metatarsal fractures and metatarsal fractures.pptx

Orthopedic presentation

1. Metacarpal and Metatarsal fractures Theodor Haiyala medical intern Orthopedic department 14/02/2025

2. Table of content Introduction 1 . Metacarpal fractures : Anatomy Classification of metacarpal fractures Etiologies and mechanism of injury, History , physical evaluation and diagnosis Management Complications 2 . Metatarsals fractures: Anatomy Classification of Metatarsal fractures, Etiology , History ,physical evaluation and diagnosis Management of Metatarsal fractures Complications References

3. 1.Metacarpal fractures Metacarpal fractures are common in the general population with relative propensity seen in contact-sport athlete ( e.g Boxers and football players) and manual laborers. Metacarpal fractures are the 3 rd M.C fractures of the upper extremities (1 st being distal radius and 2nd being phalangeal fractures respectively). They are the 2 nd M.C hand fractures, accounts for 40% of hands injuries. 76% of all metacarpal injuries occurs In males

4. The incidence rate of fracture associated with each digits metacarpal bone increases from the radial to the ulnar side. The incidence rate of the 5 th metacarpal fractures is higher than that of 2 nd metacarpal fractures. Metacarpal fractures may occur as isolated fractures, associated with other metacarpal fractures.

5. Metacarpal Anatomy

6. OTA classifications of metacarpal fractures (Orthopedic trauma associations) Alpha-numeric classification schematic Thumb: D1 metacarpal # Index finger : D2 metacarpal # Middle finger : D3 metacarpal # Ring finger: D4 metacarpal # Little finger: D5 metacarpal # The bony location of the fracture (divided into 4 Parts) Head , Neck (MC) , Shaft (transverse, spiral, oblique), Base Of special considerations are Fractures of base of the 1 st metacarpal bone ( Bennett and Roland )

7. Metacarpal fractures are also described by appearance of their respective fractures patterns as and whether Articular involvement or not Transverse Oblique Spiral and Comminuted

8. OTA classification

9. Fractures of base of the first metacarpal bone : Bennett –Type I, Roland –Type II and Comminuted

10. Bennett # (M.C thumb fracture) On the Volar view : an oblique intra-articular 1 st metacarpal fracture, the radial base of 1 st metacarpal dislocate/pulled proximally due to the pulling effects of the abductor pollicis longus muscle. The intra-articular triangular bone fragment sheared off and it remains articulating with trapezoid and is held in place by Palmar oblique ligament.

11. Roland # and comminuted # This is a complete intra-articular three-part or comminuted fracture of the 1 st metacarpal. Fracture line is typically T or Y shaped type fracture of 1 st metacarpal The volar fragment remains attached to the CMCJ while the main dorsal fragment subluxation or dislocate dorsally and radially due to the pull of the abductor pollicis longus muscle. Note !! Perfect reduction in these fractures is impossible : Treatment is K-wire with immobilization.

12. Mechanism of injury : Bennett & Roland #’s Axial force applied/directed against the partially flexed metacarpal (thumb in flexion) e.g blow with fist ( when a person punches a hard object , it can also occur as a result of a fall onto the thumb. Roland Fracture requires greater force than a Bennett fracture.

13. Etiology of metacarpal fractures metacarpal bones are superficial, making them vulnerable to fractures . Direct blows to the Dorsum of hand by any hard objects can results into varying degrees of metacarpal fractures Axial loading e.g boxer’s fracture (fracture of the neck of the 5 th metacarpal with volar displacement). Rotational forces Bending forces

14. History, clinical evaluation and diagnosis Patient may report hx of traumatic injuries e.g direct impact Swelling , pain or unable to flex or dorsi extend. evaluation Edema Ecchymosis obvious deformity with/without wound, Reduced ROM Bones Crepitation Also examine for neurovascular integrity

15. Radiological diagnostic imaging

16. Management of metacarpal fractures Conservatively vs Surgical Mx For non displaced – Immobilize with Cast (volar slab) For displaced fractures – reduce and if stable fractures –Cast If unstable fractures – CR PCP with K-wires vs ORIF If shortened – ORIF Intra-articular – Bennett and Roland are problematic fractures and requires ORIF, as they can lead to APL deforms and Degenerative joint disease (DJD).

17. A short thumb spica Cast vs splint

18. Radiological imaging : trauma vs post op

19. Complications

20. 2. Metatarsal fractures Are relatively common foot injuries encountered in trauma and emergency department. Prevalence : Metatarsal fractures account for 5-6% of all fractures and 35% of all foot fractures. Commonly affected bones: the 5 th Metatarsal is the most frequently fractured, followed by the central Metatarsals : 2,3 , and 4 th Metatarsals. First Metatarsal fractures are less common as compared to central Metatarsal fractures. Although most 1 st and 5 th Metatarsal fractures are isolated fractures, multiple Metatarsal fractures often occurs in Central Metatarsals.

21. Metatarsal fractures If a single fracture is identified in a single metatarsal, the orthopedist must closely inspect adjacent metatarsals and joints especially the Lisfranc articulation. Stress fractures seen typically in athletes with repetitive stress injuries, and military recruits can also occur in metatarsals ,mostly in 2 nd but also in 3 rd and 4 th metatarsals

22. Metatarsal fractures : Anatomy Proximally: Metatarsal bones articulates with tarsal bones at tarsometatarsal joint ( Lisfranc joint ) Distally : Metatarsals articulates with bases of Proximal phalanges

23. Classifications of Metatarsal fractures

24. 5 th MT base Fractures According to Dameron’s classification Zone 1: Avulsion (of tuberosity) fractures – a small bone is pulled away by attached peroneus brevis tendon. 93% Zone 2: transverse fractures that occurs at the Metaphysial-diaphysial junction ( Jone’s fracture ) 4% Zone 3: stress fractures of the Proximal 1.5cm of the shaft of 5 th Metatarsal. Stress fractures 3% - resulting from repetitive stress and overuse.

25. Peroneus brevis tendon Originate from peroneus muscle and inserted lateral aspects of Base of 5 th Metatarsal bone

26. Clinical significance of zones

27. Etiology Direct crush injury eg due to fall of the heavy object on the foot ( may lead to multiple Metatarsal fractures) indirect trauma mechanism eg in twisting movements Due repetitive micro stress effects e.g such as in sustained and acute increase in the activity’s intensity- athletes or due endocrine (osteoporosis) and metabolic deficiency Fall from height

28. History, physical evaluation and diagnosis History Patient report hx of traumatic injuries e.g direct impact (contact sports, hit by object on dorsum etc….) Swelling , pain or unable to bear weight evaluation Edema ,ecchymosis, obvious deformity with/without wound, Reduced ROM ,unable to bear weight Bones Crepitation

29. Radiological imaging : to confirm the fractures AP and lateral views

30. Management of Metatarsal # : Treatment approach will depend which metatarsal involved, how many involved and severity of injury Conservative ( non-operative ) treatment For non-displaced or minimally displaced, stress fractures, isolated fractures, fractures without significant angulations or rotation. Pain management and swelling Analgesics + RICE : rest , icepack, compression and limb elevation For stable fractures (after reduction) Immobilize : a cast boot/ Hard walking boot Surgical management Indicated for : Displaced # , multiple #, unstable # , Comminuted #, significant angulation or rotation, Zone 2/3 fractures of base of 5 th Metatarsal. Closed reduction of any fracture with displacement of more than 3-4mm and angulations of more than 10° , followed by Intramedullary fixation with k-wire (for unstable fractures).

31. Management…… Non operative Mx Avoid high impact activities eg running , jumping . WBAT usually in the boots special consideration: Jones fractures because of higher risk of non-union, often requires NWB in a boot for up to 6-8weeks. Avulsions fractures usually heals well with WBAT in the boot. Surgical Mx… External fixators ORIF with plates and screws (for failed reductions and stable, multiple fractures)

32. Short leg Cast and walking boot

33. Fixations with K-wires , internal fixation with plates and screws

34. Complications Infections Hardware irritations Non-union (failure to heal) Delayed union (Slowed healing) Mal-union (healing in misaligned position) Metatarsalgia

35. Take home message Metacarpals and metatarsals form the Osseous base of the complex lever system of flexor and extensor tendons of the hand and foot. Fractures of the Metacarpal and Metatarsal disrupts this mechanism causing a significant disability for the active or working patient. Due to complexity of its form and functions, the orthopedic surgeon and other Clinical providers must be able to recognize metacarpal and metatarsal fractures readily and treat these injuries in a timely fashion to avoid complications.

36. References Rüedi , T. P., Murphy, W. M. (2000). AO Principles of Fracture Management. Germany: AO Publishing. Thompson, J. C. (2010). Netter's Concise Orthopaedic Anatomy. United Kingdom: Saunders Elsevier. Trauma and Orthopaedic Classifications: A Comprehensive Overview. (2014). United Kingdom: Springer London. Anwar, R.,  Tuson , K. W. R., Khan, S. A. (2008). Classification and Diagnosis in Orthopaedic Trauma. United Kingdom: Cambridge University Press.