- Email: [email protected]
Fractures of the metatarsals: management of complicated injuries with a simple traction system
Injury (1988) 19,345-349
Printed in Great Britain
345
Fractures of the metatarsals: management of complicated injuries with a simple traction system Altaf Ahmed Department of Orthopaedic and Traumatic Surgery, Dundee Royal Infirmary, Dundee
Arthur J. Espley Bridge of Earn Hospital, Perthshire
Summary
METHODS
A simple method of skeletal traction is described to facilitate management of complicated multiple fractures of the metatarsals following crush injuries of the foot. The system uses Brock’s pins and a modified Nissen loop to achieve either balanced traction or fixed traction. Satisfactory alignment of the fractures can he maintained whilst soft tissue disorders are dealt with.
For multiple, cornminuted fractures of the shaft, skeletal or pulp traction is achieved using Brock’s pins (Brock, 1935) (Fig. 1). These are modified safety pins which are used to transfix the distal phalanx under general anaesthesia. Rubber bands are then passed through the eye of the pin and attached to a modified Nissen loop (Fig. 1). If extensive soft tissue damage has occurred, decompression is carried out through longitudinal incisions. If skin necrosis or sloughing has already oa~rred as a consequence of previous treatment, the skin is excised and the foot prepared for later skin grafting. Balanced traction is then applied through the Nissen loop sulhcient to keep the heel off the bed (Fig. 2), and gentle ankle mobilization is started. Traction is continued until the foot can be incorporated into a cast. If delayed healing occurs and skin grafting is required the traction can be continued for 6 weeks. The cast and pins are then removed, and mobiliza-
INTRODUCTION
FRACTURES of the metatarsals frequently occur following a direct crushing injury. Occasionally severe crushing of the foot can occur resulting in associated extensive soft tissue injury with skin necrosis and sloughing (Conwell and Reynolds, 1961; Garcia et al., 1973; Anderson, 1977; Blodgett and Jahns, 1982; Heckman et al., 1985), the fragile dorsal skin being particularly vulnerable (Heckman et al., 1985). Rarely, foot-board injuries cause severe dorsiflexion and fractures through the metatarsal necks (Anderson, 1977). Shattering of the metatarsals occurs in gunshot or blast injuries (Blodgett and Jahns, 1982). Multiple metatarsals were involved in 13-30 per cent of metatarsal fractures in various series (McKeever, 1950; Sewell, 1965; Lindholm and Lindholm, 1970; Orecchia and Barral, 1972). The heads, necks, or shafts of multiple metatarsals may be affected with varying degrees of comminution and displacement (Anderson, 1977; Jahna, 198 1; Wilson, 1986), and in such cases management of the associated soft tissue injury takes priority. If unsuccessfully treated, prolonged disability can occur (Key and Conwell, 1946; Garcia et al., 1973; Anderson, 1977; De Lee and Mann, 1986; Wilson, 1986). Controlled Environmental Treatment (CET) has been shown to reduce oedema (Redhead et al., 1974; Troup, 1980), but if circulatory compromise is suspected, decompression by longitudinal fasciotomies should be performed urgently (Blodgett and Jahns, 1982). In these cases management in below-knee casts or by internal fixation may not be possible and skeletal traction is recommended. We describe a system of traction which allows treatment of the soft tissue injury while maintaining reasonable alignment of the fractured metatarsals. Our method has advantages over previously described methods. 0
1988 Butterworth & Co (Publishers) Ltd
002&1383/88/050345-X)5
.SO3.00
*
Fig. 1. a, Brock’s pins. b, Modified Nissen loop.
Injury: the British Journal of Accident
Surgery (1988) Vol. 1 g/No. 5
weeks, and weight-bearing for a further 4 weeks. If radiographs confirm union, the plaster is removed and physiotherapy is commenced. Two illustrative cases are described. CASE REPORTS
Case 1 A 17-year-old motorcyclist sustained a crushing injury to the left foot in a road traffic accident. He was wearing training shoes. Clinically there was extensive soft tissue injury to the foot with wounds along the dorsomedial aspect of his foot overlying the metatarsals (Fig. 4). Radiographs showed fractures involving all five metatarsals, with comminution of the first (Fig. 5). Initial management consisted of excision of the wound and Kirschner wire fixation of the first metatarsal. However, skin necrosis occurred and reduction of the fractures could not be maintained. After 2 weeks from the time of injury, the necrotic skin was excised and skeletal traction was applied using the balanced traction method (Fig. 2). A week later skin grafting was performed. After 5 weeks traction was discontinued and the foot mobilized free in bed for a further week, with partial weight bearing progressing to full weight bearing. At review 8 months after the accident he was pain free with good function in the foot but for slight clawing of the 3rd and 4th toes. No shoe modification was required.
Fig. 2. Balanced traction with heel off the bed. tion
commenced,
initially
partial
weight
bearing.
Full
weight bearing is allowed at 8 weeks. In fractures of the metatarsal head and neck, with associated soft tissue damage, closed reduction using the Brock’s pins is first attempted. If unsuccessful, traction can be maintained as described earlier, and when swelling has subsided, open reduction is performed and alignment maintained, incorporating the Nissen loop in plaster (Fig. 3). The patient is mobilized non-weight-bearing for 2
Fig. 3. Fixed traction with Nissen loop incorporated in plaster.
Case 2 A 16-year-old motorcyclist was involved in a road traffic accident. He, too, was wearing training shoes and sustained a crushing injury of his right foot. On examination there was extensive swelling of the foot and circulation was impaired; radiographs showed comminuted fractures of the distal third of the second to fifth metatarsals with displacement of the heads plantarwards
Fig. 4. Dorsal and medial views of Case I showing extent of soft tissue injury.
Ahmecl and Espley: Metatarsal fractures-a
simple traction system
Fig. 5. Dorsoplantar and oblique radiographs of Case 1 showing cornminuted fractures of the metatarsals.
347
Fig. 6. Dorsoplantar
and oblique radiographs of Case 2 showing multiple fractures through the necks of the metatarsals.
(Fig. 6). The foot was elevated and intermittent ice-packs applied. Open reduction of the metatarsal fractures was performed 2 days later using two longitudinal incisions, allowing access to adjacent metatarsals. Due to the comminution, Kirschner wire fixation was abandoned. Brock’s pins were passed through the distal phalanges of the involved toes and fixed traction applied (Fig. 7). A plaster back slab was applied and a Nissen loop incorporated. Traction was achieved using rubber bands passed from the pins to the loop (Fig. 3). After 3 weeks’ elevation the patient was mobilized non-weight bearing after completion of the plaster. At 6 weeks the pins and cast were removed and physiotherapy commenced. He was back at work 2 months following the injury and at final review at 6 months after injury, he had no complaints and had good function in the foot.
DISCUSSION Fractures of the metatarsal
are relatively common, but may cause prolonged disability if inadequately treated. It is considered particularly important to achieve accurate reduction in the sagittal plane in order to avoid later maldistribution of weight on the metatarsal head (Harrison, 1968; De Palma, 1970; Anderson, 1977; Heckman et al., 1985; De Lee and Mann, 1986). The single metatarsal fracture rarely gives difficulty, although accurate reduction of the first metatarsal in all planes is particularly important (Irwin, 1938; Conwell and Reynolds, 1961; Heck, 1965; Heim, 1970; Heckman et al., 1985). Multiple fractures of the metatarsals are the result of greater injury, are more likely to be displaced, and are often associated with soft tissue problems. Closed reduction with ‘Chinese finger traps’ and the application of a moulded non-weight bearing plaster cast is widely recommended (Sewell, 1965;
Fig. 7. Dorsoplantar
radiographs of Case 2 following reduction and application of traction.
348
Lucht, 1969; De Palma, 1970; Garcia et al., 1973; Heckman et al., 1985). Alternatively, open reduction through dorsal longitudinal incisions giving access to adjacent metatarsals (Lindholm and Lindholm, 1970; Anderson, 1977; De Lee 1986) and internal fixation by a variety of methods (including intramedullary Kirschner wires, closed K wires, crossed screws, and ASIF small fragment plates), has been described (Heck, 1965; De Palma, 1970; Heim, 1970; Ilyenkov, 1971; Reichelt and Derkman, 1972; Johnson and Bateman, 1976; Moschinski and Rotzschen, 1980; De Lee, 1986; Sisk and Crenshaw, 1987). Recognizing the difficulty of achieving and maintaining reduction of multiple fractures of the metatarsals associated with soft tissue injuries, some authors recommend leaving the fracture to unite with angulation and later undertaking corrective osteotomy, or excision of metatarsal heads (Sewell, 1965; Garcia et al., 1973; Blodgett and Jahns, 1982; Heckman et al., 1985). If there is extensive soft tissue injury, or associated skin loss, plaster-of-Paris immobilization imposes considerable limitations on management of the wound. Skin grafting or delayed primary closure may be necessary, and in these circumstances internal fixation may be inadvisable, risking further soft tissue damage and infection. Biihler (1935,1958) and Irwin (1938) described traction for fractures of the metatarsals using stainless steel wire passed through the tips of the toes, threaded through holes in pieces of wood, and tied over a round stick or incorporated into extensions of below-knee plasters. In 1935, Brock described his modified safety pin for use in pulp or skeletal traction. Lewin (1940, 1959), advised the use of elastic traction in combination with the banjo splint. Later authors (Key and Conwell, 1942, 1946; McKeever, 1950), advised skeletal or pulp traction for certain fractures of the metatarsals using stainless steel wire, pins or ‘silkworm gut’ attached by rubber bands to wire loops incorporated into plaster casts. However, some advised early mobilization while others advised immobilization for at least 6 weeks. Indications for skeletal traction were not specific until De Palma’s (1970), description. He felt it was impossible to obtain and maintain reduction of severely cornminuted fractures unless skeletal traction was used. Moschinski and Rotzscher (1980), described the use of a Steinmann pin passed through the OScalcis and incorporated into the plaster. In open injuries, a frame was constructed around the foot using the Steinmann pin. They felt that use of a pin in the OScalcis overcame the pull of the intrinsic muscles of the foot and prevented the dorsum of the ankle being pulled into the front of the plaster. Blodgett and Jahns (1982), advised traction for 7 weeks using pins through the proximal or middle phalanx in cases of shatter fractures of the metatarsal heads. In his opinion limited metatarsophalangeal flexion was to be expected. The argument against traction has been that fixed traction in plaster leads to stiffness of the forefoot (Garcia et al., 1973; Johnson, 1976; Heckman et al., 1985; Wilson, 1986), but no alternatives are suggested for cases where internal fixation is not possible (Heckman et al., 1985). The use of Kirschner wires across the metatarsophalangeal joints leads to stiffness and risks the introduction of infection to the fracture site due to protrusion through the skin (Lindholm, 1961). Flexion contracture of the metatarsophalangeal joint has also been noted (Sisk and Crenshaw, 1987). The use of a Steinmann pin in the OS
Injury: the British Journal of Accident
Surgery (1988) Vol. 1 g/No. 5
calcis causes additional trauma to the foot. Traction using rubber bands is slight (Blodgett and Jahns, 1982), and is unlikely to cause pressure of the ankle against the front of the plaster. Moreover, using balanced traction with the heel off the bed, ankle and foot exercises were begun early and we had no stiff, rigid feet, in spite of using it in severe injuries. Potential problems due to implants in open wounds are prevented. Our technique is simple and requires no expensive equipment. The pin is easy to apply. The Nissen loop prevents the rubber bands from slipping and altering alignment. The pin does not cut out through the pulp and Brock (1935), reports leaving a pin in situ for 3 months. In our opinion long periods of traction are unnecessary. CONCLUSIONS
Most fractures of the metatarsals are amenable to methods described in the literature and it has been shown that variation in the type of immobilization has little bearing on the final outcome (Lindholm and Lindholm, 1970). However, certain fractures require methods of traction similar to ours which allow access to the soft tissues. Acknowledgements
I should like to acknowledge the help of Miss M. Aitken, Secretary, University Department of Orthopaedic and Traumatic Surgery, Dundee Royal Infirmary and the Departments of Medical Photography in Bridge of Earn Hospital and Dundee Royal Infirmary.
REFERENCES
Anderson L. D. (1977) Injuries of the forefoot. Clin. Orrhop. 122, 23. Blodgett W. H. and Jahns M. H. (eds) (1982) Injuries of the forefoot and toes. In: Disorders ofthe Foot, Vol. II. Philadelphia, W. B. Saunders, 1149. Biihler L. (1958) The Treatment ofFractures, Vol. III. New York, Grune and Stratton, 2142. Brock R. C. (1935) A simple instrument for finger extension. Lancet, 382.
Conwell H. E. and Reynolds F. C. (1961) Metatarsal fractures. In: Key J. A., and Conwell H. E. (eds) The Management of Fracture Dislocations and Sprains, 7th ed. St Louis, C. V.
Mosby, 1068. De Lee J. C. and Mann A. R. (eds.) (1986) Fractures of the metatarsals. In: Surgery of the Foot, 5th ed. St Louis, C. V. Mosby, 729. De Palma A. F. (1970) Metatarsal fractures In: The management offractures and dislocations-an atlas, Vol. II, 2nd ed. Philadelphia, W. B. Saunders, 1697. Garcia A., Parkes J. C. and Giannestras N. J. (eds) (1973) Fractures of the foot. In: Foot Disorders: Medical and Surgical Management, 2nd ed. Philadelphia, Lea and Febiger, 557. Harrison M. (1968) Fractures of the metatarsal head. Can. J. Surg. 11, 511. Heck C. V. (1965) Fractures of the bones of the foot (except talus). Surg. Clin. North Am. 45, 103. Heckman J. D., Rockwood C. A. Jr and Green D. P. (eds) (1985) Fractures and dislocations of the foot. In: Fractures in adults, Vol II, 2nd ed. Philadelphia, J. B. Lippincott, 1806. Heim U. (1970) The treatment of fractures of the metatarsals and toes with special reference to osteosynthesis. 2. Unfallmed. Berujskr. 63,305.
Ilyenkov S. I. (197 1) Osteosynthesis in the treatment of fractures of the metatarsus. Khirurgila (Mask) 47, 71.
Ahmed and Espley: Metatarsal fractures-a
simple traction system
Irwin C. G. (1938) Fractures of the metatarsals. Proc. R. Sot. Med. 31, 789. Jahna H. (1981) Fractures and dislocation fractures of os calcis, tarsi, metatarsi and hallux. Lungenbecks Arch. Chir. 355,427. Johnson V. S. and Bateman J. E. (eds) (1976) Treatment of fractures of the forefoot in industry. In: Foot Science. Philadelphia, W. B. Saunders, 257. Key J. A. and Conwell H. E. (eds) (1942) Fractures of the metatarsals. In: The Management of Fractures, Dislocations and Sprains, 3rd ed. St Louis, C. V. Mosby. Key J. A. and Conwell H. E. (eds) (1946) Fractures of the metatarsal bones. In: The Management of Fractures, Dislocations and Sprains, 4th ed. Henry Kimpton, 1280. Lewin P. (1940) The Foot and Ankle. Philadelphia, Lea and Febiger. Lewin P. (1959) The Foot and Ankle, 4th ed. Philadelphia, Lea and Febiger, 262. Lindholm T. S. and Lindholm R. V. (1970) Metatarsal fractures. Nord. Med. 22, 103.
Lindholm R. (1961) Operative treatment of dislocated simple fractures of the neck of the metatarsal bone. Ann. Chir. Gynaelec. Fenn. 50,328.
Lucht A. U. (1969) Metatarsal fractures. Ugeskr. Leg. 131, 1197. McKeever F. M. (1950) Fractures of tarsal and metatarsal
Moschinski D. and Rotzscher V. M. (1980) The treatment of metatarsal fractures. Vnfallkeilkunde 83, 115. Orecchia L. and Barral P. (1972) Treatment of metatarsal and anterior tarsal fractures with a removable plastic splint. Ann. Chir. 26, 1341.
Redhead R. G., Snowdon C., Burgerr E. M. et al. (1974) Controlled environment treatment for the postoperative management of wounds of the upper and lower limb including amputation stumps. 1st World Congress I.S.P.O., Montreux Reichelt A. and Derkmann G. (1972) Therapy of metatarsal fractures. Arch. Orthop. Unfall. Chir. 72, 139. Sewell J. H. (1965) Metatarsal Med.) 61, 558.
fractures.
Tex. St. J. Med. (Tex.
Sisk T. D. and Crenshaw A. H. (eds) (1987) Fractures of the lower extremity. In: Campbell’s Operative Orthopaedics, 7th ed. St Louis, C. V. Mosby, 1608. Troup I. M. (1980) Controlled environmental treatment (C.E.T.). The use of a new concept of wound environment in amputation surgery and other conditions of extremities. Prosthet. Orthot. Int. 4, 15. Wilson J. N. (ed) (1986) Injuries of the foot. In: Watson-Jones Fractures and Joint Injuries, Vol2,6th ed. Edinburgh, Churchill Livingstone, 1200.
bones. Surg. Gynaecal. Obstet. 90,735.
Morrissey E. J. (1946) Metatarsal fractures. J. Bone Joint Surg. 28,594.
Paper accepted 2 June 1988.
Requestsforreprintsshould be addressed IO: Mr A. J. Espley FRCS,Consultant Orthopaedic Surgeon, Department of Orthopaedic Surgery, Bridge of Earn Hospital, Bridge of Earn PH2 9QT, Perthshire.
Printed in Great Britain
345
Fractures of the metatarsals: management of complicated injuries with a simple traction system Altaf Ahmed Department of Orthopaedic and Traumatic Surgery, Dundee Royal Infirmary, Dundee
Arthur J. Espley Bridge of Earn Hospital, Perthshire
Summary
METHODS
A simple method of skeletal traction is described to facilitate management of complicated multiple fractures of the metatarsals following crush injuries of the foot. The system uses Brock’s pins and a modified Nissen loop to achieve either balanced traction or fixed traction. Satisfactory alignment of the fractures can he maintained whilst soft tissue disorders are dealt with.
For multiple, cornminuted fractures of the shaft, skeletal or pulp traction is achieved using Brock’s pins (Brock, 1935) (Fig. 1). These are modified safety pins which are used to transfix the distal phalanx under general anaesthesia. Rubber bands are then passed through the eye of the pin and attached to a modified Nissen loop (Fig. 1). If extensive soft tissue damage has occurred, decompression is carried out through longitudinal incisions. If skin necrosis or sloughing has already oa~rred as a consequence of previous treatment, the skin is excised and the foot prepared for later skin grafting. Balanced traction is then applied through the Nissen loop sulhcient to keep the heel off the bed (Fig. 2), and gentle ankle mobilization is started. Traction is continued until the foot can be incorporated into a cast. If delayed healing occurs and skin grafting is required the traction can be continued for 6 weeks. The cast and pins are then removed, and mobiliza-
INTRODUCTION
FRACTURES of the metatarsals frequently occur following a direct crushing injury. Occasionally severe crushing of the foot can occur resulting in associated extensive soft tissue injury with skin necrosis and sloughing (Conwell and Reynolds, 1961; Garcia et al., 1973; Anderson, 1977; Blodgett and Jahns, 1982; Heckman et al., 1985), the fragile dorsal skin being particularly vulnerable (Heckman et al., 1985). Rarely, foot-board injuries cause severe dorsiflexion and fractures through the metatarsal necks (Anderson, 1977). Shattering of the metatarsals occurs in gunshot or blast injuries (Blodgett and Jahns, 1982). Multiple metatarsals were involved in 13-30 per cent of metatarsal fractures in various series (McKeever, 1950; Sewell, 1965; Lindholm and Lindholm, 1970; Orecchia and Barral, 1972). The heads, necks, or shafts of multiple metatarsals may be affected with varying degrees of comminution and displacement (Anderson, 1977; Jahna, 198 1; Wilson, 1986), and in such cases management of the associated soft tissue injury takes priority. If unsuccessfully treated, prolonged disability can occur (Key and Conwell, 1946; Garcia et al., 1973; Anderson, 1977; De Lee and Mann, 1986; Wilson, 1986). Controlled Environmental Treatment (CET) has been shown to reduce oedema (Redhead et al., 1974; Troup, 1980), but if circulatory compromise is suspected, decompression by longitudinal fasciotomies should be performed urgently (Blodgett and Jahns, 1982). In these cases management in below-knee casts or by internal fixation may not be possible and skeletal traction is recommended. We describe a system of traction which allows treatment of the soft tissue injury while maintaining reasonable alignment of the fractured metatarsals. Our method has advantages over previously described methods. 0
1988 Butterworth & Co (Publishers) Ltd
002&1383/88/050345-X)5
.SO3.00
*
Fig. 1. a, Brock’s pins. b, Modified Nissen loop.
Injury: the British Journal of Accident
Surgery (1988) Vol. 1 g/No. 5
weeks, and weight-bearing for a further 4 weeks. If radiographs confirm union, the plaster is removed and physiotherapy is commenced. Two illustrative cases are described. CASE REPORTS
Case 1 A 17-year-old motorcyclist sustained a crushing injury to the left foot in a road traffic accident. He was wearing training shoes. Clinically there was extensive soft tissue injury to the foot with wounds along the dorsomedial aspect of his foot overlying the metatarsals (Fig. 4). Radiographs showed fractures involving all five metatarsals, with comminution of the first (Fig. 5). Initial management consisted of excision of the wound and Kirschner wire fixation of the first metatarsal. However, skin necrosis occurred and reduction of the fractures could not be maintained. After 2 weeks from the time of injury, the necrotic skin was excised and skeletal traction was applied using the balanced traction method (Fig. 2). A week later skin grafting was performed. After 5 weeks traction was discontinued and the foot mobilized free in bed for a further week, with partial weight bearing progressing to full weight bearing. At review 8 months after the accident he was pain free with good function in the foot but for slight clawing of the 3rd and 4th toes. No shoe modification was required.
Fig. 2. Balanced traction with heel off the bed. tion
commenced,
initially
partial
weight
bearing.
Full
weight bearing is allowed at 8 weeks. In fractures of the metatarsal head and neck, with associated soft tissue damage, closed reduction using the Brock’s pins is first attempted. If unsuccessful, traction can be maintained as described earlier, and when swelling has subsided, open reduction is performed and alignment maintained, incorporating the Nissen loop in plaster (Fig. 3). The patient is mobilized non-weight-bearing for 2
Fig. 3. Fixed traction with Nissen loop incorporated in plaster.
Case 2 A 16-year-old motorcyclist was involved in a road traffic accident. He, too, was wearing training shoes and sustained a crushing injury of his right foot. On examination there was extensive swelling of the foot and circulation was impaired; radiographs showed comminuted fractures of the distal third of the second to fifth metatarsals with displacement of the heads plantarwards
Fig. 4. Dorsal and medial views of Case I showing extent of soft tissue injury.
Ahmecl and Espley: Metatarsal fractures-a
simple traction system
Fig. 5. Dorsoplantar and oblique radiographs of Case 1 showing cornminuted fractures of the metatarsals.
347
Fig. 6. Dorsoplantar
and oblique radiographs of Case 2 showing multiple fractures through the necks of the metatarsals.
(Fig. 6). The foot was elevated and intermittent ice-packs applied. Open reduction of the metatarsal fractures was performed 2 days later using two longitudinal incisions, allowing access to adjacent metatarsals. Due to the comminution, Kirschner wire fixation was abandoned. Brock’s pins were passed through the distal phalanges of the involved toes and fixed traction applied (Fig. 7). A plaster back slab was applied and a Nissen loop incorporated. Traction was achieved using rubber bands passed from the pins to the loop (Fig. 3). After 3 weeks’ elevation the patient was mobilized non-weight bearing after completion of the plaster. At 6 weeks the pins and cast were removed and physiotherapy commenced. He was back at work 2 months following the injury and at final review at 6 months after injury, he had no complaints and had good function in the foot.
DISCUSSION Fractures of the metatarsal
are relatively common, but may cause prolonged disability if inadequately treated. It is considered particularly important to achieve accurate reduction in the sagittal plane in order to avoid later maldistribution of weight on the metatarsal head (Harrison, 1968; De Palma, 1970; Anderson, 1977; Heckman et al., 1985; De Lee and Mann, 1986). The single metatarsal fracture rarely gives difficulty, although accurate reduction of the first metatarsal in all planes is particularly important (Irwin, 1938; Conwell and Reynolds, 1961; Heck, 1965; Heim, 1970; Heckman et al., 1985). Multiple fractures of the metatarsals are the result of greater injury, are more likely to be displaced, and are often associated with soft tissue problems. Closed reduction with ‘Chinese finger traps’ and the application of a moulded non-weight bearing plaster cast is widely recommended (Sewell, 1965;
Fig. 7. Dorsoplantar
radiographs of Case 2 following reduction and application of traction.
348
Lucht, 1969; De Palma, 1970; Garcia et al., 1973; Heckman et al., 1985). Alternatively, open reduction through dorsal longitudinal incisions giving access to adjacent metatarsals (Lindholm and Lindholm, 1970; Anderson, 1977; De Lee 1986) and internal fixation by a variety of methods (including intramedullary Kirschner wires, closed K wires, crossed screws, and ASIF small fragment plates), has been described (Heck, 1965; De Palma, 1970; Heim, 1970; Ilyenkov, 1971; Reichelt and Derkman, 1972; Johnson and Bateman, 1976; Moschinski and Rotzschen, 1980; De Lee, 1986; Sisk and Crenshaw, 1987). Recognizing the difficulty of achieving and maintaining reduction of multiple fractures of the metatarsals associated with soft tissue injuries, some authors recommend leaving the fracture to unite with angulation and later undertaking corrective osteotomy, or excision of metatarsal heads (Sewell, 1965; Garcia et al., 1973; Blodgett and Jahns, 1982; Heckman et al., 1985). If there is extensive soft tissue injury, or associated skin loss, plaster-of-Paris immobilization imposes considerable limitations on management of the wound. Skin grafting or delayed primary closure may be necessary, and in these circumstances internal fixation may be inadvisable, risking further soft tissue damage and infection. Biihler (1935,1958) and Irwin (1938) described traction for fractures of the metatarsals using stainless steel wire passed through the tips of the toes, threaded through holes in pieces of wood, and tied over a round stick or incorporated into extensions of below-knee plasters. In 1935, Brock described his modified safety pin for use in pulp or skeletal traction. Lewin (1940, 1959), advised the use of elastic traction in combination with the banjo splint. Later authors (Key and Conwell, 1942, 1946; McKeever, 1950), advised skeletal or pulp traction for certain fractures of the metatarsals using stainless steel wire, pins or ‘silkworm gut’ attached by rubber bands to wire loops incorporated into plaster casts. However, some advised early mobilization while others advised immobilization for at least 6 weeks. Indications for skeletal traction were not specific until De Palma’s (1970), description. He felt it was impossible to obtain and maintain reduction of severely cornminuted fractures unless skeletal traction was used. Moschinski and Rotzscher (1980), described the use of a Steinmann pin passed through the OScalcis and incorporated into the plaster. In open injuries, a frame was constructed around the foot using the Steinmann pin. They felt that use of a pin in the OScalcis overcame the pull of the intrinsic muscles of the foot and prevented the dorsum of the ankle being pulled into the front of the plaster. Blodgett and Jahns (1982), advised traction for 7 weeks using pins through the proximal or middle phalanx in cases of shatter fractures of the metatarsal heads. In his opinion limited metatarsophalangeal flexion was to be expected. The argument against traction has been that fixed traction in plaster leads to stiffness of the forefoot (Garcia et al., 1973; Johnson, 1976; Heckman et al., 1985; Wilson, 1986), but no alternatives are suggested for cases where internal fixation is not possible (Heckman et al., 1985). The use of Kirschner wires across the metatarsophalangeal joints leads to stiffness and risks the introduction of infection to the fracture site due to protrusion through the skin (Lindholm, 1961). Flexion contracture of the metatarsophalangeal joint has also been noted (Sisk and Crenshaw, 1987). The use of a Steinmann pin in the OS
Injury: the British Journal of Accident
Surgery (1988) Vol. 1 g/No. 5
calcis causes additional trauma to the foot. Traction using rubber bands is slight (Blodgett and Jahns, 1982), and is unlikely to cause pressure of the ankle against the front of the plaster. Moreover, using balanced traction with the heel off the bed, ankle and foot exercises were begun early and we had no stiff, rigid feet, in spite of using it in severe injuries. Potential problems due to implants in open wounds are prevented. Our technique is simple and requires no expensive equipment. The pin is easy to apply. The Nissen loop prevents the rubber bands from slipping and altering alignment. The pin does not cut out through the pulp and Brock (1935), reports leaving a pin in situ for 3 months. In our opinion long periods of traction are unnecessary. CONCLUSIONS
Most fractures of the metatarsals are amenable to methods described in the literature and it has been shown that variation in the type of immobilization has little bearing on the final outcome (Lindholm and Lindholm, 1970). However, certain fractures require methods of traction similar to ours which allow access to the soft tissues. Acknowledgements
I should like to acknowledge the help of Miss M. Aitken, Secretary, University Department of Orthopaedic and Traumatic Surgery, Dundee Royal Infirmary and the Departments of Medical Photography in Bridge of Earn Hospital and Dundee Royal Infirmary.
REFERENCES
Anderson L. D. (1977) Injuries of the forefoot. Clin. Orrhop. 122, 23. Blodgett W. H. and Jahns M. H. (eds) (1982) Injuries of the forefoot and toes. In: Disorders ofthe Foot, Vol. II. Philadelphia, W. B. Saunders, 1149. Biihler L. (1958) The Treatment ofFractures, Vol. III. New York, Grune and Stratton, 2142. Brock R. C. (1935) A simple instrument for finger extension. Lancet, 382.
Conwell H. E. and Reynolds F. C. (1961) Metatarsal fractures. In: Key J. A., and Conwell H. E. (eds) The Management of Fracture Dislocations and Sprains, 7th ed. St Louis, C. V.
Mosby, 1068. De Lee J. C. and Mann A. R. (eds.) (1986) Fractures of the metatarsals. In: Surgery of the Foot, 5th ed. St Louis, C. V. Mosby, 729. De Palma A. F. (1970) Metatarsal fractures In: The management offractures and dislocations-an atlas, Vol. II, 2nd ed. Philadelphia, W. B. Saunders, 1697. Garcia A., Parkes J. C. and Giannestras N. J. (eds) (1973) Fractures of the foot. In: Foot Disorders: Medical and Surgical Management, 2nd ed. Philadelphia, Lea and Febiger, 557. Harrison M. (1968) Fractures of the metatarsal head. Can. J. Surg. 11, 511. Heck C. V. (1965) Fractures of the bones of the foot (except talus). Surg. Clin. North Am. 45, 103. Heckman J. D., Rockwood C. A. Jr and Green D. P. (eds) (1985) Fractures and dislocations of the foot. In: Fractures in adults, Vol II, 2nd ed. Philadelphia, J. B. Lippincott, 1806. Heim U. (1970) The treatment of fractures of the metatarsals and toes with special reference to osteosynthesis. 2. Unfallmed. Berujskr. 63,305.
Ilyenkov S. I. (197 1) Osteosynthesis in the treatment of fractures of the metatarsus. Khirurgila (Mask) 47, 71.
Ahmed and Espley: Metatarsal fractures-a
simple traction system
Irwin C. G. (1938) Fractures of the metatarsals. Proc. R. Sot. Med. 31, 789. Jahna H. (1981) Fractures and dislocation fractures of os calcis, tarsi, metatarsi and hallux. Lungenbecks Arch. Chir. 355,427. Johnson V. S. and Bateman J. E. (eds) (1976) Treatment of fractures of the forefoot in industry. In: Foot Science. Philadelphia, W. B. Saunders, 257. Key J. A. and Conwell H. E. (eds) (1942) Fractures of the metatarsals. In: The Management of Fractures, Dislocations and Sprains, 3rd ed. St Louis, C. V. Mosby. Key J. A. and Conwell H. E. (eds) (1946) Fractures of the metatarsal bones. In: The Management of Fractures, Dislocations and Sprains, 4th ed. Henry Kimpton, 1280. Lewin P. (1940) The Foot and Ankle. Philadelphia, Lea and Febiger. Lewin P. (1959) The Foot and Ankle, 4th ed. Philadelphia, Lea and Febiger, 262. Lindholm T. S. and Lindholm R. V. (1970) Metatarsal fractures. Nord. Med. 22, 103.
Lindholm R. (1961) Operative treatment of dislocated simple fractures of the neck of the metatarsal bone. Ann. Chir. Gynaelec. Fenn. 50,328.
Lucht A. U. (1969) Metatarsal fractures. Ugeskr. Leg. 131, 1197. McKeever F. M. (1950) Fractures of tarsal and metatarsal
Moschinski D. and Rotzscher V. M. (1980) The treatment of metatarsal fractures. Vnfallkeilkunde 83, 115. Orecchia L. and Barral P. (1972) Treatment of metatarsal and anterior tarsal fractures with a removable plastic splint. Ann. Chir. 26, 1341.
Redhead R. G., Snowdon C., Burgerr E. M. et al. (1974) Controlled environment treatment for the postoperative management of wounds of the upper and lower limb including amputation stumps. 1st World Congress I.S.P.O., Montreux Reichelt A. and Derkmann G. (1972) Therapy of metatarsal fractures. Arch. Orthop. Unfall. Chir. 72, 139. Sewell J. H. (1965) Metatarsal Med.) 61, 558.
fractures.
Tex. St. J. Med. (Tex.
Sisk T. D. and Crenshaw A. H. (eds) (1987) Fractures of the lower extremity. In: Campbell’s Operative Orthopaedics, 7th ed. St Louis, C. V. Mosby, 1608. Troup I. M. (1980) Controlled environmental treatment (C.E.T.). The use of a new concept of wound environment in amputation surgery and other conditions of extremities. Prosthet. Orthot. Int. 4, 15. Wilson J. N. (ed) (1986) Injuries of the foot. In: Watson-Jones Fractures and Joint Injuries, Vol2,6th ed. Edinburgh, Churchill Livingstone, 1200.
bones. Surg. Gynaecal. Obstet. 90,735.
Morrissey E. J. (1946) Metatarsal fractures. J. Bone Joint Surg. 28,594.
Paper accepted 2 June 1988.
Requestsforreprintsshould be addressed IO: Mr A. J. Espley FRCS,Consultant Orthopaedic Surgeon, Department of Orthopaedic Surgery, Bridge of Earn Hospital, Bridge of Earn PH2 9QT, Perthshire.