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Isolated osteochondral fracture of the metatarsal head of lesser toes
Foot and Ankle Surgery 21 (2015) e40–e44
Contents lists available at ScienceDirect
Foot and Ankle Surgery journal homepage: www.elsevier.com/locate/fas
Case report
Isolated osteochondral fracture of the metatarsal head of lesser toes T.H. Lui MBBS (HK), FRCS (Edin), FHKAM, FHKCOS* Department of Orthopaedics and Traumatology, North District Hospital, 9 Po Kin Road, Sheung Shui, NT, Hong Kong Special Administrative Region
A R T I C L E I N F O
A B S T R A C T
Article history: Received 21 October 2014 Received in revised form 11 January 2015 Accepted 21 January 2015
Isolated fracture of the metatarsal head is very rare and no consensus has been reached regarding their best management. We reported four cases of isolated osteochondral fracture of the metatarsal head with different method of treatment to achieve the common goal of restoration of the congruity of the metatarsal head. ß 2015 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.
Keywords: Metatarsal head Fracture Osteochondral Osteotomy
1. Introduction
3. Case 2
An osteochondral fracture of the metatarsal (MT) head is an uncommon injury and normally co-exists with other fractures of the medially adjacent metatarsals [1,2]. Isolated fracture of the metatarsal head is very rare and no consensus has been reached regarding their best management. The best method for treatment of this fracture is unclear, with both open and closed methods having been used with success [1–4]. We reported four cases of isolated osteochondral fracture of the metatarsal head with different method of treatment to achieve the common goal of restoration of the congruity of the metatarsal head.
A 46 years lady had her right foot hitting on steps. She complained of pain and swelling over her right second toe. She was admitted to our department on the same date. Clinically, there was tenderness over the right second MTP joint. The sensation of her right second toe was intact and the capillary refill was less than 2 s. X-rays showed a displaced osteochondral fracture of her right second MT head with distraction of the MTP joint. Open reduction and internal fixation of the fracture was performed on the same date. Post-operative X-rays showed good reduction of the fracture but there was plantar protrusion of the screw tip. The fracture healed but she complained of painful stiffness of the MTP joint. The screws were removed 10 months later. At 11 months after the removal of screws, the pain subsided and MTP motion improved (Fig. 2).
2. Case 1 A 32 years lady hurt her right foot while she ran up the escalator. She was treated by bonesetter initially and was referred to our clinic 4 weeks later because of persistent pain. There was mild tenderness over her right fourth metatarsal head. X-rays showed isolated osteochondral fracture of the metatarsal head. Computed tomogram showed the metatarsophalangeal joint surface remained congruent (Fig. 1). She was treated conservatively and the fracture healed. Upon 25 months of follow up, the patient did not have any pain except some limitation of plantarflexion of the fourth metatarsophalangeal (MTP) joint.
* Tel.: +852 26837588. E-mail address: [email protected]
4. Case 3 A 14 years girl had her right 4th toe contusion during a football game. X-rays was taken and told to be normal. She consulted our clinic 5 weeks later because of persistent pain. Clinically, there was tenderness over her right 4th MT head. X-rays and computed tomogram showed displaced osteochondral fracture of the 4th MT head. Open reduction and internal fixation was performed (Fig. 3). At 31-month followup, the fracture healed. The patient was able to walk normally with minimal pain, and had a good range of motion of the 4th MTP joint.
http://dx.doi.org/10.1016/j.fas.2015.01.011 1268-7731/ß 2015 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.
T.H. Lui / Foot and Ankle Surgery 21 (2015) e40–e44
e41
Fig. 1. X-rays (A and B) of Case 1 showed the fracture of the fourth metatarsal head. Computed tomogram (C and D) showed the congruency of the fourth metatarsophalangeal joint.
Fig. 2. X-rays (A and B) of Case 2 showed displaced fracture of the second metatarsal head with distraction of the metatarsophalangeal joint. (C) Post-operative X-rays showed protrusion of the screw tip. (D) X-rays after removal of screws.
5. Case 4 A 16 years boy had history of direct contusion of his right second toe resulting in stiffness and on and off pain over the toe. He did not consult any doctor for this injury. He injured his right second toe again during landing from jump 1 year later resulting in severe pain. X-rays and computed tomogram showed an old second metatarsal head fracture with notching at the base of
proximal phalanx. Magnetic resonance imaging showed bone edema around the MTP joint (Fig. 4). A dorsal approach was made and the joint was exposed between the extensor tendons. Intraoperative findings showed the dorsally displaced unhealed MT head fragment with the dorsal part of the MT head filled up with fibrous tissue. The remaining cartilage of the MT was normal. After debridement of the fibrous tissue, there was a significant bone gap at the fracture site. Dorsal closing wedge osteotomy was
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T.H. Lui / Foot and Ankle Surgery 21 (2015) e40–e44
Fig. 3. (A) Injury film of Case 3. (B) Computed tomogram showed displaced osteochondral fracture of the fourth metatarsal head. (C and D) Post-operative X-rays.
Fig. 4. (A and B) X-rays of Case 4 showed displaced fragment of the metatarsal head. (C) Computed tomogram showed displaced fragment of the metatarsal head with notching at the base of proximal phalanx. (D) Magnetic resonance imaging showed bone edema around the metatarsophalangeal joint.
performed at the site of previous MT head fracture (Figs. 5 and 6). At 6-month followup, the osteotomy site healed. There was no pain or tenderness over his right 2nd MTP joint and residual stiffness of the MTP joint. There was no evidence of transfer metatarsalgia. 6. Discussion Isolated osteochondral fracture of the articular surface of the metatarsal head can be missed in the acute phase because of its rarity and the X-rays appearance can be subtle as in case 1 and case
3. The importance of careful clinical and radiological assessment cannot be overemphasized in these rare injuries [1]. Computed tomogram is useful in case of uncertain diagnosis. The fracture involved the dorsal part of the MT head in all cases of this series. The mechanism of injury was considered to be a result of shear force by the base of the proximal phalanx to the metatarsal head [4], but not certain as two of our cases had a delayed presentation. There was no radiograph taken shortly after the injury in case 4 to demonstrate the acute fracture. The differential diagnosis would be Freiberg’s infarction. However, the clinical presentation
T.H. Lui / Foot and Ankle Surgery 21 (2015) e40–e44
e43
Fig. 5. Intra-operative photos of Case 4. (A) Dorsal fragment. (B) Dorsal part of the metatarsal head filled up by fibrous tissue. (C) After dorsal closing wedge osteotomy. (D) Trimming of the metatarsal edge after the osteotomy was closed up and fixed.
Fig. 6. Post-operative X-rays of Case 4.
favored that the condition was followed an acute fracture as the pain started and persisted after an acute injury. Moreover, the computed tomogram showed there was malunion of the fracture with rotation of the fragment and caused notching of the proximal phalanx rather than collapse of the metatarsal head in Freiberg’s infarction. Although the optimal treatment of this fracture had not been established, the goal of treatment should be the same as other intra-articular fractures. Dutkowsky and Freeman [3] described an
isolated, osteochondral fracture of the third metatarsal head which was treated successfully with closed reduction and casting. We agree that conservative treatment is a viable choice if joint congruency can be achieved as in case 1. However, it can be difficult if not impossible to achieve good reduction by closed manipulation as shown in Mereddy [2] and Tanaka’s [4] cases because of the small size of the fragment, rotated or locked fragment and the probable delayed presentation. As with all intraarticular fractures, the greatest prognostic indicator for this
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T.H. Lui / Foot and Ankle Surgery 21 (2015) e40–e44
fracture type is the ability to adequately reduce the joint surface. If this is not achievable by closed manipulation, then open reduction is necessary [1]. In order to preserve the viability of the osteochondral fragment, the procedure has been suggested to be performed within 8 h [2]. Moreover, during open reduction, capsular stripping should be avoided to preserve the extra osseous blood supply [2]. In contrast, delayed open reduction has been successful in Liddle’s case as well as in Case 3 of our series. Residual stiffness of the MTP joint was quite common of this series. It was probably related to the capsular fibrosis associated with intra-articular procedure in the operated cases and prolonged immobilization in the non-operated case. This was particularly severe in Case 2 and can be due to impingement of the plantar plate or the collateral capsuloligamentous structure by the protruded screw tips. In case 4, adequate reduction of the joint surface was not possible. Because of the large size and the presence of a reasonable depth of bony margin, it is likely that microfracture would not have given a healthy congruent joint surface to the prerequisite height [2]. Transplantation with an osteochondral autograft has the problem of mismatch of the shape or cartilage thickness between the graft and recipient site. Additionally, an optimal size plug for this location has yet to be identified [5]. Because the lesion was at the dorsal part of the metatarsal head, intra-articular dorsal closing
wedge osteotomy was performed to restore congruity of the MTP joint [6]. The potential complication of transfer metatarsalgia did not occur in this case.
Conflict of interest None declared.
References [1] Liddle AD, Rosenfeld PF. Locked second metatarsal head fracture: a case report. Foot Ankle Int 2008;29:1054–6. [2] Mereddy PK, Molloy A, Hennessy MS. Osteochondral fracture of the fourth metatarsal head treated by open reduction and internal fixation. J Foot Ankle Surg 2007;46:320–2. [3] Dutkowsky J, Freeman 3rd BL. Fracture-dislocation of the articular surface of the third metatarsal head. Foot Ankle 1989;10:43–4. [4] Tanaka Y, Takakura Y, Kamei S, Tamai S. An unusual osteochondral fracture of the second metatarsal head. The Foot 1995;5:47–9. [5] Tsujii M, Hasegawa M. Subchondral insufficiency fracture of the second metatatarsal head in an elderly woman treated with autologous osteochondral transplantation. Arch Orthop Trauma Surg 2008;128:689–93. [6] Lee SK, Chung MS, Baek GH, Oh JH, Lee YH, Gong HS. Treatment of Freiberg disease with intra-articular dorsal wedge osteotomy and absorbable pin fixation. Foot Ankle Int. 2007;28:43–8.
Contents lists available at ScienceDirect
Foot and Ankle Surgery journal homepage: www.elsevier.com/locate/fas
Case report
Isolated osteochondral fracture of the metatarsal head of lesser toes T.H. Lui MBBS (HK), FRCS (Edin), FHKAM, FHKCOS* Department of Orthopaedics and Traumatology, North District Hospital, 9 Po Kin Road, Sheung Shui, NT, Hong Kong Special Administrative Region
A R T I C L E I N F O
A B S T R A C T
Article history: Received 21 October 2014 Received in revised form 11 January 2015 Accepted 21 January 2015
Isolated fracture of the metatarsal head is very rare and no consensus has been reached regarding their best management. We reported four cases of isolated osteochondral fracture of the metatarsal head with different method of treatment to achieve the common goal of restoration of the congruity of the metatarsal head. ß 2015 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.
Keywords: Metatarsal head Fracture Osteochondral Osteotomy
1. Introduction
3. Case 2
An osteochondral fracture of the metatarsal (MT) head is an uncommon injury and normally co-exists with other fractures of the medially adjacent metatarsals [1,2]. Isolated fracture of the metatarsal head is very rare and no consensus has been reached regarding their best management. The best method for treatment of this fracture is unclear, with both open and closed methods having been used with success [1–4]. We reported four cases of isolated osteochondral fracture of the metatarsal head with different method of treatment to achieve the common goal of restoration of the congruity of the metatarsal head.
A 46 years lady had her right foot hitting on steps. She complained of pain and swelling over her right second toe. She was admitted to our department on the same date. Clinically, there was tenderness over the right second MTP joint. The sensation of her right second toe was intact and the capillary refill was less than 2 s. X-rays showed a displaced osteochondral fracture of her right second MT head with distraction of the MTP joint. Open reduction and internal fixation of the fracture was performed on the same date. Post-operative X-rays showed good reduction of the fracture but there was plantar protrusion of the screw tip. The fracture healed but she complained of painful stiffness of the MTP joint. The screws were removed 10 months later. At 11 months after the removal of screws, the pain subsided and MTP motion improved (Fig. 2).
2. Case 1 A 32 years lady hurt her right foot while she ran up the escalator. She was treated by bonesetter initially and was referred to our clinic 4 weeks later because of persistent pain. There was mild tenderness over her right fourth metatarsal head. X-rays showed isolated osteochondral fracture of the metatarsal head. Computed tomogram showed the metatarsophalangeal joint surface remained congruent (Fig. 1). She was treated conservatively and the fracture healed. Upon 25 months of follow up, the patient did not have any pain except some limitation of plantarflexion of the fourth metatarsophalangeal (MTP) joint.
* Tel.: +852 26837588. E-mail address: [email protected]
4. Case 3 A 14 years girl had her right 4th toe contusion during a football game. X-rays was taken and told to be normal. She consulted our clinic 5 weeks later because of persistent pain. Clinically, there was tenderness over her right 4th MT head. X-rays and computed tomogram showed displaced osteochondral fracture of the 4th MT head. Open reduction and internal fixation was performed (Fig. 3). At 31-month followup, the fracture healed. The patient was able to walk normally with minimal pain, and had a good range of motion of the 4th MTP joint.
http://dx.doi.org/10.1016/j.fas.2015.01.011 1268-7731/ß 2015 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.
T.H. Lui / Foot and Ankle Surgery 21 (2015) e40–e44
e41
Fig. 1. X-rays (A and B) of Case 1 showed the fracture of the fourth metatarsal head. Computed tomogram (C and D) showed the congruency of the fourth metatarsophalangeal joint.
Fig. 2. X-rays (A and B) of Case 2 showed displaced fracture of the second metatarsal head with distraction of the metatarsophalangeal joint. (C) Post-operative X-rays showed protrusion of the screw tip. (D) X-rays after removal of screws.
5. Case 4 A 16 years boy had history of direct contusion of his right second toe resulting in stiffness and on and off pain over the toe. He did not consult any doctor for this injury. He injured his right second toe again during landing from jump 1 year later resulting in severe pain. X-rays and computed tomogram showed an old second metatarsal head fracture with notching at the base of
proximal phalanx. Magnetic resonance imaging showed bone edema around the MTP joint (Fig. 4). A dorsal approach was made and the joint was exposed between the extensor tendons. Intraoperative findings showed the dorsally displaced unhealed MT head fragment with the dorsal part of the MT head filled up with fibrous tissue. The remaining cartilage of the MT was normal. After debridement of the fibrous tissue, there was a significant bone gap at the fracture site. Dorsal closing wedge osteotomy was
e42
T.H. Lui / Foot and Ankle Surgery 21 (2015) e40–e44
Fig. 3. (A) Injury film of Case 3. (B) Computed tomogram showed displaced osteochondral fracture of the fourth metatarsal head. (C and D) Post-operative X-rays.
Fig. 4. (A and B) X-rays of Case 4 showed displaced fragment of the metatarsal head. (C) Computed tomogram showed displaced fragment of the metatarsal head with notching at the base of proximal phalanx. (D) Magnetic resonance imaging showed bone edema around the metatarsophalangeal joint.
performed at the site of previous MT head fracture (Figs. 5 and 6). At 6-month followup, the osteotomy site healed. There was no pain or tenderness over his right 2nd MTP joint and residual stiffness of the MTP joint. There was no evidence of transfer metatarsalgia. 6. Discussion Isolated osteochondral fracture of the articular surface of the metatarsal head can be missed in the acute phase because of its rarity and the X-rays appearance can be subtle as in case 1 and case
3. The importance of careful clinical and radiological assessment cannot be overemphasized in these rare injuries [1]. Computed tomogram is useful in case of uncertain diagnosis. The fracture involved the dorsal part of the MT head in all cases of this series. The mechanism of injury was considered to be a result of shear force by the base of the proximal phalanx to the metatarsal head [4], but not certain as two of our cases had a delayed presentation. There was no radiograph taken shortly after the injury in case 4 to demonstrate the acute fracture. The differential diagnosis would be Freiberg’s infarction. However, the clinical presentation
T.H. Lui / Foot and Ankle Surgery 21 (2015) e40–e44
e43
Fig. 5. Intra-operative photos of Case 4. (A) Dorsal fragment. (B) Dorsal part of the metatarsal head filled up by fibrous tissue. (C) After dorsal closing wedge osteotomy. (D) Trimming of the metatarsal edge after the osteotomy was closed up and fixed.
Fig. 6. Post-operative X-rays of Case 4.
favored that the condition was followed an acute fracture as the pain started and persisted after an acute injury. Moreover, the computed tomogram showed there was malunion of the fracture with rotation of the fragment and caused notching of the proximal phalanx rather than collapse of the metatarsal head in Freiberg’s infarction. Although the optimal treatment of this fracture had not been established, the goal of treatment should be the same as other intra-articular fractures. Dutkowsky and Freeman [3] described an
isolated, osteochondral fracture of the third metatarsal head which was treated successfully with closed reduction and casting. We agree that conservative treatment is a viable choice if joint congruency can be achieved as in case 1. However, it can be difficult if not impossible to achieve good reduction by closed manipulation as shown in Mereddy [2] and Tanaka’s [4] cases because of the small size of the fragment, rotated or locked fragment and the probable delayed presentation. As with all intraarticular fractures, the greatest prognostic indicator for this
e44
T.H. Lui / Foot and Ankle Surgery 21 (2015) e40–e44
fracture type is the ability to adequately reduce the joint surface. If this is not achievable by closed manipulation, then open reduction is necessary [1]. In order to preserve the viability of the osteochondral fragment, the procedure has been suggested to be performed within 8 h [2]. Moreover, during open reduction, capsular stripping should be avoided to preserve the extra osseous blood supply [2]. In contrast, delayed open reduction has been successful in Liddle’s case as well as in Case 3 of our series. Residual stiffness of the MTP joint was quite common of this series. It was probably related to the capsular fibrosis associated with intra-articular procedure in the operated cases and prolonged immobilization in the non-operated case. This was particularly severe in Case 2 and can be due to impingement of the plantar plate or the collateral capsuloligamentous structure by the protruded screw tips. In case 4, adequate reduction of the joint surface was not possible. Because of the large size and the presence of a reasonable depth of bony margin, it is likely that microfracture would not have given a healthy congruent joint surface to the prerequisite height [2]. Transplantation with an osteochondral autograft has the problem of mismatch of the shape or cartilage thickness between the graft and recipient site. Additionally, an optimal size plug for this location has yet to be identified [5]. Because the lesion was at the dorsal part of the metatarsal head, intra-articular dorsal closing
wedge osteotomy was performed to restore congruity of the MTP joint [6]. The potential complication of transfer metatarsalgia did not occur in this case.
Conflict of interest None declared.
References [1] Liddle AD, Rosenfeld PF. Locked second metatarsal head fracture: a case report. Foot Ankle Int 2008;29:1054–6. [2] Mereddy PK, Molloy A, Hennessy MS. Osteochondral fracture of the fourth metatarsal head treated by open reduction and internal fixation. J Foot Ankle Surg 2007;46:320–2. [3] Dutkowsky J, Freeman 3rd BL. Fracture-dislocation of the articular surface of the third metatarsal head. Foot Ankle 1989;10:43–4. [4] Tanaka Y, Takakura Y, Kamei S, Tamai S. An unusual osteochondral fracture of the second metatarsal head. The Foot 1995;5:47–9. [5] Tsujii M, Hasegawa M. Subchondral insufficiency fracture of the second metatatarsal head in an elderly woman treated with autologous osteochondral transplantation. Arch Orthop Trauma Surg 2008;128:689–93. [6] Lee SK, Chung MS, Baek GH, Oh JH, Lee YH, Gong HS. Treatment of Freiberg disease with intra-articular dorsal wedge osteotomy and absorbable pin fixation. Foot Ankle Int. 2007;28:43–8.