Metatarsal Bone Fractures – Causes, Symptoms, Treatment

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Metatarsal Bone Fractures are relatively common in football and are typically caused either by a direct blow or by a twisting injury. Pain and tenderness over the fifth metatarsal following inversion injury should prompt investigation for a fracture. This fracture can present in the football player’s foot as an avulsion fracture, Jones fracture or metaphyseal fracture and is often difficult to treat. Most other metatarsal fractures heal relatively predictably.

Metatarsal fractures are relatively common and if malunited, a frequent source of pain and disability. Nondisplaced fractures and fractures of the second to the fourth metatarsal with displacement in the horizontal plane can be treated conservatively with protected weight-bearing in a cast shoe for 4-6 weeks. In most displaced fractures, the closed reduction can be achieved but the maintenance of the reduction needs internal fixation. Percutaneous pinning is suitable for most fractures of the lesser metatarsals. Fractures with joint involvement and multiple fragments frequently require open reduction and plate fixation. Transverse fractures at the metaphyseal-diaphyseal junction of the fifth metatarsal (“Jones fractures”) require an individualized approach tailored to the level of activity and time to union.

Fractures of the fifth metatarsal are common injuries that must be recognized and treated appropriately to avoid poor clinical outcomes for the patient. Since orthopedic surgeon Sir Robert Jones first described these fractures in 1902, there has been an abundance of literature focused on the proximal aspect of the fifth metacarpal due to its tendency towards poor bone healing. Nevertheless, it is critical that the physician recognizes all injury patterns of the fifth metatarsal and initiate the appropriate treatment plan or referral process to avoid potential complications.

Alternative Names

Broken foot – metatarsal; Jones fracture; Dancer’s fracture; Foot fracture

Types of Metatarsal Fractures

Classified by Lawrence and Bottle, the base, or proximal aspect, of the fifth metatarsal is broken up into three anatomical zones:

  • zone 1 – the tuberosity;
  • zone 2 – the metaphyseal-diaphyseal junction; and
  • zone 3 – the diaphyseal area within 1.5 cm of the tuberosity. Fractures through zone 1 have the name to as pseudo-Jones fractures, and fractures through zone 2 are referred to as Jones fractures. Additionally, a patient may sustain a shaft fracture greater than 1.5 cm distal to the tuberosity, a long spiral fracture extending into the distal metaphyseal area, the so-called dancer’s fracture, or a stress fracture of the metatarsal.

Classification of these fractures is crucial to making management decisions. Metaphyseal arteries and diaphyseal nutrient arteries provide the blood supply to the fifth metatarsal base. The avascular watershed area exists in zone 2, contributing to the high nonunion rates seen with these fractures.

The radiographic appearance of fifth metatarsal base stress fractures classify into three types based on the Torg classification system

Type I fractures:

  • Early
  • No intramedullary sclerosis
  • Sharp fracture line with no widening
  • Minimal cortical hypertrophy
  • Minimal periosteal reaction

Type II:

  • Delayed
  • Evidence of intramedullary sclerosis
  • Widened fracture line with the involvement of both cortices
  • Periosteal reaction present

Type III:

  • Nonunion
  • Complete obliteration of the medullary canal by sclerotic bone
  • Wide fracture line with new periosteal bone

Are there different types of a break?

Breaks (fractures) can be acute or caused immediately by injury. They can also occur over a longer period of time, when they are called stress fractures.

  • Acute metatarsal fracture – is usually caused by a sudden forceful injury to the foot, such as dropping a heavy object on to the foot, a fall, kicking against a hard object when tripping, or from a sporting injury.An acute metatarsal fracture may be open or closed, and displaced or not displaced:
    • Open or closed – an open fracture is one where the skin is broken over the fracture so that there is a route of possible infection from the outside into the broken bones. This is a more serious type of fracture, with more damage to the soft tissues around it making treatment and healing more complicated. A specialist assessment is needed.
    • Displaced or not displaced – a displaced fracture is one where, following the break, the bones have slipped out of line. A displaced fracture needs specialist care, as the bones will need to be properly lined up and stabilized. This may involve an anesthetic and some kind of metal pinning or plating to the bones.
  • A stress fracture – is a hairline break in a bone, caused by repetitive stress. This is cracking which goes only partway through the bone. There may be a single split in the bone or multiple small splits. The hairline break or breaks do not go through the full thickness of the bone, so stress fractures are not generally displaced. However, several small stress fractures can develop around the same area, over time.
  • Avulsion Fractures – The avulsion fracture is by far the most common fifth metatarsal fracture. They occur at the bottom-most portion of the bone. They are frequently confused with Jones fractures and are often referred to as pseudo-Jones fractures.
  • Jones Fracture – The Jones fracture is the most notorious fifth metatarsal fracture because it is very difficult to heal. The Jones fracture occurs near the bottom of the bone at an anatomic location called the metaphyseal-diaphyseal junction. This area of bone is thought to have less blood supply than other bones, impeding the rate of healing (particularly if the fracture further impedes circulation).
  • Dancer’s Fracture – The dancer’s fracture has become a universal term for any fifth metatarsal fracture, but foot surgeons generally reserve for fracture of a specific orientation. A true dancer’s fracture occurs mostly in the middle tissues of the long metatarsal bone and will be oriented obliquely in the shaft of the bone. The fracture line may even spiral and rotate throughout the bone. Sometimes the dancer’s fracture can cause the bone to chip into smaller pieces (called comminution).

Causes of Metatarsal Fractures

Zone 1 fractures are tuberosity avulsion fractures, also called pseudo-Jones fractures, and occur when the hindfoot gets forced into inversion during plantarflexion. This acute injury pattern may occur after an athlete lands awkwardly after a jump. These fractures rarely involved the fifth tarsometatarsal joint and lay proximal to the fourth and/or fifth intermetatarsal joint

  • Zone 2 injuries – have the name Jones fractures. These acute injuries may occur with a significant adduction force to the foot with a lifted heel. This type of injury pattern can occur with a sudden change of direction by an athlete. These fractures usually involve the fourth and/or fifth metatarsal articulation and have nonunion rates as high as 15 to 30%.
  • Zone 3 injuries – are chronic injuries of repetitive microtrauma, causing increasing pain with activity over months. There is an increased risk of nonunion with these fractures.
  • The dancer’s fracture – or long spiral fracture of the distal metatarsal, is typically caused by the dancer rolling over their foot while in the demi-pointe position or sustained while landing a jump.

Symptoms of Metatarsal Fractures

Symptoms of stress fractures include

  • Pain with or after normal activity
  • Pain that goes away when resting and then returns when standing or during activity
  • Pinpoint pain (pain at the site of the fracture) when touched
  • Swelling but no bruising
  • Bruising or discoloration that extends to nearby parts of the foot
  • Pain with walking and weight-bearing
  • Swelling in the heel area
  • Pain at the site of the fracture, which in some cases can extend from the foot to the knee.
  • Significant swelling, which may occur along the length of the leg or maybe more localized.
  • Blisters may occur over the fracture site. These should be promptly treated by a foot and ankle surgeon.
  • Bruising that develops soon after the injury.
  • Inability to walk; however, it is possible to walk with less severe breaks, so never rely on walking as a test of whether or not a bone has been fractured.
  • Change in the appearance of the ankle—it will look different from the other ankle.
  • Bone protruding through the skin—a sign that immediate care is needed. Fractures that pierce the skin require immediate attention because they can lead to severe infection and prolonged recovery.
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Diagnosis of Metatarsal Fractures

History and Physical

  • These patients typically present with pain about the lateral aspect of the forefoot that is worse with weight-bearing activity. This pain may occur in the setting of acute trauma or repetitive microtrauma over weeks to months. One should be suspicious of stress fracture with antecedent pain or pain of worsening quality or duration over time. The examiner must obtain a thorough past medical history and social history to make treatment decisions and optimize patients with surgical indications. It is important to evaluate the skin for open injuries that may require more urgent debridement.
  • Physical examination may reveal tenderness to palpation, swelling, and ecchymosis at the site of injury. Patients will also have pain with resisted foot eversion. It is critical to evaluate the patient for other injuries, including injury to the lateral ankle ligamentous structures and Lisfranc injury.
  • An exam of the circulatory system, feeling for pulses, and assessing how quickly blood returns to the tip of a toe after it is pressed and the toe turns white (capillary refill).
  • A neurologic exam, assessing sensation such as light touch and pin prick sensations
  • Motor function, asking the patient to move the injured area. This assists in assessing muscle and tendon function. The ability to move the foot means only that the muscles and tendons work, and does not guarantee bone integrity or stability. The concept that “it can’t be broken because I can move it” is not correct.
  • A range of motion exam of the foot may be helpful in assessing ligament stability. However, if the fracture is obvious, the health care practitioner may choose to keep the foot immobilized to prevent further pain.

Evaluation

Radiographs are the initial imaging of choice used to evaluate for these injuries. AP, lateral, and oblique images of the foot are essential to making the diagnosis. In zone 1 injuries, the medial fracture line lies proximal to the fourth to the fifth intermetatarsal joint. In zone 2 injuries, the medial fracture line extends towards or even into the fourth and/or fifth intermetatarsal joint. In zone 3 injuries, the medial fracture line will typically exit distal to the fourth and/or fifth intermetatarsal joint, but some may be more proximal. The usual fracture pattern seen in dancer fractures is an oblique spiral fracture beginning distal and lateral and extending proximal and medial. Other distal diaphyseal fractures are generally seen on radiographs running in the transverse plane.

Imaging

  • X-rays – are often taken to evaluate the status of the bones in the foot and to check for a fracture. Usually, three views are taken to help the health care professional and radiologist adequately view the bones. Special views may be taken if there is a concern for a fracture of the calcaneus. X-rays may not be taken for simple toe injuries, since the result may not affect the treatment plan.
  • For some foot fractures, X-rays – may not be adequate to visualize the injury. This is often true for metatarsal stress fractures, where bone scans may be used if the history and physical examination suggest a potential stress fracture, but the plain X-rays are normal.
  • Computerized tomography (CT) – may be used to assess fractures of the calcaneus and talus, since it may better be able to illustrate the anatomy of the ankle and midfoot joint and potential associated injuries. Magnetic resonance imaging (MRI) may be used in some cases of foot fractures.
  • The Lisfranc joint describes  – the connection between the first, second, and third metatarsals and the three cuneiform bones. A Lisfranc fracture-dislocation often requires a CT scan to evaluate this region of the foot. While X-rays may hint at the damage in this type of injury, the CT scan delineates the numerous bones and joints that may be damaged.

Metatarsal fractures

Treatment of Metatarsal Fractures

Fractures of the toe bones are almost always traumatic fractures. Treatment for traumatic fractures depends on the break itself and may include these options:

Initial Treatment Includes

  • Get medical help immediately – If you fall on an outstretched leg, get into a car accident or are hit while playing a sport and feel intense pain in your leg area, then get medical care immediately. Cause significant pain in the front part of your leg closer to the base of your leg. You’ll innately know that something is seriously wrong because you won’t be able to lift your leg up above the heart level. Cleaning and treating any wounds on the skin of the injured hand.
  • Aggressive wound care – as needed for contaminated wounds. Clear with disinfectant material 
  • ICE and elevation – It help for prevention swelling, edema
  • Rest – Sometimes rest is all that is needed to treat a traumatic fracture of the toe.mSometimes rest is the only treatment needed to promote healing of a stress or traumatic fracture of a metatarsal bone.
  • Elevation – Elevation initially aims to limit and reduce any swelling. For example, keep the foot up on a chair to at least hip level when you are sitting. When you are in bed, put your foot on a pillow. Sometimes rest is the only treatment that is needed, even in traumatic fracture.
  • Splinting – The toe may be fitted with a splint to keep it in a fixed position.
  • Rigid or stiff-soled shoes – Wearing a stiff-soled shoe protects the toe and helps keep it properly positioned. Use of a postoperative shoe or boot walker is also helpful.
  • Buddy taping the fractured toe to another toe is sometimes appropriate, but in other cases, it may be harmful.
  • Avoid the offending activity – Because stress fractures result from repetitive stress, it is important to avoid the activity that led to the fracture. Crutches or a wheelchair are sometimes required to offload weight from the foot to give it time to heal.
  • Immobilization, casting, or rigid shoe – A stiff-soled shoe or another form of immobilization may be used to protect the fractured bone while it is healing. The use of a postoperative shoe or boot walker is also helpful.
  • Casting, or rigid shoe A stiff-soled shoe or another form of immobilization may be used to protect the fractured bone while it is healing. The use of a postoperative shoe or boot walker is also helpful.
  • Stop stressing the foot – If you’ve been diagnosed with a stress fracture, avoiding the activity that caused it is important for healing. This may mean using crutches or even a wheelchair.

Medication

The following medications may be considered doctor to relieve acute and immediate pain

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Surgery

Treatment decisions have their basis on the anatomic zone of injury, the social and medical history of the injured patient, and evidence of radiographic signs of healing.

  • Nondisplaced zone 1 injuries – can be treated conservatively with protected weight-bearing in a hard-soled shoe, walking boot, or walking cast. Progression to weight-bearing as tolerated can initiate as pain and discomfort subside over 3 to 6 weeks. Fractures involving 30% of the articular surface or with an articular step off over 2 mm have treatment with open reduction and internal fixation, closed reduction, and percutaneous pinning, or excision of the fragment.
  • Nondisplaced zone 2 injuries or Jones fractures – may also be treated conservatively with 6 to 8 weeks of non-weight bearing in a short leg cast. The physician may advance weight-bearing status as radiographic evidence of bone healing appears. Indications for surgical interventions include the high-performance athlete, the informed patient who elects to proceed with surgical treatment, or displaced fractures. There are many forms of surgical interventions, including intramedullary screw fixation, tension band constructs, and low profile plates and screws. Surgical management of high-performance athletes minimizes the risk of nonunion and prevents prolonged restriction from physical activity.
  • Diaphyseal zone 3 stress fractures – paint a more complicated picture for the patient and physician. A trial of conservative management with non-weight bearing in a short leg cast may be the initial therapy, however, immobilization for up to 20 weeks may be necessary before there is observable radiographic union, and even then, nonunion development is not uncommon. High-performance athletes or individuals with Torg Type II or III fractures may require surgical interventions. Surgical options include intramedullary screw fixation, bone grafting procedures, or a combination of the two.
  • The bone grafting inlay technique – requires removing a 0.7 by 2.0 cm rectangular section of bone at the fracture site and replacing it with an autogenous corticocancellous bone graft of the same dimensions taken from the anteromedial distal tibia. The medullary cavity must be curetted or drilled until all of the sclerotic bone has been removed and the medullary canal reestablished prior to inserting the donor graft.
  • Nondisplaced dancer’s fractures – and other fractures of the fifth metatarsal shaft and neck receive the same treatment as nondisplaced zone 1 injuries. Weight-bearing status can advance as tolerated by pain. If evidence of delayed union or nonunion exists, surgical interventions may be required. If there is more than 3 mm of displacement or angulation exceeds 10 degrees, the fracture should be reduced and splinted. If the fracture remains malreduced or there is evidence of loss of reduction on follow-up radiographs, surgical interventions with percutaneous pinning or plate and screw fixation should be a consideration.

Patients treated with intramedullary screw fixation or bone graft inlay technique should remain non-weight bearing in a plaster splint or short leg cast for six weeks with a gradual return to sport or activity.

Other Treatments

Bisphosphonates

Bisphosphonates have the potential to decrease the incidence of stress fractures by decreasing bone turnover by inhibiting osteoclast function. However, a prospective, randomized trial of 324 military recruits showed no difference in the incidence of stress fractures of the lower extremities between those receiving prophylactic risedronate and placebo. There was a trend toward a harmful effect of alendronate treatment in an animal study, possibly due to inhibition of remodeling of microfractures from woven to lamellar bone. The 25-year experience of the Israeli Army on prevention of stress fractures showed sleep minimums and training modifications, but not bisphosphonate treatment, decreased the incidence of stress fractures.

Bone Stimulators

There are 2 types of stimulators, electromagnetic stimulators and ultrasound simulators.

Electromagnetic stimulators generate electromagnetic fields with coils on either side of the fracture. Mechanical stresses cause fluid flow around and through bones that induce electrical currents around cells, which can open calcium channels in cell membranes increasing calmodulin, thus increasing cell proliferation. Very few controlled studies are available that evaluate the efficacy of these stimulators in stress fractures. One such study found no significant difference in time to healing between placebo and those using an electromagnetic simulator. However, when higher grade stress fractures were compared exclusively, there was a significantly shorter time to healing noted, though power was not sufficient to draw conclusions. When compliance was adequate, electromagnetic stimulators correlated to shorter healing times. Despite some early promising results, electromagnetic stimulators have not been shown conclusively to enhance healing in stress fractures.

Pulsed ultrasound bone stimulators can increase vascular endothelial growth factor (VEGF) and fibroblast growth factor (FGF), which promote angiogenesis, and increase alkaline phosphatase, bone sialoprotein, and intracellular calcium (markers of bone metabolism). Most studies report on acute fractures. A systematic review of pulsed ultrasound showed low to moderate grade evidence for a positive effect: there was a 33.6% decrease in radiographic healing time. Stress fractures may respond differently to pulsed ultrasound because they heal through intramembranous remodeling instead of endochondral remodeling as acute fractures do. Literature specifically on stress fractures treated with pulsed ultrasound is sparse. In a military study of 43 tibial shaft stress fractures, there was no significant difference in time to healing using low-intensity pulsed ultrasound. In a rat ulnar stress fracture model, low-intensity pulsed ultrasound alone produced better results than ultrasound and NSAIDs combined as well as controls.

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Oral Contraceptives

Low levels of sex steroids are associated with low bone mineral density. Abnormally low levels of sex hormones are seen for 24 to 48 hours in endurance athletes following rigorous training sessions, and secondary amenorrhea causes a hormone-deficient state. Hormone replacement therapy via oral contraceptive pills (OCPs) is controversial. Data suggest that hormone replacement in amenorrheic women and endurance athletes improves bone mineral density. A randomized study of 150 young female runners with low-dose OCP or no treatment showed that oligo- and amenorrheic runners who used OCPs gained 1% bone mineral density (BMD) per year. Stress fracture incidence trended lower in the OCP group, but was not significant. A military study of female recruits found a fivefold increase in lower extremity stress fractures in women who had been amenorrheic, though OCP use did not have a significant protective effect.

If OCPs are used in exercise-induced hypoestrogenic amenorrhea, other factors such as nutrition status or other hypothalamic perturbations should be worked up and may require treatment, as energy status, calcium intake, and body mass index have proven to be independent predictors of improved BMD and normal bone turnover.

Calcium and Vitamin D

Calcium and vitamin D can improve BMD but are not definitively proven to prevent stress fractures., In track and field athletes and military recruits, no significant difference was found with increased calcium and vitamin D intake and incidence of all types of stress fractures. One of the largest studies on the topic showed that in female military recruits, 2000 mg of calcium and 800 IU of vitamin D daily had a 20% lower incidence of stress fractures during basic training than those taking a placebo. Another group found that each cup of skim milk consumed daily by female distance runners lowered the rate of stress fracture by 62%. These reports support several previous studies suggesting that low dietary calcium and vitamin D is associated with increased risk of stress fracture, and adequate intake or supplementation can reduce the risk of stress fractures., The recommended daily dose of calcium depends on age, while vitamin D intake is more controversial. A specific amount of calcium and vitamin D needed to prevent stress fractures has not been determined. In some studies, daily supplementation of 500 to 800 mg of calcium and 400 to 800 IU vitamin D improves BMD and decreases fracture (not specifically stress fracture) risk significantly.,

Calcitonin

Calcitonin inhibits osteoclasts, the offending agent in the imbalanced remodeling process of stress fractures.,, Increased BMD and biomechanical properties has been shown with calcitonin, but its role in stress fracture prevention or healing is controversial.,,

Orthotics

Several biomechanical studies have shown predictable, repetitive stress patterns in the foot and ankle with weight-bearing., However, there is inconclusive data to support orthotics for the prevention of stress fractures of the foot and ankle. A systematic review of 5 articles on orthotics and stress fractures concluded that orthotic use reduced the overall rate of stress fractures of the proximal femur and tibia in military personnel; no conclusion could be made regarding prevention in stress fractures of the foot and ankle.

More About Your Injury

  • There are five metatarsal bones in your foot. The 5th metatarsal is the outer bone that connects to your little toe. It is the most commonly fractured metatarsal bone.
  • A common type of break in the part of your 5th metatarsal bone closest to the ankle is called a Jones fracture. This area of the bone has low blood flow. This makes healing difficult.
  • An avulsion fracture occurs when a tendon pulls a piece of bone away from the rest of the bone. An avulsion fracture on the 5th metatarsal bone is called a “dancer’s fracture.”

What to Expect

If your bones are still aligned (meaning that the broken ends meet), you will probably wear a cast or splint for 6 to 8 weeks.

  • You may be told not to put weight on your foot. You will need crutches or other support to help you get around.
  • You may also be fitted for a special shoe or boot that may allow you to bear weight.

If the bones are not aligned, you may need surgery. A bone doctor (orthopedic surgeon) will do your surgery. After surgery you will wear a cast for 6 to 8 weeks.

Relieving Your Symptoms

You can decrease swelling by:

  • Resting and not putting weight on your foot
  • Elevating your foot

Make an ice pack by putting ice in a plastic bag and wrapping a cloth around it.

  • DO NOT put the bag of ice directly on your skin. Cold from the ice could damage your skin.
  • Ice your foot for about 20 minutes every hour while awake for the first 48 hours, then 2 to 3 times a day.

For pain, you can use ibuprofen (Advil, Motrin, and others) or naproxen (Aleve, Naprosyn, and others).

  • DO NOT use these medicines for the first 24 hours after your injury. They may increase the risk of bleeding.
  • Talk with your health care provider before using these medicines if you have heart disease, high blood pressure, kidney disease, liver disease, or have had stomach ulcers or internal bleeding in the past.
  • DO NOT take more than the amount recommended on the bottle or more than your provider tells you to take.

Activity

As you recover, your provider will instruct you to begin moving your foot. This may be as soon as 3 weeks or as long 8 weeks after your injury.

When you restart an activity after a fracture, build up slowly. If your foot begins to hurt, stop and rest.

Some exercises you can do to help increase your foot mobility and strength are:

  • Write the alphabet in the air or on the floor with your toes.
  • Point your toes up and down, then spread them out and curl them up. Hold each position for a few seconds.
  • Put a cloth on the floor. Use your toes to slowly pull the cloth toward you while you keep your heel on the floor.

Follow-up

As you recover, your provider will check how well your foot is healing. You will be told when you can:

  • Stop using crutches
  • Have your cast removed
  • Start doing your normal activities again

References

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