Forefoot Fractures Sean E. Nork, MD Sean E. Nork, MD Created March 2004; revised March 2006 &...

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

Questions?

Return to Lower Extremity

Index

E-mail OTA about

Questions/Comments

If you would like to volunteer as an author for the Resident Slide Project or recommend updates to any of the following slides, please send an e-mail to ota@aaos.org

Thank You