Metatarsal Fractures

Metatarsal fractures.

Search Strategy

Databases used: Pubmed, BIBLIO VUB, Web of Knowledge
Keywords used: metatarsal fracture(s), stress fracture(s), Jones fracture, fractures of the fifth metatarsal (or a combination of these words).
Databases used: Pubmed, Spingerlink, BIBLIO VUB, Web of Knowledge, MEDscape, BioMED Central, National Institute of Health, Medline Plus
Keywords used: metatarsal fracture(s), Jones fracture, foot fractures, diaphyseal fractures of the fifth metatarsal, fractures of the fifth metatarsal (or a combination of these words)
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Definition/ Description

A metatarsal bone fracture is a complete or incomplete break in one of the five metatarsal bones in each foot. These long thin bones are located between the toes and the ankle (between the tarsal bones in the hindfoot and the phalanges in the forefoot).

'Clinical Relevant Anatomy

The foot consists out of 5 metatarsal bones per foot. Every metatarsal bone consists out of three parts: caput ossis metatarsi, corpus ossis metarisi and the basis ossis metatarsi .
They form joints with at the proximal side: ossa cuneiformia and at the medial and lateral side the os cuboideum. At the distal side they articulate with the basis of the proximal phalanges.
The tarsometatarsal joint is also called the line of Lisfranc. The tarsometatarsal joints have relatively flat articular surfaces and strong, short ligaments who admit small translations and tilting movements.
The basis of the os metatarsale 2 is surrounded the three ossae cuneïforme with strong ligaments. The strong dorsal ligament of lisfranc between the lateral side of C1 and the medial side of M2.

Lateral is the ligamentsystem with fibers between C2 and M2, just as crossed fibers between C3-M2 and C2-M3[53,55].

Epidemiology/ Etiology

5 to 6% of all fractures treated in primary care are metatarsal fractures. They are equally amoung men and women and among all racial groups.

Many metatarsal fractures are caused by twisting injuries or direct impact (a heavy object falling on the foot).
Athletes, individuals who are obese, and individuals with osteoporosis or rheumatoid arthritis have an increased risk of developing metatarsal fractures.
It also appears in sports like jogging, ballet, gymnastics, and high-impact aerobic activities
Shoe shock attenuation can prevent metatarsal stress fractures.

Different fractures

The metatarsal can be fractured at 3 locations: on the head, shaft/neck or on the base. Like that we can differentiate multiple different fractures:
- subcapital fracture
- shaft fracture
- base fracture
- avulsion fracture on the base of os metatarsal V: 2 types
- 1) the proximal diaphyseal fracture (Jones fracture-> most common!)
- 2) In the area of the metatarsal tuberosity
- fatigue fracture of os metatarsal 2, 3 (marcher’s fracture) 

The most common fracture site is at the base of the fifth metatarsal (Jones fracture) and occurs as a result of inversion of the forefoot.
The location of the fracture must be carefully evaluated since the treatment for a Jones fracture is radically different from fractures of the shaft of the fifth metatarsal.
More force is placed on the second and third metatarsals when walking; therefore, stress fractures and bone remodeling from stress are common in the second or third metatarsal, a condition sometimes called a “marcher’s fracture” after its high incidence among military recruits.

Characteristics/ clinical presentation

- Painful swelling
- Palpable trapje
- Axial pressure pain

Treatment

There are 2 types of treatment:

Conservative treatment:
- Multiple metatarsal fractures
- Avulsion fractures without dislocation (most common)
- Fractures of os metatarsal 1
Operative treatment:
- sevear dislocated fractures
- Avulsion fractures with dislocation (most common)
- Luxation fractures

A standard conservative treatment for jones fractures: this treatment is only applied when the bones are not too much dislocated.

1) For 2-3 days in a short leg cast with additional antiphlogistic medication.
2) After edema reduces, the leg cast gets replaced by an adapted Caligamed 11 brace for several weeks, followed by intense mobilization and walking therapy.

A standard operative treatment for Jones fractures.

1) Placing a propeller in the bone
2) If the bone does not cure with a propeller, a bone graft is possible.

According to studies, there is a high incidence of failure after cast treatment of acute Jones fractures. Early screw fixation results in quicker times to union and return to sports compared with cast treatment.

Resources:

1. http://www.mdguidelines.com/fracture-metatarsal-bones/definition

2.http://books.google.be/books?id=vrhZC9rwjGoC&pg=PA584&lpg=PA584&dq=metatarsale+fracturen&source=bl&ots=-cCt0hlXZc&sig=iTbWR_OrshPpWLL9_Ir_QQ4b28E&hl=nl&ei=CYGtTf7zJI-fOt7A_fUL&sa=X&oi=book_result&ct=result&resnum=6&ved=0CDoQ6AEwBQ#v=onepage&q=metatarsale%20fracturen&f=false

3.https://www.louortho.com/documents/GEQ%20Fx%20of%20Prox%205th%20Met%20artical.pdf

References:

1. Prevention of overuse injuries of the foot by improved shoe shock attenuation
Milgrom C, Finestone A, Shlamkovitch N, Wosk J, Laor A, Voloshin A, Eldad A - Clinical Orthopaedics and Related Research 1992 Aug; (281):189-192
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2. Para-basal metatarsal V fracture: conservative functional treatment
Weinberg AM, Rzesacz EH, Illgner A, Reilmann H – Unfallchirurg 1993 Jul; 96(7):395-398

3. Early Screw Fixation Versus Casting in the Treatment of Acute Jones Fractures
Mologne TS, Lundeen JM, Clapper MF, O'Brien TJ- Am J Sports Med July 2005; (33): 970-975
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