Foot fractures -meta tarsal fractures

foot anatomy and foot fractures

1. Foot fractures Dr P. ROHIT RAJ MBBS MS ORTHO ASSISTANT PROFESSOR ORTHOPAEDIC DEPARTMENT VISHWABHARATHI MEDICAL COLLEGE

2. Foot bones comprise 2 bones in the hindfoot (calcaneus, talus), 5 bones in the midfoot (navicular, cuboid, 3 cuneiforms) 19 bones in the forefoot (5 metatarsals, 14 phalanges)

3. Bones of the right foot and their divisions. Oblique view

4. Bones of the left foot and their divisions. Lateral view

5. Important joints of the foot

6. Description A metatarsal bone fracture is a complete or incomplete break in one of the five metatarsal bones in each foot. These long thin bones are located between the toes and the ankle

7. Etiology  It are the most common injuries of the foot. They are about ten times as frequent as Lisfranc-dislocations. They are equally among men and women 

8. Direct Trauma e.g. foot stamp to top of foot Martial artists frequently injure the dorsum of their foot when kicking with this region Indirect Trauma e.g. foot pinned and lateral force or twisting motion applied. Avulsion fracture Overuse (stress) injury e.g. so called ‘ march fracture ’ Mechanism of injury

9.   stress fracture   A  stress fracture  is a break in the bone that happens with repeated injury or  stress Stress  fractures are caused by overly stressing the foot when using it in the same way repeatedly. A stress fracture is different from an acute fracture, which is caused by a sudden and traumatic injury .

10. Stress fractures are more common in people who: Increase their activity level suddenly. Do activities that put a lot of pressure on their feet, such as running, dancing, jumping, or marching (as in the military) . Have a bone condition such as  osteoporosis  (thin, weak bones) Have a nervous system disorder that causes loss of feeling in the feet (such as  nerve damage due to diabetes ).

11. Findings Pain is an early sign of a metatarsal stress fracture. The pain may occur: During activity, but go away with rest Over a wide area of your foot Over time, the pain will be: Present all the time Stronger in one area of your foot

12. Proximal Fifth Metatarsal Fractures Dameron, TB, JAAOS, 1995 Relative Frequency Zone 1 93% Zone 2 4% Zone 3 3%

13. distribution of the fractures  First metatarsal: 5% Second metatarsal: 12% Third metatarsal: 14% Fourth metatarsal: 13% Fifth metatarsal: 56% Multiple metatarsal fractures: 15,6%

14. Classification Classification of metatarsal fractures is descriptive and should include location fracture pattern displacement angulation articular involvement

15. Presentation History look for antecedent pain when suspicious for stress fracture Symptoms pain, inability to bear weight Physical Exam

16. Physical Examination Gross deformity D i s locations Sensation Capillary refill Foot Compartments

17. Imaging Radiographs X RAY recommended views required  AP, lateral and oblique views of the foot optional contralateral foot views stress or weight bearing radiographs

18. Multiple new (blue arrows) and a healing (red arrow) distal MT fractures in a child…

19. CT not routinely obtained may be of use in periarticular injuries or to rule out Lisfranc injury MRI or bone scan useful in detection of occult or stress fractures

20. TREATMENT

21. First MT Shaft Fractures Nondisplaced Consider conservative treatment Immobilization Displaced Most require ORIF ORIF Plate and screws Anatomically reduce

22. Shaft fracture Post-op X-ray

23. Articular injuries Frequently require ORIF First MT Base Fractures

24. 36 year old male s/p MVC Active Note articular comminution

25. After O R I F Fixation Strategy Direct ORIF of comminuted first MT base fractre

26. Radiographic appearance at 3 months after removal of the metatarsal neck k-wire fixation.

27. Ex-fix

28. Closed reduction with percutaneous pinning Two months post-op

29. Crush injury

30. Orthofix mini-pennig ex-fix

31. Non-displaced Metatarsal Fractures 2-4 Single metatarsal fractures Treatment usually nonoperative Symptomatic: hard shoe vs AFO vs cast Multiple metatarsal fractures Usually symptomatic treatment May require ORIF if other associated injuries

32. Displaced Metatarsal Shaft Fractures Sagittal plane displacement & angulation is most important. Reestablish length, rotation, & declination Treatment Options Closed Reduction Intramedullary pinning with k-wire ORIF with dorsal plate fixation

33. 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.

34. Fixation consisted of a dorsal 2.0 mm plate application after appropriate irrigation of the open fracture .

35. 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 m etatarsals.

36. 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

37. Usually displace plantarly May require reduction and fixation: Closed reduction and pinning Open reduction and pinning ORIF (dorsal plate ) Metatarsal Neck Fractures

38. This patient sustained multiple metatarsal neck fractures after an MVA. Note additional fractures at the first and fifth metatarsals

39. Medullary wire fixation of metatarsal neck fractures 2, 3, 4 Compliments of S.K. Benirschke

40. Unusual Articular injuries May require ORIF (especially if first MT ) Metatarsal Head Fractures Circular saw injury to the articular surface of the first MT head

41. Fifth Metatarsal Fractures Mid diaphyseal fractures Stress fractures (proximal diaphysis) Jones fractures (metadiaphyseal jxn) Tuberosity fractures

42. Proximal Fifth Metatarsal Fractures Dameron, TB, JAAOS, 1995 Zone 1 cancellous tuberosity insertion of PB & plantar fascia involve metatarsocuboid joint Zone 2 distal to tuberosity extend to 4/5 articulation Zone 3 distal to proximal ligaments usually stress fractures extend to diaphysis for 1.5 cm

43. Proximal Fifth Metatarsal Fractures Dameron, TB, JAAOS, 1995 Relative Frequency Zone 1 93% Zone 2 4% Zone 3 3%

44. Fifth Metatarsal Blood Supply

45. Zone 1 Fractures: Tuberosity Etiology Avulsion from lateral plantar aponeurosis Treatment S y m p to m a t ic Hard shoe Healing usually uneventful (Dameron, T, JBJS, 1975)

46. Fracture to base of fifth metatarsal - avulsion fracture as demonstrated in picture i.e. inversion injury.

47. Zone 2 Fractures: Metadiaphyseal

48. Treatment Controversial Union frequently a concern Early weight bearing associated with increased nonunion Nondisplaced Fractures: Treatment Cast with non weight bearing Cast with weight bearing (Kavanaugh, 1978; Dameron, 1975) Zone 2 Fractures: Metadiaphyseal

49. Operative Treatment Medullary Screw Stabilization (Delee, 1983; Kavanaugh, 1978; Dameron, 1975) Bone Graft Stabilization (Dameron, 1975; Hens, 1990; Torg, 1984) Zone 2 Fractures: Metadiaphyseal

50. Zone 2 Fractures: Metadiaphyseal Operative T r ea t m e nt Medullary Screw S t a b ili z a tion Bone Graft S t a b ili z a tion Lehman, Foot Ankle 1987

51. Comminuted fracture of the base of the fifth metatarsal

52. After ORIF of the fifth metatarsal

53. Simple closed injuries can (mostly) be managed with a stiff sole boot Open injuries, multiple fractures, severe displacement and compartment syndrome usually require surgical intervention Treatment

54. Phalanx Fractures

55. Epidemiology Proximal phalanx most commonly injured

56. Mechanism Heavy object dropped on toe (crush injury) Stubbed toe( accidentally strike)

57. Signs Focal pain, swelling and  Ecchymosis Painful ambulation

58. Imaging

59. Management: Great Toe Fractures Reduce displaced  Fracture  as with Lesser Toe Fractures Initial: Immobilization Short Leg Walking Cast  for 2-3 weeks Continue immobilization if persistent symptoms Undisplaced fracture - Buddy taping for 3-4 weeks Displaced fracture – k wire fixation Healing course Expect 4-6 weeks total Athletes may require >8 weeks to return fully to activity

60. Undisplaced fracture - Buddy taping for 3-4 weeks

61. Displaced fracture – k wire fixation

62. Management: Undisplaced Lesser Toe Fractures Acute management for first 72 hours Rest Ice Therapy  for 20 minutes of each hour Elevation Splinting  3-6 weeks until non-tender Hard soled shoe and Buddy taping  Fracture d toe to adjacent toe Use cotton padding between toes and tape together Re-tape every 2-3 days

63. Management: Displaced lesser (2-5) Toe Fractures Digital Block  to anesthetize affected toe Reduce  Fracture  with longitudinal traction Continue manipulation if rotational deformity Toe nail should lie in same plan as adjacent toes Splint with buddy taping after reduction

64. Management: Subungual Hematoma Decompress with needle or cautery Avoid nail removal if possible Acts as distal phalanx splint Some recommend nail removal for hematoma >50% Explore wound and suture  Nail Bed Laceration

65. Complications Malunion resulting in persistent pain Degenerative Joint Disease  (intraarticular  Fracture ) Osteomyelitis  (open  Fracture s)