Metatarsal Fractures

Metatarsal fractures.[edit | edit source]

Search Strategy
[edit | edit source]

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)
'

Definition/ Description[edit | edit source]

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). [1]

'Clinical Relevant Anatomy
[edit | edit source]

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 [2].
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[3][4].
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[5][6].
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[7][8].
Lateral is the ligamentsystem with fibers between C2 and M2, just as crossed fibers between C3-M2 and C2-M3[9][10].

Epidemiology/ Etiology[edit | edit source]

5 to 6% of all fractures treated in primary care are metatarsal fractures. It are the most common injuries of the foot. They are about ten times as frequent as Lisfranc-dislocations.[11]They are equally amoung men and women and among all racial groups.  [12]

The distribution of the fractures looks as follow (figure 1)[13]:
• First metatarsal: 5%
• Second metatarsal: 12%
• Third metatarsal: 14%
• Fourth metatarsal: 13%
• Fifth metatarsal: 56%
• Multiple metatarsal fractures: 15,6%

Figure 1: distribution of metatarsal fractures according to their location [14].

Metatarsal fractures are common in the pediatric population, accounting for close to 60% of all pediatric foot fractures[15]. The highest rate of fracture in childhood involves the fifth metatarsal[16], followed by the third metatarsal[17]. The lowest rate is the first metatarsal. Children under the age of 5 years are more likely to have first metatarsal fractures, with a frequency of isolated first metatarsal fractures of 51%, in contrast to those more than 5 years old, who are more likely to have fifth metatarsal fractures, depending on the age group, a frequency as high as 65%[18]. The next most common fracture finding was a specific combination of second, third and fourth metatarsal fractures [19][20][21][22].
Injury to the metatarsals is common in both acute and chronic settings[16] and they are the most common site of stress fractures in the human skeleton[23][24][25][26]. Among stress fractures of the metatarsal bones, the middle and the distal portions of the corpus ossis metatarsalis II or III are most common. Stress fractures at the base of the first or second metatarsals (or rately other metatarsal bones) are less common[27]. Metatarsal stress fractures are a common occurrence in athletes, particularly in runners, in whom they account for 20% of lower extremity stress fractures. Given the increased stresses experienced by the second and third metatarsals during walking and running, these metatarsals are at greatest risk for stress fracture[28][29].

Metatarsal fractures may result either from direct or indirect violence, and they display a wide variety of injuries ranging from isolated, simple fractures of one metatarsal to crush injuries with serial fractures and severe soft tissue compromise[30]. Direct trauma is common in industrial workers who have a heavy object fall on the foot. Indirect trauma occurs when the leg and hindfoot are twisted with the forefoot fixed[31]. The percentages looks as follow[32]:
• Supination injury: 48%
• Fall from height: 26%
• Crush injury: 12%


Athletes, individuals who are obese, and individuals with osteoporosis or rheumatoid arthritis or diabetes have an increased risk of developing metatarsal fractures.
It also appears in sports like jogging, ballet, gymnastics, and high-impact aerobic activities.[33] Shoe shock attenuation can prevent metatarsal stress fractures. [34]
The act of repetitive cyclic loading, especially in the setting of a young athlete or military recruit, can lead to a chronic overloading predisposing one to a stress reaction and ultimately fracture.[35]

It has been shown that the fracture pattern and severity of injury vary according to age and mechanism of injury.([36] This association can further be correlated with both osseous development and the age-related levels of activity.[37]

Specific causes of fractures:
• Most fractures of the corpus ossis metatarsalis are caused by direct blows or twisting forces. An abrupt increase in activity or chronic overload may cause a stress fracture of the metatarsal corpus.[38]
• The most common mechanism of injury in fifth metatarsal fractures involves a fall from standing height or an ankle twist with the forefoot fixed. In this position, a pulling force from the lateral cord of the plantar aponeurosis along with tension from the peroneus brevis tendon causes a longitudinal and torsional strain.[39]
• An avulsion fracture of the fifth metatarsal base (‘tennis fracture’) may occur as a result of inversion injuries to the foot, seen that the base of the fifth metatarsal is the endpoint of the ‘supination fracture line’.[40][41][42][43]
• A Jones fracture is the most common fracture site and occurs as a result of inversion of the forefoot[44][45][46] or from a vertical mediolateral force in the base of the fifth metatarsal, while the patient’s weight is over the lateral aspect of the plantar flexed foot[47].
Another cause lies in overuse, repetitive stress, trauma or a sudden change in direction with the heel off the ground [48][49].
• A tuberosity avulsion fracture usually results from ankle inversion while the foot is in plantar flexion. The history often suggests a lateral ankle sprain, and these fractures are often missed.[50]
• A diaphysial stress fracture is often due to a chronic overloading, especially from jumping and pivoting activities in younger athletes.
• Fractures of the corpus ossis metatarsalis are generally fatigue fractures and are related to chronic stress. It is the result from repetitive force, as seen in athletes, ballet dancers and soldiers[51]. After all, more force is placed on the second and third metatarsal when walking and gives more stress. Therefore stress fractures and bone remodeling from stress are common in the second or third metatarsal. It also knows a high incidence with military recruits.[52]
• Fractures from the first through the fourth metatarsals are the kind of fractures that are less common than other metatarsal fractures. They warrant special consideration, because they are often associated with injury to the Lisfranc ligament complex. These crucial ligaments hold the metatarsal bases rigidly in place, maintaining the arch of the foot and anchoring the metatarsals to the rest of the body.
• Proximal metatarsal fractures are usually caused by crush injuries or direct blows. They may also result from falling forward over a plantar-flexed foot. In athletes, the most common mechanism for a Lisfranc injury is an axial load placed on a plantar-flexed foot.[53]
• Stress fractures are common in people who:
o increase their activity level suddenly[54]
o do activities that put a lot of pressure on their feet, such as running, dancing, jumping, or marching (as in the military)[55]
o have a bone condition such as osteoporosis (thin, weak bones) or arthritis (inflamed joints)[56]
o have a nervous system disorder that causes loss of feeling in the feet[57]
o run more than 30km per week[58]

Different fractures[edit | edit source]

The metatarsal can be fractured at 3 locations: on the caput, corpus or on the basis ossis metatarsalis. Like that we can differentiate multiple different fractures:
 Subcapital fracture.
 Fracture of the corpus ossis metatarsalis.
 Fracture of the basis ossis metatarsalis.

Figure 2: Locations of fracture zones for proximal fifth metatarsal fractures[59].


Three distinct fractures occur in the proximal fifth metatarsal. The joint between the basis ossis metatarsalis IV and V is a key landmark for classifying proximal fifth metatarsal fractures (figure 2).[60][61][62][63]
 Avulsion fractures:
An avulsion fracture on the 5th metatarsal bone is called a ‘dancer’s fracture’[64].
 Specifically, there are two types of fractures of the fifth metatarsal bone:
o The Jones fracture:
o The tuberosity avulsion (styloid) fracture.
Currently, it is accepted that tuberosity avulsion fractures are ‘pseudo-Jones fractures’. [65][66][67]
 The diaphyseal stress fracture.
 Fracture of the unfused fifth metatarsal base apophysis.
 Marcher’s fracture[68]:
 This fracture is also called a fatigue fracture of os metatarsal II and/or III.[69]
Further on, there are the fractures from the first through the fourth metatarsals[70].

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. [71]


Characteristics/ clinical presentation[edit | edit source]

Common fractures of metatarsal fractures are[72]:

- Painful swelling
- Palpable trapje
- Axial pressure pain
[73] 

Patients with metatarsal fractures complain about pain on ambulation or the impossibility of weight bearing. The forefoot is swollen and tender to palpation. Gross deformities are only seen with complex injury patterns including serial fractures and additional toe dislocations.[74][75]


'Treatment[edit | edit source]

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
[76]

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.
[77]

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.
[78]

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. [79]




Resources:
[edit | edit source]


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:[edit | edit source]

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
[A1]

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
[A1]


  1. ↑ 1. http://www.mdguidelines.com/fracture-metatarsal-bones/definition
  2. ↑ PUTZ R, PABST R, Sobotta Atlas of Human Anatomy 14th edition. München (2009): Urban & Fischer.
  3. ↑ KAPANDJI IA, Bewegingsleer Deel II De onderste extremiteit. Houten 2009: Bohn Stafleu van Longhum.
  4. ↑ PUTZ R, PABST R, Sobotta Atlas of Human Anatomy 14th edition. München (2009): Urban & Fischer.
  5. ↑ KAPANDJI IA, Bewegingsleer Deel II De onderste extremiteit. Houten 2009: Bohn Stafleu van Longhum.
  6. ↑ FRONTERA WR, Clinical Sports Medicine: Medical Management and Rehabilitation. China (2007): Elsevier Health Sciences.
  7. ↑ FRONTERA WR, Clinical Sports Medicine: Medical Management and Rehabilitation. China (2007): Elsevier Health Sciences.
  8. ↑ PUTZ R, PABST R, Sobotta Atlas of Human Anatomy 14th edition. München (2009): Urban & Fischer.
  9. ↑ PUTZ R, PABST R, Sobotta Atlas of Human Anatomy 14th edition. München (2009): Urban & Fischer.
  10. ↑ FRONTERA WR, Clinical Sports Medicine: Medical Management and Rehabilitation. China (2007): Elsevier Health Sciences.
  11. ↑ Cakir H, Van Vlit-Koppert ST, Van Lieshout EM, De Vries MR, Van Der Elst M, Schepers T [Foto]. Demographics and outcome of metatarsal fractures. Archives of Orthopaedic and Trauma Surgery (2011); 131: 241-245.
  12. ↑ 1. http://www.mdguidelines.com/fracture-metatarsal-bones/definition
  13. ↑ Cakir H, Van Vlit-Koppert ST, Van Lieshout EM, De Vries MR, Van Der Elst M, Schepers T, Demographics and outcome of metatarsal fractures. Archives of Orthopaedic and Trauma Surgery (2011); 131: 241-245.
  14. ↑ Cakir H, Van Vlit-Koppert ST, Van Lieshout EM, De Vries MR, Van Der Elst M, Schepers T, Demographics and outcome of metatarsal fractures. Archives of Orthopaedic and Trauma Surgery (2011); 131: 241-245.
  15. ↑ Rammelt S, Heineck J, Zwipp H, Metatarsal fractures. Injury 35 (Suppl 2) 2004; SB77-SB86.
  16. ↑ Robertson NB, Roocroft JH, Edmonds EW, Childhood metatarsal shaft fractures: treatment outcomes and relative indications for surgical intervention. J Child Orthop 2012; 6:125-129.
  17. ↑ Johnson VS, Treatment of fractures of the forefoot in industry. Bateman JE Foot Science (1976); Philadelphia: WB Saunders.
  18. ↑ Robertson NB, Roocroft JH, Edmonds EW, Childhood metatarsal shaft fractures: treatment outcomes and relative indications for surgical intervention. J Child Orthop 2012; 6:125-129.
  19. ↑ Robertson NB, Roocroft JH, Edmonds EW, Childhood metatarsal shaft fractures: treatment outcomes and relative indications for surgical intervention. J Child Orthop 2012; 6:125-129.
  20. ↑ Owen RJ, Hickey FG, Finlay DB, A study of metatarsal fractures in children. Injury 1995; 26(8): 537-538.
  21. ↑ Singer G, Cichocki M, Schalamon J et al., A study of metatarsal fractures in children. J Bone Joint Surg Am 2008; 90(4): 772-776.
  22. ↑ Holubec KD, Karlin JM, Scurran BL, Retrospective study of fifth metatarsal fractures. J Am Podiatr Med Assoc 1993; 83 (4): 215-222.
  23. ↑ Geyer M, Sander-Beuermann A, Wegner U, et al., Stress reactions and stress fractures in the high performance athlete: Causes, diagnosis and therapy. Unfallchirurg (1993); 96: 66-74.
  24. ↑ Harrington T, Crichton KJ, Anderson IF, Overuse ballet injury of the base of the second metatarsal: a diagnostic problem. American Journal of Sports Medicine (1993); 21(4): 591-598.
  25. ↑ O’ Malley MJ, Hamilton WG, Munyak J et al. Stress fractures at the base of the second metatarsal in ballet dancers. Foot Ankle International Journal (1996); 17: 89-94.
  26. ↑ Torg JS, Balduini FC, Zelko RR, et al., Fractures of the base of the fifth metatarsal distal to the tuberosity. Classification and guidelines for non-surgical and surgical management. American Journal of Bone and Joint Surgery (1984); 66: 209-214.
  27. ↑ Resnick D, Diagnosis of bone and joint disorder. Philadelphia (1995): saunders; 2580-2596.
  28. ↑ Anderson RB, Hunt KJ, McCormick JJ, Management of common sports-related injuries about the foot and ankle. J Am Acad Orthop Surg 2010; 18(9): 546-556.
  29. ↑ Wall J, Feller JF, Imaging of stress fractures in runners. Clin Sports Med 2006; 25(4): 781-802.
  30. ↑ Zwipp H, Rammelt S, (2002). Frakturen und Luxationen. Orthopädie und Orthopädische Chirurgie. Fuß. Stuttgart, New York: Georg Thieme Verlag: 531—618.
  31. ↑ Hellpap W, The neglected lower ankle. The ”fracture“ line of supination. Arch Orthop Unfallchir (1963); 55: 289—300.
  32. ↑ Cakir H, Van Vlit-Koppert ST, Van Lieshout EM, De Vries MR, Van Der Elst M, Schepers T, Demographics and outcome of metatarsal fractures. Archives of Orthopaedic and Trauma Surgery (2011); 131: 241-245.
  33. ↑ 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
  34. ↑ Hatch RL, Alsobrook JA, Clugston JR, Diagnosis and Management of Metatarsal Fractures. American Academy of Family Physicians 2007; 76 (6).
  35. ↑ Ding BC, Weatherall JM, Mroczek KJ et al., Fractures of the proximal fifth metatarsal – Keeping up with the Joneses. Bulletin of the NYU Hospital for Joint Diseases 2012; 70(1): 49-55.
  36. ↑ Simons SM, Foot injuries in the runner. In: O’Conner FG, Wilder RP, eds. Textbook of Running Medicine. New York, N.Y.: McGraw-Hill, 2001: 213-26.
  37. ↑ Singer G, Cichocki M, Schalamon J et al., A study of metatarsal fractures in children. J Bone Joint Surg Am 2008; 90(4): 772-776.
  38. ↑ Hatch RL, Alsobrook JA, Clugston JR, Diagnosis and Management of Metatarsal Fractures. American Academy of Family Physicians 2007; 76 (6).
  39. ↑ Ding BC, Weatherall JM, Mroczek KJ et al., Fractures of the proximal fifth metatarsal – Keeping up with the Joneses. Bulletin of the NYU Hospital for Joint Diseases 2012; 70(1): 49-55.
  40. ↑ Anderson LD. Injuries of the forefoot. Clinical Orthopedics (1977); 122: 18-27.
  41. ↑ Dameron TB, Fractures and anatomic variations of the proximal portion of the fifth metatarsal. American Journal of Bone an Joint Surgery (1975); 57(6): 788-792.
  42. ↑ . Hellpap W, The neglected lower ankle. The ”fracture“ line of supination. Arch Orthop Unfallchir (1963); 55: 289-300.
  43. ↑ Quil GEJ, Fractures of the proximal fifth metatarsal. Orthopedic Clinics of North America (1995); 26: 353-361.
  44. ↑ Hatch RL, Alsobrook JA, Clugston JR, Diagnosis and Management of Metatarsal Fractures. American Academy of Family Physicians 2007; 76 (6).
  45. ↑ Ding BC, Weatherall JM, Mroczek KJ et al., Fractures of the proximal fifth metatarsal – Keeping up with the Joneses. Bulletin of the NYU Hospital for Joint Diseases 2012; 70(1): 49-55.
  46. ↑ Burge AJ, Gold SL, Potter HG, Imaging of sports-related midfoot and forefoot injuries. Sports Health 2012; 4(6): 518-534.
  47. ↑ Kavanaugh JH, Brower TD, Mann RV, The Jones fracture revisited, J Bone Joint Surg Am 1978; 60: 776-82.
  48. ↑ Hatch RL, Alsobrook JA, Clugston JR, Diagnosis and Management of Metatarsal Fractures. American Academy of Family Physicians 2007; 76 (6).
  49. ↑ Fractures of the Fifth Metatarsal. (2013). Geraadpleegd op 20 november 2013, op http://www.foothealthfacts.org/Content.aspx?id=1416
  50. ↑ Stiell IG, Greenberg GH, McKnight RD, Nair RC, McDowell I, Reardon M, et al., Decision rules for the use of radiography in acute ankle injuries. Refinement and prospective validation. JAMA 1993; 269: 1127-32.
  51. ↑ Asal W, Überlastungsschäden am Knochensystem bei Soldaten. Langenbecks Arch Chir (1936); 186: 511-522.
  52. ↑ Stiell IG, Greenberg GH, McKnight RD, Nair RC, McDowell I, Reardon M, et al., Decision rules for the use of radiography in acute ankle injuries. Refinement and prospective validation. JAMA 1993; 269: 1127-32.
  53. ↑ Hatch RL, Alsobrook JA, Clugston JR, Diagnosis and Management of Metatarsal Fractures. American Academy of Family Physicians 2007; 76 (6).
  54. ↑ Metatarsal stress fractures – aftercare. (2009). Geraadpleegd op 20 november 2013, op http://www.nlm.nih.gov/medlineplus/ency/patientinstructions/000553.htm
  55. ↑ Metatarsal stress fractures – aftercare. (2009). Geraadpleegd op 20 november 2013, op http://www.nlm.nih.gov/medlineplus/ency/patientinstructions/000553.htm
  56. ↑ Metatarsal stress fractures – aftercare. (2009). Geraadpleegd op 20 november 2013, op http://www.nlm.nih.gov/medlineplus/ency/patientinstructions/000553.htm
  57. ↑ Metatarsal stress fractures – aftercare. (2009). Geraadpleegd op 20 november 2013, op http://www.nlm.nih.gov/medlineplus/ency/patientinstructions/000553.htm
  58. ↑ Lehman RC, Torg, JS, Pavlov H, et al., Fractures of the base of the fifth metatarsal distal to the tuberosity: a review. Foot Ankle (1987); 7: 245-252.
  59. ↑ Fractures of the Fifth Metatarsal. [Foto]. (2013). Geraadpleegd op 20 november 2013, op http://www.foothealthfacts.org/Content.aspx?id=1416
  60. ↑ Fractures of the Fifth Metatarsal. [Foto]. (2013). Geraadpleegd op 20 november 2013, op http://www.foothealthfacts.org/Content.aspx?id=1416
  61. ↑ Hatch RL, Alsobrook JA, Clugston JR, Diagnosis and Management of Metatarsal Fractures. American Academy of Family Physicians 2007; 76 (6).
  62. ↑ Ding BC, Weatherall JM, Mroczek KJ et al., Fractures of the proximal fifth metatarsal – Keeping up with the Joneses. Bulletin of the NYU Hospital for Joint Diseases 2012; 70(1): 49-55.
  63. ↑ Burge AJ, Gold SL, Potter HG, Imaging of sports-related midfoot and forefoot injuries. Sports Health 2012; 4(6): 518-534.
  64. ↑ Metatarsal fracture (acute) – aftercare. (2009). Geraadpleegd op 20 november 2013, op http://www.nlm.nih.gov/medlineplus/ency/patientinstructions/000571.htm
  65. ↑ Hatch RL, Alsobrook JA, Clugston JR, Diagnosis and Management of Metatarsal Fractures. American Academy of Family Physicians 2007; 76 (6).
  66. ↑ Ding BC, Weatherall JM, Mroczek KJ et al., Fractures of the proximal fifth metatarsal – Keeping up with the Joneses. Bulletin of the NYU Hospital for Joint Diseases 2012; 70(1): 49-55.
  67. ↑ Burge AJ, Gold SL, Potter HG, Imaging of sports-related midfoot and forefoot injuries. Sports Health 2012; 4(6): 518-534.
  68. ↑ Simons SM, Foot injuries in the runner. In: O’Conner FG, Wilder RP, eds. Textbook of Running Medicine. New York, N.Y.: McGraw-Hill, 2001: 213-26.
  69. ↑ Stiell IG, Greenberg GH, McKnight RD, Nair RC, McDowell I, Reardon M, et al., Decision rules for the use of radiography in acute ankle injuries. Refinement and prospective validation. JAMA 1993; 269: 1127-32.
  70. ↑ Hatch RL, Alsobrook JA, Clugston JR, Diagnosis and Management of Metatarsal Fractures. American Academy of Family Physicians 2007; 76 (6).
  71. ↑ 1. http://www.mdguidelines.com/fracture-metatarsal-bones/definition
  72. ↑ Wolfe MW, Uhl TL, Mattacola CG, McCluskey LC, Management of ankle sprains. (Published correction appears in Am Fam Physician 2001; 64:386) Am Fam Physician 2001; 63:93-104.
  73. ↑ 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
  74. ↑ Geyer M, Sander-Beuermann A, Wegner U, et al., Stress reactions and stress fractures in the high performance athlete: Causes, diagnosis and therapy. Unfallchirurg (1993); 96: 66-74.
  75. ↑ Harrington T, Crichton KJ, Anderson IF, Overuse ballet injury of the base of the second metatarsal: a diagnostic problem. American Journal of Sports Medicine (1993); 21(4): 591-598.
  76. ↑ 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
  77. ↑ 2. Para-basal metatarsal V fracture: conservative functional treatment Weinberg AM, Rzesacz EH, Illgner A, Reilmann H – Unfallchirurg 1993 Jul; 96(7):395-398
  78. ↑ 3.https://www.louortho.com/documents/GEQ%20Fx%20of%20Prox%205th%20Met%20artical.pdf
  79. ↑ 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 [A1]



Retrieved from "https://www.physio-pedia.com/index.php?title=Metatarsal_Fractures&oldid=85386"