forefoot fractures sean e. nork, md sean e. nork, md created march 2004; revised march 2006 &...
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Forefoot FracturesForefoot Fractures
Sean E. Nork, MDSean E. Nork, MD
Created March 2004; revised March 2006 & 2011Created March 2004; revised March 2006 & 2011
Foot Trauma and OutcomesTurchin et al, JOT, 199928 patients: Polytrauma +/- foot injury
Age, gender, ISS matched
Results:
SF-36 5/8 components worse with foot injury
WOMAC All 3 components worse with foot injury
Jurkovich et al, JT, 1995
Highest Sickness Impact Profile (SIP) @ 6 & 12 monthsPatients with foot trauma (compared to other lower
extremity injuries)
Foot FunctionFoot Function
Hindfoot:Hindfoot: Shock absorption, propulsion, Shock absorption, propulsion, decelerationdeceleration
Midfoot:Midfoot: Controls relationship between Controls relationship between hindfoot and forefoothindfoot and forefoot
Forefoot:Forefoot: Platform for standing and lever for Platform for standing and lever for push offpush off
Forefoot Function
• Platform for weight bearing
• Lever for propulsion
AnatomyFirst Metatarsal
Shorter & wider
Bears 1/3 body weight
Tendon attachments: (Tibialis Anterior & Peroneus Longus)
Tibialis Anterior: varus, supination, elevation
Peroneus Longus: valgus, pronation, depression
Lesser Metatarsals
More mobile medial to lateral
Bear 1/6 weight each
Intermetatarsal ligaments (2-3, 3-4,
4-5)
Anatomy: SesamoidsMedial (tibial) & Lateral (fibular)
Within FHB tendons
Articulate with 1st MT head
Weight bearing through sesamoids
Tibial Sesamoid: Tibial FHB
Abductor Hallucis
Fibular Sesamoid: Fibular FHB
Adductor HallucisDeep Tverse MT
ligament
Anatomy: Phalanges
Great toe (2)
Lesser toes (3 each)
FDB attaches @ intermediate
FDL/EDL attaches @ distal
BiomechanicsMetatarsal heads in contact with floor 60-80% of stance phase
Toes in contact with floor 75% of stance
phase
Cavanagh, PR, F&A, 1987Hughes, J, JBJS[Br], 1990
Cross-sectional Geometry of the Human Forefoot
Griffin & Richmond, Bone, 2005
Examines the relationship between external loads during walking & running and the geometrical
properties of the human forefoot
Metatarsals 2-4 are the weakest in most cross-sectional geometric properties
Metatarsal 2 (and 3 to a lesser extent) experience high peak pressures; this may explain the preponderance of stress fractures
in these metatarsals
Mechanisms of Injury: Forefoot
Industrial accidents
MVA (airbags)
Indirect (twisting injuries)
Other
Physical Examination
Gross deformity
Dislocations
Sensation
Capillary refill
Foot Compartments
RadiographsFoot trauma series
AP/lat/oblique
Don’t forget oblique
Sesamoid view
Tangential view (MT heads)
Contralateral foot films (comparison)
CT Scan (occasionally)
Treatment Principles: FootTreatment Principles: Foot
Hindfoot:Hindfoot: Protect subtalar, ankle and Protect subtalar, ankle and talonavicular jointstalonavicular joints
Midfoot:Midfoot: restore length and alignment of restore length and alignment of medial and lateral “columns”medial and lateral “columns”
Forefoot:Forefoot: Even weight distribution Even weight distribution
Treatment
Border Rays
First metatarsal
Fifth metatarsal
Dislocations
Multiple metatarsal shafts
Intraarticular fractures
First MT Shaft FracturesNondisplaced
Consider conservative treatment
Immobilization with toe plate
DisplacedMost require ORIF
Strong muscle forces (TA, PL)
Deformity common
Bears 2/6 body weight
ORIFPlate and screwsAnatomically reduceMay cross first MTP joint (temp)
First MT Base Fractures
Articular injuries
Frequently require ORIF
Fixation:
Spans TMT
Doesn’t span TMT
Temporarily Spans TMT
36 year old males/p MVC
Active
Note articularcomminution
After ORIF
Fixation Strategy
Direct ORIF of comminuted first MT base fractre
Temporary spanning acrossfirst TMT joint
43 year old male injured in a MVCObserve the articular segment impaction of the base of the first.
The first MT is shortened and dorsally displaced while the plantar ligaments remain attached.
The patient underwent ORIF of the base of the first metatarsal with spanning of the
first TMT, given the level of comminution observed. Additionally, temporary
spanning external fixation was used.
Radiographic appearance at 3 months
after removal of the external fixator and
metatarsal neck k-wire fixations.
Non-displaced Metatarsal Fractures 2-4
Single metatarsal fractures (non-displaced)
Treatment usually nonoperative
Symptomatic: hard shoe vs AFO vs cast vs elastic bandage
Multiple metatarsal fractures (non-displaced)
Usually symptomatic treatment (as above)
May require ORIF if other associated injuries
Minimally Displaced Lesser Metatarsal Fractures
Zenios et al, Injury 2005
Prospective and randomized (n=50)
Case vs elastic support bandage
MINIMALLY DISPLACED fractures
Higher AOFAS mid-foot scores at 3 months and less pain if treated with an elastic support
bandage.
Displaced Metatarsal Shaft FracturesSagittal plane displacement & angulation is most important.
Reestablish length, rotation, & declination
Dorsal deformity can produce transfer metatarsalgia
Plantar deformity can produce increased load at affected metatarsal
Treatment Options
Closed ReductionIntramedullary pinning with k-wire (0.054” or 0.062”)
Pinning of distal segment to adjacent metatarsalORIF with dorsal plate fixation
This patient sustained an open second metatarsal fracture in a crush injury. Given the soft tissue injury
and continued pressure on the dorsal skin, operative fixation was elected.
Fixation consisted of a dorsal 2.0 mm plate
application after appropriate irrigation of
the open fracture.
This patient was treated with ORIF of multiple
metatarsal fractures (3,4,5) through a dorsal
approach. Fixation consisted of a 2.7 mm
DCP on the fifth and 2.0 mm plates on the third and fourth metatarsals.
Medullary K-wires in Lesser MTs
Exit wire distally through the proximal phalanx
Plantar wire exit may produce a hyperextension deformity
of the MTP
ST Hansen, Skeletal Trauma
Compliments: Daphne Beingessner, MD
This patient sustained multiple metatarsal neck fractures (2, 3, 4) and a dislocation of the fifth MTP joint. Note the lateral translation, lateral
angulation, and the displacement on the lateral radiograph.
Compliments: Daphne Beingessner, MD
Stabilization consisted of closed reduction and percutaneous pin fixation of the multiple metatarsal fractures and closed reduction of the fifth MTP
dislocation. Note the location and trajectory of the K-wires.
Compliments: Daphne Beingessner, MD
Following healing and removal of the pins, good alignment of the forefoot is demonstrated on the multiple radiographic views.
Stress Fractures of Metatarsals 2 - 4
Identify CauseFirst ray hypermobility
Short first ray
Tight gastrocnemius
Long metatarsal
TreatmentTreat cause if identifiable
If overuse, activity restriction
Reserve ORIF for displaced fractures
Metatarsal Neck Fractures
Usually displace plantarly
May require reduction and fixation:
Closed reduction and pinning
Open reduction and pinning
ORIF (dorsal plate)
This patient sustained multiple metatarsal neck fractures after
an MVA. Note additional fractures at
the first and fifth metatarsals
Medullary wire fixation of
metatarsal neck fractures 2, 3, 4
Compliments of S.K. Benirschke
Metatarsal Head FracturesUnusual
Articular injuries
May require ORIF
(especially if first MT)Circular saw injury to the
articular surface of the first MT head
Fifth Metatarsal Fractures
Mid diaphyseal fractures
Stress fractures (proximal diaphysis)
Jones fractures (metadiaphyseal jxn)
Tuberosity fractures
Proximal Fifth Metatarsal FracturesDameron, TB, JAAOS, 1995
Zone 1 cancellous tuberosity
insertion of PB & plantar fascia
involves metatarsocuboid joint
Zone 2 distal to tuberosity
extends to 4/5 articulation
Zone 3 distal to proximal ligaments
usually stress fractures
extends to diaphysis for 1.5 cm
Proximal Fifth Metatarsal FracturesDameron, TB, JAAOS, 1995
Relative Frequency
Zone 1 93%
Zone 2 4%
Zone 3 3%
Fifth Metatarsal Blood SupplySmith, J et al, F&A, 1992
Cadaver Arterial Injection Study (n = 10)
Nutrient artery with intramedullary branches (retrograde flow to
proximal fifth metatarsal)
Multiple metaphyseal arteries
Conclusions: Fracture distal to the tuberosity disrupts the nutrient
arterial supply and creates relative avascularity
Shereff, M et al, F&A, 1991
Fresh leg specimens (after BKA) (n = 15)
Extraosseus circulation:dorsal metatarsal arteryplantar metatarsal arteryfibular plantar marginal
artery
Intraosseus circulation:Nutrient artery
Metaphyseal vesselsPeriosteal complex
Fifth Metatarsal Blood Supply
Smith et al, Foot Ankle 1993
Zone 1 Fractures: Tuberosity
Etiology
Avulsion from lateral plantar aponeurosis (Richli & Rosenthal, AJR, 1984)
Treatment
Symptomatic
Hard shoe
Healing usually uneventful (Dameron, T, JBJS, 1975)
Lawrence, SL, Foot Ankle, 1993
Zone 1 Fractures: TuberosityWeiner, et al, F & A Int, 1997
60 patients
Randomized to short leg cast vs soft dressing only
Weight bearing in hard shoe in all
Healing in 44(average) - 65(all) days
Soft dressing only: shorter recuperation (33 vs 46 days) and similar foot score (92 vs 86)
Conclusions: Faster return to function without compromising radiographic union or clinical outcome in patients treated
without casting.
Zone 1 Fractures: TuberosityEgol et al, F & A Int, 2007
50 fractures in 49 patients
Prospective outcomes study of fifth metatarsal base avulsion fractures
Protocol: hard shoe, weight bearing as tolerated
Average of 22 days lost from work
86% to pre-injury status at 6 months (only 20% at 3 months)
Conclusions: Fifth metatarsal base fractures associated with loss of work productivity. Return is expected but takes
significant time, with recovery of 6 months or longer in some patients
Zone 2 Fractures: Metadiaphyseal
Zone 2 Fractures: MetadiaphysealTreatment Controversial
Union frequently a concern
Early weight bearing associated with increased nonunion (Torg, Ortho, 1990; Zogby, AJSM, 1987)
Nondisplaced Fractures: Treatment
Cast with non weight bearing (Shereff, Ortho, 1990; Heckman, 1984; Hens, 1990;
Lawrence, 1993)
Cast with weight bearing(Kavanaugh, 1978; Dameron, 1975)
Zone 2 Fractures: MetadiaphysealOperative Treatment
Medullary Screw Stabilization(Delee, 1983; Kavanaugh, 1978; Dameron, 1975)
Bone Graft Stabilization(Dameron, 1975; Hens, 1990; Torg, 1984)
Zone 2 Fractures: Metadiaphyseal
Operative Treatment
Medullary Screw Stabilization
Bone Graft Stabilization
Lehman, Foot Ankle 1987
Zone 2 Fractures: Metadiaphyseal
Operative Treatment
Biomechanical Comparison of Screws(Sides et al, Foot & Ankle Int, 2006)
Compared 6.5 mm cancellous screw and variable pitch, tapered screw
CONCLUSIONS: Headless, tapered, variable pitch compression screws of the size tested are not entirely comparable to 6.5-mm lag screws in this application. They are effective in resisting bending but do not offer
equivalent resistance to thread pull-out.
Recent Review:Zwitser and Breederveld, Injury, 2009
Fracture of the fifth metatarsal: Diagnosis and Treatment
Tuberosity fractures:Non-displaced treated non-operatively
If displaced >2mm or with >30% of the cubometatarsal joint, operative treatment
Shaft fractures:Non-displaced treated non-operatively
If displaced >3 or 4mm or >10 degrees angulation, consider operative treatment
Recent Review:Zwitser and Breederveld, Injury, 2009
Recent Review:Zwitser and Breederveld, Injury, 2009
Comminuted fracture of the base of the fifth metatarsal
After ORIF of the fifth metatarsal
MTP Joint Injuries
Sprains“Turf Toe”: hyperextension with injury to
thee plantar plate
Hyperflexion sprains
Dislocations
First MTP DislocationsJahss, F&A, 1980
Type I: Hallux dislocation without disrupting sesamoid
Irreducible closed!
MT incarcerated by conjoined tendons and intact sesamoid
Open reduction required (dorsal, plantar, or medial approach)
Type II: Disruption of intersesamoid ligament (type A)
Transverse fracture of one of the sesamoids (type B)
Usually stable after reduction
Treatment usually conservative and symptomatic (hard shoe for 4-6 weeks)
Lesser MTP DislocationsUncommon
Dorsal vs Lateral
Usually stable post reduction
Rarely require open reduction
If unstable post reduction, consider k-wire fixation
Fractures of the Great Toe
Proximal Phalanx FracturesORIF for transverse & displaced (?)
ORIF intraarticular fractures (?)
Interphalangeal Joint FracturesNonoperative treatment usually
Distal Phalanx FracturesTaping usually adequate
Hard shoe
Sesamoid InjuriesSesamoiditis
Acute fractures
Stress fractures in dancers and runners
TreatmentAcute: padding
strap MTP @ neutral or slight flexion
immobilization in cast/shoeChronic: consider bone grafting
sesamoidectomy: not a simple procedure, assoc with hallux drift and transfer lesions, requires tendon (FHB) repair.
Fractures of the LesserToes
Correct alignment & rotation
Attempt taping to adjacent toe
May require open reduction and pinning if adequate reduction
not obtained
ST Hansen, Skeletal Trauma
Newer ImplantsLocking plates
May be useful in patients with osteoporosis or comminuted fractures that require spanning fixation from the metatarsals to the midfoot.
Not needed in routine fractures of the foot.
Anatomic platesCuboid specific plates
Navicular specific plates
both may be useful for complex fractures of these bones
Compliments: Steve Benirschke, MD
This patient sustained a complex constellation of injuries to the midfoot and the metatarsals. Additionally, there are associated fractures of the cuboid. This has
resulted in lateral translation of the forefoot.
Compliments: Steve Benirschke, MD
Stabilization consisted of fixation of all components of the injury including the cuboid fracture, the multiple LisFranc joint dislocations, and fixation of the third
metatarsal base fracture. Because of the comminution at the base of the third metatarsal, a locking implant was used.
This patient was referred after temporary stabilization of a comminuted first metatarsal base fracture
Compliments: Steve Benirschke, MD
Compliments: Steve Benirschke, MD
Because of the significant intraarticular involvement of the base of the first, fixation consisted of a direct reduction of the articular surface combined with
spanning of the first TMT joint. A locking plate was used to ensure maintenance of length of the medial column given the limited fixation possibilities in the
medial cuneiform
The Crushed Foot
Soft Tissue EvaluationSoft Tissue Evaluation
Assess whether salvageableAssess whether salvageable– sensate, perfused, adequate plantar tissuesensate, perfused, adequate plantar tissue
Wash open woundsWash open wounds
Reposition bone deformity that threatens Reposition bone deformity that threatens the skinthe skin
Reduce dislocationsReduce dislocations
Release compartments as neededRelease compartments as needed
Compliments: Steve Benirschke, MD
This patient’s multiple and complex fractures of the midfoot (and calcaneus; and pilon) were sequentiallly fixed. Because of the significant comminution of the
fourth metatarsal, a locking plate was used.
Recommended ReadingsCavanaugh, PR, et al. Pressure Distribution Patterns under Symptom-free
Feet during barefoot standing. Foot Ankle, 7:262-276, 1987
Dameron, TB, Fractures of the Proximal Fifth Metatarsal: Selecting the Best Treatment Option. J Acad Orthop Surg, 3(2): 110-114, 1995.
Holmes, James. AAOS Monograph “The Traumatized Foot”, pages 55-75, 2002.
Lawrence, SJ, and Botte, MJ. Foot Fellow’s Review: Jones’ Fractures and Related Fractures of the Proximal Fifth Metatarsal. Foot & Ankle, 14(6),
358-365, 1987.
Smith, JW, et al. The Intraosseus Blood Supply of the Fifth Metatarsal: Implications for Proximal Fracture Healing. Foot & Ankle, 13(3), 143-
152, 1992
Recommended ReadingsAdelaar, RS: Complications of forefoot and midfoot fractures. Clin Orthop
Relat Res, (391): 26-32, 2001.
Armagan, OE, and Shereff, MJ: Injuries to the toes and metatarsals. Orthop Clin North Am, 32(1): 1-10, 2001.
Griffin, NL, and Richmond, BG: Cross-sectional geometry of the human forefoot. Bone, 37(2): 253-60, 2005.
Mittlmeier, T, and Haar, P: Sesamoid and toe fractures. Injury, 35 Suppl 2: SB87-97, 2004.
Zenios, M; Kim, WY; Sampath, J et al.: Functional treatment of acute metatarsal fractures: a prospective randomised comparison of
management in a cast versus elasticated support bandage. Injury, 36(7): 832-5, 2005.
Recent Literature1. Blundell, C. M.; Nicholson, P.; and Blackney, M. W.: Percutaneous screw fixation for fractures of
the sesamoid bones of the hallux. J Bone Joint Surg Br, 84(8): 1138-41, 2002.
2. Dalal, R., and Mahajan, R. H.: Single transverse, dorsal incision for lesser metatarsophalangeal exposure. Foot Ankle Int, 30(3): 226-8, 2009.
3. Den Hartog, B. D.: Fracture of the proximal fifth metatarsal. J Am Acad Orthop Surg, 17(7): 458-64, 2009.
4. Egol, K.; Walsh, M.; Rosenblatt, K.; Capla, E.; and Koval, K. J.: Avulsion fractures of the fifth metatarsal base: a prospective outcome study. Foot Ankle Int, 28(5): 581-3, 2007.
5. Leumann, A.; Pagenstert, G.; Fuhr, P.; Hintermann, B.; and Valderrabano, V.: Intramedullary screw fixation in proximal fifth-metatarsal fractures in sports: clinical and biomechanical analysis. Arch
Orthop Trauma Surg, 128(12): 1425-30, 2008.
6. Raikin, S. M.; Slenker, N.; and Ratigan, B.: The association of a varus hindfoot and fracture of the fifth metatarsal metaphyseal-diaphyseal junction: the Jones fracture. Am J Sports Med, 36(7): 1367-
72, 2008.
7. Sides, S. D.; Fetter, N. L.; Glisson, R.; and Nunley, J. A.: Bending stiffness and pull-out strength of tapered, variable pitch screws, and 6.5-mm cancellous screws in acute Jones fractures. Foot Ankle
Int, 27(10): 821-5, 2006.
8. Zwitser, E. W., and Breederveld, R. S.: Fractures of the fifth metatarsal; diagnosis and treatment. Injury, 2009.
Sean E. Nork, MDSean E. Nork, MD
Harborview Medical CenterHarborview Medical Center
University of WashingtonUniversity of Washington
HMC FacultyHMC Faculty
Barei, Beingessner, Bellabarba, Benirschke, Chapman, Barei, Beingessner, Bellabarba, Benirschke, Chapman, Dunbar, Hanel, Hanson, Henley, Krieg, Routt, Dunbar, Hanel, Hanson, Henley, Krieg, Routt,
Sangeorzan, Smith, TaitsmanSangeorzan, Smith, Taitsman
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