Metatarsal Fractures – Causes, Symptoms, Treatment

• Types of Metatarsal Fractures
• Causes of Metatarsal Fractures
• Symptoms of Metatarsal Fractures
• Diagnosis of Metatarsal Fractures
• Treatment of Metatarsal Fractures
• Other Treatments
• More About Your Injury

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.

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.[rx] 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.[rx] 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[rx]

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.[rx] 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.[rx] 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.

Diagnosis of Metatarsal Fractures

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.

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 [rx]
• 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.

Do no HARM for 72 hours after injury

• Heat—hot baths, electric heat, saunas, heat packs, etc has the opposite effect on the blood flow. Heat may cause more fluid accumulation in the fracture joints by encouraging blood flow. Heat should be avoided when inflammation is developing in the acute stage. However, after about 72 hours, no further inflammation is likely to develop and heat can be soothing.
• Alcohol stimulates the central nervous system that can increase bleeding and swelling and decrease healing.
• Running, and walking may cause further damage, and causes healing delay.
• Massage also may increase bleeding and swelling. However, after 72 hours of your fracture, you can take a simple message, and applying heat may be soothing the pain.

Medication

The following medications may be considered by your doctor to relieve acute and immediate pain, long term treatment

• Antibiotic – Cefuroxime or Azithromycin, or  Flucloxacillin or any other cephalosporin/quinolone, meropenem antibiotic must be used to prevent infection or clotted blood removal to prevent further swelling, inflammation, and edema.
• NSAIDs – Prescription-strength drugs that reduce both pain and inflammation. Pain medicines and anti-inflammatory drugs help to relieve pain and stiffness, allowing for increased mobility and exercise. There are many common over-the-counter medicines called non-steroidal anti-inflammatory drugs (NSAIDs). They include first choice NSAIDs is Ketorolac, then Etoricoxib, then Aceclofenac, naproxen.
• Muscle Relaxants –  These medications provide relief from spinal muscle spasms, spasticity.  Muscle relaxants, such as baclofen, tolperisone, eperisone, methocarbamol, carisoprodol, and cyclobenzaprine, may be prescribed to control postoperative muscle spasms, spasticity, stiffness, contracture.
• Calcium & vitamin D3 – To improve bone health, blood clotting, helping muscles to contract, regulating heart rhythms, nerve functions, and healing fractures. As a general rule, too absorbed more minerals for men and women age 50 and older should consume 1,200 milligrams of calcium a day, and 600 international units of vitamin D a day to heal back pain, fractures, osteoarthritis.
• Neuropathic Agents – Drugs(pregabalin & gabapentin) that address neuropathic—or nerve-related—pain. This includes burning, numbness, tingling sensation, and paresthesia.
• Glucosamine & Diacerein, Chondroitin sulfate – can be used to tighten the loose tendon, cartilage, ligament, and cartilage, ligament regenerates cartilage or inhabits the further degeneration of cartilage, ligament. The dosage of glucosamine is 15oo mg per day in divided dosage and chondroitin sulfate approximately 500mg per day in different dosages, and diacerein minimum of 50 mg per day may be taken if the patient suffers from osteoarthritis, rheumatoid arthritis, and any degenerative joint disease.[rx]
• Topical Medications and essential oil – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation in acute trauma, pain, swelling, tenderness through the skin. If the fracture is closed and not open fracture then you can use this item.
•  Antidepressants – A drug that blocks pain messages from your brain and boosts the effects of endorphins in your body’s natural painkillers. It also helps in neuropathic pain, anxiety, tension, and proper sleep.
• Corticosteroids – Also known as oral steroids, these medications reduce inflammation. To heal the nerve inflammation and clotted blood in the joints.
• Dietary supplement – To eradicate the healing process from fracture your body needs a huge amount of vitamin C, and vitamin E. From your dietary supplement, you can get it, and also need to remove general weaknesses &  improved health.
• Cough Syrup – If your doctor finds any chest congestion or fracture-related injury in your chest, dyspnoea, post-surgical breathing problem, then advice you to take bronchodilator cough syrup.

What To Eat and What  to avoid

Eat Nutritiously During Your Recovery

All bones and tissues in the body need certain micronutrients in order to heal properly and in a timely manner. Eating a nutritious and balanced diet that includes lots of minerals and vitamins is proven to help heal broken bones and all types of fractures. Therefore, focus on eating lots of fresh food produce (fruits and veggies), whole grains, cereal, beans, lean meats, seafood, and fish to give your body the building blocks needed to properly repair your fracture. In addition, drink plenty of purified mineral water, milk, and other dairy-based beverages to augment what you eat.

• Broken bones or fractures bones need ample minerals (calcium, phosphorus, magnesium, boron, selenium, omega-3) and protein to become strong and healthy again.
• Excellent sources of minerals/protein include dairy products, tofu, beans, broccoli, nuts and seeds, sardines, sea fish, and salmon.
• Important vitamins that are needed for bone healing include vitamin C (needed to make collagen that your body essential element), vitamin D (crucial for mineral absorption, or machine for mineral absorber from your food), and vitamin K (binds calcium to bones and triggers more quickly collagen formation).
• Conversely, don’t consume food or drink that is known to impair bone/tissue healing, such as alcoholic beverages, sodas, fried fast food, most fast food items, and foods made with lots of refined sugars and preservatives.

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.[rx]
• 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.[rx]
• 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.[rx] 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.[rx]

Other Treatments