patients and females accounting for the majority of fractures among older patients.

CONCLUSION

Mechanism of injury is a predictor for fracture location. Gender and age have a role in fracture incidence. In younger patient populations, males account for the majority of fifth metatarsal fractures. In older patient populations, females account for the majority of fifth metatarsal fractures.

LEVEL OF EVIDENCE

Prognostic study, Level II: Retrospective Study.

Fifth metatarsal fractures in the athlete: evidence for management

Shortest time to union, and to return to sporting activity, are the goals of management of fifth metatarsal fractures in the athlete. Whereas zone 1 injuries are largely treated conservatively, zone 2 and 3 injuries are best treated with surgical fixation in athletes, most commonly with intramedullary screw fixation. Fixation with the addition of bone graft has also yielded good results. In the chronic setting, good results have been shown with intramedullary screw fixation, surgical debridement and bone grafting alone, and tension band wiring. Shock wave therapy and pulsed electromagnetic fields may have a place in chronic and acute injury.

Closed antegrade intramedullary pinning for reduction and fixation of metatarsal fractures

The purpose of this study was to present the results of the metatarsal fractures treated with a closed antegrade intramedullary pinning technique. The records of 35 consecutive patients with metatarsal fractures operated on from August 2005 to June 2010 by the authors were retrospectively reviewed. Four patients were not contactable and 1 patient refused to participate. Accordingly, the study cohort was composed of 30 patients (24 male, 6 female) with 46 metatarsal head, neck, or shaft fractures. Inclusion criteria were metatarsal head, neck, or shaft fractures with a displacement of more than 3 to 4 mm or an angulation of more than 10° in the sagittal plane. Fractures combined with Lisfranc injury or metatarsal base fractures were excluded, as were bicortical comminuted fractures or long oblique fractures. Times to bone union, limitations of motion at affected metatarsophalangeal joints, and residual pain were evaluated at 6 weeks after surgery and at final follow-up. American Orthropedic Foot and Ankle Society scale was evaluated at final follow-up. Fracture union was obtained at an average of 7.1 (range 6 to 10) weeks. Two patients had moderate limitation of metatarsophalangeal joint at 6 weeks but recovered to full range at final follow-up. Average American Orthropedic Foot and Ankle Society score at final follow-up was 96.7 (range 83 to 100) points. Closed antegrade intramedullary pinning was found to be a useful method for treating displaced metatarsal fractures and to allow immediate joint motion and partial weightbearing in a stiff-soled shoe.

[Fractures of the forefoot]

Fractures of the forefoot are common and comprise approximately two thirds of all foot fractures. Forefoot fractures are caused by direct impact or the effect of indirect force. The forces exerted can range from repetitive minor load (stress fractures) to massive destructive forces (complex trauma). The clinical course in forefoot fractures is typically more favourable than in fractures of the mid- and hindfoot. The incidence of complications like infection or pseudarthrosis is low. Exceptions are rare fractures of the proximal shaft of the fifth metatarsal and the sesamoids with higher pseudarthrosis rates. Malunited metatarsal fractures can cause painful conditions that should even be treated operatively. Differences in structure and function of the different forefoot areas and specific fracture types require an adapted management of these special injuries.

Metatarsal fractures

Metatarsal fractures can present with a variety of situations. Ranging from the relatively benign, isolated central metatarsal fracture to the crush injury leading to extensive damage of the soft tissue and osseous components, these fractures can cause a significant inconvenience to the patient. With the exception of fifth metatarsal base fractures, little standardization is available for the treatment of metatarsal fractures. Controversy still exists regarding the proper treatment of various patient populations for junctional fifth metatarsal fractures. This article discusses the fractures of the first, central, and fifth metatarsals, as well as the treatment for the same.

Biomechanical analysis of stresses to the fifth metatarsal bone during sports maneuvers: implications for fifth metatarsal fractures

Fifth metatarsal stress fractures are an increasing problem in elite and recreational athletic populations. One possible mechanism of injury is the many bending moments applied to the fifth metatarsal during dynamic sports maneuvers involving rapid changes in direction and speed. A potentially important bending moment is loading of the base versus the head of the fifth metatarsal, which tends to cause a bending moment along the bone. To determine which maneuver applies the greatest pressure differential between the base and head of the fifth metatarsal, 10 college-aged male athletes performed running straight, jump take-off, jump landing, cutting right, cutting left, and accelerating while plantar pressures were recorded using a Pedar insole system (Novel Electronics, Inc., St. Paul, MN). Peak pressure at the fifth metatarsal base was subtracted from the peak pressure at the fifth metatarsal head to obtain the fifth metatarsal pressure differential-a corollary to the bending moment. The greatest fifth metatarsal pressure differential was observed during acceleration maneuvers (20 + or - 13.1 N/cm(2); P < 0.0001) followed by running straight (11.6 + or - 8 N/cm(2); P < 0.0008). The other maneuvers had low pressure differentials: jump take-off (4.2 + or - 10.6 N/cm(2)), jump landing (3.7 + or - 9.2 N/cm(2)), cutting left (2.3 + or - 4.2 N/cm(2)), and cutting right (-2.1 + or - 10 N/cm(2)). It appears that acceleration maneuvers may apply the largest bending moments to the fifth metatarsal and could lead to stress fractures. Because fifth metatarsal stress fractures are associated with rapid increases in training volume, reducing the number of acceleration events may be effective in altering the balance between bone resorption and bone formation and reducing stress fracture risk. Careful planning of training programs allowing for adequate rest between intense bouts of exercise involving many acceleration maneuvers may be the best preventative measure.

Metatarsal shaft fractures and fractures of the proximal fifth metatarsal

Metatarsal fractures represent a relatively common injury, especially in athletes. The pertinent anatomy, evaluation, diagnosis, classification, and treatment of acute and chronic (stress) metatarsal shaft fractures are discussed. Fractures of the proximal fifth metatarsal, which are unique and important injuries, are also discussed. Treatment remains relatively straightforward for the traumatic metatarsal injury, whereas traditional stress fractures typically heal with decreased activity. The problematic proximal fifth metatarsal fracture (Jones fracture) frequently requires surgical intervention in patients who want to avoid non-weight-bearing cast immobilization. The authors' current treatment for this fracture includes the option of intramedullary fixation versus cast immobilization.

The epidemiology of metatarsal fractures

BACKGROUND

Metatarsal fractures are common injuries; however little has been written regarding their epidemiology in an adult population.

METHODS

All patients with metatarsal fractures during a 1-year time period were included in the study. Demographic information, grade, and mechanism of injury, associated injuries, and fracture location and type were recorded.

RESULTS

Three hundred and fifty-five patients with 411 metatarsal fractures were identified. The average age of the patients was 42 years. There was a higher proportion of women in the higher age groups, and the most common fracture was that of the fifth metatarsal. Multiple metatarsal fractures occurred in contiguous metatarsals, and 63% of third metatarsal fractures were associated with a fracture of either the second or fourth metatarsal.

CONCLUSION

Knowledge of the epidemiology and injury patterns of metatarsal fractures can aid in the accurate identification and subsequent treatment of fractures of the metatarsals.

Detachable functional focused rigidity cast for metatarsal fractures

This article aims to assess whether a detachable functional focused rigidity cast can be used as a one-off definitive treatment for proximal 5th metatarsal fractures. A prospective trial was carried out over a 2-year period. Forty-one patients with proximal 5th metatarsal fractures (tuberosity and Jones) were recruited and treated with a detachable focused rigidity cast after appropriate consent. Of the 39 patients with follow-up, six had a Jones fracture and 33 had tuberosity fractures. All 33 patients with tuberosity fractures achieved clinical union within 4-5 weeks (mean of 4.2 weeks). Four of the six patients with Jones fractures achieved clinical union in 8-12 weeks. One achieved union in 14 weeks and one underwent open reduction and internal fixation for delayed union. There were no complications related to the cast. The results support the use of a detachable focused rigidity cast as a one-off definitive treatment of tuberosity fractures of the 5th metatarsal. However, all the Jones fractures and the diaphyseal fractures should be referred to an orthopaedic team for further management.

Ankle and Foot Injuries in Pediatric and Adult Athletes

Foot and ankle injuries are among the most common in athletes.Differential diagnosis, imaging decisions, and treatment plan should be influenced by the age of the athlete. A thorough history and physical examination, with an understanding of the anatomy of the foot and ankle anatomy and the mechanism of injury, will give the best opportunity to make the correct diagnosis. For most athletes, the prognosis for returning to play after a foot or ankle injury is very good. The recipe for keeping our athletes healthy includes early intervention, undergoing proper rehabilitation, applying braces or orthotics when indicated, and preventing injuries when appropriate.

Strength analysis of intraosseous wire fixation for avulsion fractures of the fifth metatarsal base

The objective of this study was to gather pilot data of the pullout strength of intraosseous wire for fixation of fifth metatarsal avulsion fractures and to compare intraosseous wire fixation with tension-band wiring. Osteotomies consistent with fifth metatarsal avulsion fractures were created in 5 matched pairs of cadaver limbs. One limb of each pair underwent fixation with intraosseous wiring and the other with tension band wiring. Metatarsals were then loaded to failure, defined as the maximum force achieved before the slope of the load curve moved from a positive to a negative value. Tension-band wiring showed a mean strength of 164.5 +/- 103.7 N compared with a mean strength of 113.7 +/- 46.6 N for intraosseous wiring. No significant difference in strength was shown between methods of fixation. Although the power of this data is small (.143), the data indicate that intraosseous wiring shows similar pullout strength when compared with tension-band wiring for fixation of fifth metatarsal avulsion fractures.

Salter Harris type II injury of the proximal phalanx of the fifth toe: case report

Fractures of the growth plate are unique to childhood. The risk of growth disturbances depends on the type of fracture, its location, the age of the patient, the vascularization to the epiphysis, the state of the surrounding soft tissues, and whether the injury is open or closed. Epiphyseal fractures of the foot are uncommon, and only rarely are the phalanges involved. We report a Salter-Harris type II injury in the fifth toe. The patient, a 3-year-old girl, was successfully managed conservatively with no sequelae.

Joint arthroplasties and prostheses

Joint arthroplasty is the most frequently performed orthopedic procedure after fracture fixation. The major indications for any joint replacement are degenerative joint disease, inflammatory arthropathy, avascular necrosis, and complicated fractures. The major contraindications for any joint arthroplasty are systemic and joint infection and a neuropathic joint. The interpretation of radiographs in cases of joint arthroplasty is a significant part of many radiology practices, and correct recognition of the prosthetic devices and their complications by the radiologist is important. The article reviews the most common types of joint arthroplasties and prostheses of the upper and lower extremities and discusses the most frequent complications associated with their placement.

Traumatic dislocation of the fourth metatarsophalangeal joint

A32-year-old man presented to the accident and emergency department 2 hours after twisting his ankle. He had been running down stairs, barefoot, and missed a step, inverting his left ankle and landing on the lateral aspect of his left foot before falling to the ground. He was weight-bearing on his left heel, but complaining of intense pain over the lateral aspect of his forefoot. He mentioned that his wife had noticed a dimple on the sole of his foot. Besides the dimple on the plantar aspect of the left foot, about 2 cm proximal to the base of the fourth toe, no other deformity, swelling or bruising was evident. The patient was markedly tender over the dorsum of the foot over the area of the fourth metatarsophalangeal joint and over the dimple, which marked the same place on the plantar surface. Distal sensation and capillary refill were normal.