Metatarsal Fractures (Dikis 2024) PDF

Metatarsal Fractures DPM, FACFAS Ashley M. Dikis, ssor Assistant Profe iversity Des Moines Un Objectives × Identify the mechanism of injury based on radiographic findings and fracture classifica...

Metatarsal Fractures DPM, FACFAS Ashley M. Dikis, ssor Assistant Profe iversity Des Moines Un Objectives × Identify the mechanism of injury based on radiographic findings and fracture classifications. × Demonstrate knowledge of the appropriate radiographs to evaluate a suspected metatarsal fracture. × Demonstrate knowledge of the mechanisms of injury for fifth metatarsal fractures. 2 OUTLINE × Anatomy × Management × Intro/Incidence × Non-operative × Location & Type × Operative × Special Considerations × MOI × Classifications × Physical Exam × Imaging 3 Anatomy Review Functional Anatomy × Head (distal) × Neck × Diaphysis (shaft) × Metaphysis (proximal) × Base (proximal) 4 Anatomy Review × Base of each metatarsal is broad, consists of mostly cancellous bone × Strong plantar, weaker dorsal ligaments × First weakly attached to second metatarsal 5 Anatomy Review × Attached distally via transverse metatarsal ligament × First metatarsal bears majority of weight during gait 6  Metatarsal Fractures 1 -4 st th 7  Intro / Incidence Metatarsal fractures account for majority of all foot and ankle fractures (35-88%) and nearly 7% of all fractures Most common: fifth metatarsal Least common: first metatarsal 8 How did this happen?! Mechanism of Injury (MOI) 9 MOI × Direct blow × Twisting injury × Crush × In adults, high force required to fracture first metatarsal 10 MOI Central metatarsals × Single metatarsal shaft fractures are typically minimally displaced due to splinting of adjacent metatarsals and abundant ligamentous and intrinsic muscular attachments × Instability increases when multiple metatarsals involved 11 Fracture Patterns × Transverse × Oblique × Spiral × Comminuted/Crush × Avulsion × Fracture-Dislocation 12 Fracture Patterns 13 Fracture Description × Displaced / Nondisplaced × Angulated × Translated × Complete / Incomplete × Intraarticular / Extraarticular 14 Physical Exam × Antalgic gait × Edema × Ecchymosis × Pain × Neurovascular status × Soft tissue envelope 15 Physical Exam × High suspicion for Lisfranc injury × Will cover this in upcoming lecture × Compartment syndrome × Absent pulse is a late finding and should not be relied upon for diagnosis × Pain, pain with PROM, tense 16 Imaging 1. Traditional 3 views x-ray 17 Imaging 2. CT/MRI × First met × Base fractures 18 Imaging 3. Bone Scan × Tech-99 × Stress fracture × Limited use 19 Management Non-Operative Operative 20 Management: Non-Operative × In general, nondisplaced (or minimally displaced) fractures of the metatarsals may be managed nonoperatively 21 Management: Goals × Maintain parabola × Maintain sagittal plane position of metatarsal heads × Congruent metatarsophalangeal joints 22 Management: Non-Operative Non-displaced first metatarsal fracture: × 4-6 weeks NWB in cast or boot × 6-8 weeks protected WBAT in boot 23 Management: Non-Operative Non-displaced central metatarsal fracture (single): × 6-8 weeks WBAT in surgical shoe or boot × Transition to regular shoes once bone callus easily visualized and point tenderness resolves Non-displaced central metatarsal fracture (multiple): × 4-6 weeks NWB in cast or boot × 6-8 weeks WBAT in boot 24 Management: Non-Operative If indicated, can attempted closed reduction × Local/hematoma block × Sedation × Finger traps 25 Management: Operative × Greater than 3-4 mm displacement × Angulation greater than 10 degrees × Sagittal plane Shereff et al. Instr Course Lec 1990 26 Management: Operative Incision placement × First metatarsal × For isolated fx 27 Management: Operative First metatarsal × ORIF (plate / screws) 28 Management: Operative First metatarsal × Percutaneous fixation (k-wire) × Pediatric 29 Management: Operative First metatarsal × External fixation × Severe comminution, GSW 30 Management: Operative Central metatarsals × Incision placement × Directly overlying individual metatarsal, or between metatarsals for access to both 31 Management: Operative Incision placement × Transverse dorsal incision instead of numerous longitudinal when treating multiple met neck fractures Ozer & Oznur JFAS 2006 32 Management: Operative Central metatarsals × ORIF 33 Management - Operative 34 Management: Operative Central Metatarsals × Percutaneous pinning 35 special 36 Special Considerations Malunion × Particularly challenging with first metatarsal × Two most common positional complications of first ray × Dorsal angulation × Shortening 37 Special Considerations Malunion × Secondary to improper reduction or fixation × Bone loss × Catastrophic failure of fixation 38 Special Considerations Malunion × Can lead to restricted DF due to jamming × Transfer metatarsalgia × Consider addressing with either a cheilectomy, plantarflexory osteotomy or arthrodesis 39 5thMetatarsal Fractures 40 Anatomy 41  Intro / Incidence Fifth is the most commonly fractured metatarsal High incidence in athletes 42 Fracture Location/Type 43 Neck, F-D Dancer’s Jones Intra-art base Avulsion 44 MOI × Direct force × Crush × Twisting × Inversion force to a plantarflexed foot or vertical and adduction force to the fifth metatarsal 45 MOI × Can be associated with inversion ankle sprains × Peroneus brevis or lateral band of plantar fascia 46 Jones Fracture × Fracture at the level of the diaphyseal-metaphyseal junction of the proximal fifth metatarsal × Intermetatarsal facet 47 48 Jones Fracture × Occur in the “watershed” area of the fifth metatarsal where the blood supply is tenuous. × Can lead to complications and delays in healing of these fractures 49 Classifications × Lawrence & Botte (Dameron) × Stewart × Torg 50 Classifications × Lawrence & Botte × Dameron 51 Classifications 52 Classifications 2 3 53 Distal Diaphyseal Fractures × “Dancer’s fracture” × Occur following forced dorsiflexion of a plantarflexed and inverted forefoot 54 Avulsion Fractures × Very common × Peroneus brevis or plantar fascia 55 Physical Exam × Similar to previously discussed × Always palpate fifth metatarsal with evaluation of lateral ankle sprain × Resisted eversion to evaluate peroneal involvement 56 Imaging × Same as noted for other metatarsal fractures × Other imaging modalities, such as CT and MRI, may be considered in the setting of delayed healing, nonunion, or high index of suspicion for stress fracture 57 Management Non-Operative Operative 58 Management: Non-Operative Avulsion fracture × Nondisplaced and mildly displaced fractures are amenable to nonoperative care × WB to tolerance in stiff-soled shoe or boot for 4-8 weeks 59 Management: Non-Operative Avulsion fracture × Majority are amenable to nonoperative treatment Egol et al FAI 2007 × Treated WB in cast shoe × Pain free at 6 months 60 Management: Non-Operative Distal diaphyseal fracture × Based on early studies, majority treated nonoperatively × Thought to be able to tolerate a significant degree of displacement O’Malley et al AJSM 1996 61 Management: Non-Operative Distal diaphyseal fracture × Level II prospective cohort study × Nonoperatively managed distal fifth met × 142 fractures, avg 3.5 yr f/u × Excellent long-term functional outcomes Aynardi et al FAI 2013 62 Management: Non-Operative Jones: × Dameron reported a nonunion rate of nearly 25% in metaphyseal-diaphyseal fractures × Healing rates—avg 10 wks with ORIF and 24 wks with non-op has led to more aggressive treatment × 6-8 weeks NWB in cast or CAMboot 63 Management: Operative × Surgical approach 64 Management: Operative Avulsion fracture × Bicortical screw × Intramedullary screw × Tension band × Plate fixation 65 Management: Operative 66 Management: Operative 67 Management: Operative 68 Management: Operative Avulsion fracture × Occasionally, particularly in the scenario of nonunion, excision of fragment with repair of peroneus brevis attachment is indicated 69 Management: Operative Distal diaphyseal (Dancer’s) fracture × When indicated, small plate and screw construct is utilized 70 Management: Operative 71 Management: Operative 72 Management: Operative Jones fracture × Faster healing rates × Lower re-fracture rate × Intramedullary fixation × Kavanaugh 1978 × Plating more commonly seen with revision of nonunion 73 Management: Operative × Lateral decubitus position × Original placement of guidewire is key × Numerous systems available × Screw type: surgeon’s preference × Note bowing of metatarsal × 4.5, 5.0, 5.5, 6.5 × Indication-specific hardware 74 Management: Operative 75 special 76 Special Considerations × Metatarsus adductus × Cavovarus foot structure × Athletes × Skeletally immature patients 77 Special Considerations Metatarsus adductus Yoho et al JFAS 2012 × 30 acute Jones fx compared to imaging of 30 asymptomatic control subjects × Statistically significant increase in met adductus angle in Jones pts vs. control × May be a risk factor and should be taken into consideration with management and prevention 78 Special Considerations Cavovarus foot structure × Accepted association with development of stress fracture × Limited evidence on management in the presence of fracture × Patient education and consider re- alignment/reconstruction if recurrent injury 79 Special Considerations Athletes × Operative treatment advocated Lareau et al FAI 2016 × NFL players operatively managed over 10 yr period by same surgeon (N=25) × 100% RTP (avg 8.7 wks for same season) 80 Special Considerations Skeletally immature patient × Open epiphysis often confused with fracture at this location × Remember orientation 81 Summary × Metatarsal fractures are managed mainly on the degree of displacement/angulation × There are special circumstances, such as the Jones fracture, which require particular attention and patient education × Majority of these injuries go on to heal uneventfully 82 References 1. A. Becker. First Metatarsal Nonunion. Foot Ankle Clin N Am 2009; 14: 77-90. 2. Aynardi et al. Outcome of Nonoperative Management of Displaced Oblique Spiral Fractures of the Fifth Metatarsal Shaft. FAI 2013; 34(12): 1619–1623. 3. D. Porter. Fifth Metatarsal Jones Fractures in the Athlete. FAI 2018; 39(2): 250- 258. 4. Egol et al. Avulsion Fractures of the Fifth Metatarsal Base: A Prospective Outcome Study. FAI 2007; 28(5): 581-583. 5. Lareau et al. Return to Play in National Football League Players After Operative Jones Fracture Treatment. FAI 2016; 37(1): 8-16. 6. Lee et al. Hallux, Sesamoid and First Metatarsal Injuries. Clin Podiatr Med Surg 2011; 43-56. 7. Jastifer et al. Fatigue Bending Strength of Jones Fracture Specific Screw Fixation. FAI 2018; 39(4): 493-499. 8. McGlamry’s Comprehensive Textbook of Foot and Ankle Surgery. Vol 2, Chapter 104. 9. Metatarsal Shaft Fractures. Uptodate. Updated Oct 2019. Lit Review May 2020. 83 References 10. O’Malley et al. Fracture of the Distal Shaft of the Fifth Metatarsal: “Dancer’s Fracture”. AJSM 1996; 24(2): 240-243. 11. Ozer & Oznur. Transverse Dorsal Approach to Displaced Multi-Metatarsal Fractures. JFAS 2006: 45(3); 190-191. 12. Rammelt et al. Metatarsal Fractures. Injury 2004. 35; SB77-SB86. 13. Straus et al.. Metatarsal Fractures, Clinics in Podiatric Medicine and Surgery 2024. Volume 41, Issue 3, Pages 379-389, https://doi.org/10.1016/j.cpm.2024.01.001. 14. Scott et al. Screw Fixation Diameter for Fifth Metatarsal Jones Fracture: A Cadaveric Study. JFAS 2015; 54(2): 227-229. 15. Tu et al. Prevalence of Jones Fracture Repair and Impact on Short-Term NFL Participation. FAI 2018; 39(1): 6-10. 16. Yoho et al. The Association of Metatarsus Adductus to the Proximal Fifth Metatarsal Jones Fracture. JFAS 2012; 51: 739-742. 17. Yoho et al. A retrospective review of the effect of metatarsus adductus on healing time in the fifth metatarsal jones fracture. The Foot 2015; 25: 215-219. 84 References https://surgeryreference.aofoundation.org/ This website is a great resource for trauma treatment algorithms and illustrations! 85 THANKS! Any questions? Copyright Notice: This presentation may contain copyrighted material used for educational purposes under the guidelines of Fair Use and the TEACH Act. It is intended only for use by students enrolled in this course. Reproduction or distribution is prohibited. Unauthorized use is a violation of the DMU Integrity Code and may also violate federal copyright protection laws. 86 Credits Special thanks to all the people who made and released these awesome resources for free: × Presentation template by SlidesCarnival × Photographs by Startupstockphotos 87