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Metatarsal fractures
Injury, Int. J. Care Injured (2004) 35, S-B77—S-B86
Metatarsal fractures Stefan Rammelt, Jan Heineck, Hans Zwipp Department of Trauma and Reconstructive Surgery, University Hospital “Carl Gustav Carus”, Dresden, Germany
KEYWORDS: Metatarsal fractures; Stress fractures; Nonoperative treatment; Internal fixation; Corrective osteotomy.
Summary1 Metatarsal fractures are relatively common and if malunited, a frequent source of pain and disability. Nondisplaced fractures and fractures of the second to fourth metatarsal with displacement in the horizontal plane can be treated conservatively with protected weight bearing in a cast shoe for 4—6 weeks. In most displaced fractures, closed reduction can be achieved but maintenance of the reduction needs internal fixation. Percutaneous pinning is suitable for most fractures of the lesser metatarsals. Fractures with joint involvement and multiple fragments frequently require open reduction and plate fixation. Transverse fractures at the metaphyseal-diaphyseal junction of the fifth metatarsal (“Jones fractures”) require an individualized approach tailored to the level of activity and time to union. Avulsion fractures of the fifth metatarsal bone are treated by open reduction and tension-band wiring or screw fixation if displaced more than 2 mm or with more that 30% of the joint involved. The metatarsals are the most common site of stress fractures, most of which are treated nonoperatively. Symptomatic posttraumatic deformities need adequate correction, in most cases by osteotomy across the former fracture site.
Metatarsal fractures are frequent injuries to the foot that may lead to prolonged disability in cases of malunion or nonunion. If adequately assessed, these fractures are easy to treat and have a generally favorable prognosis [1, 3, 8, 11, 17, 29, 43, 44]. Treatment aims to restore alignment of the five metatarsals, thus preserving the longitudinal and transverse arch of the forefoot and a normal weight distribution under the metatarsal heads. If these goals are not achieved, disabling metatarsalgia is a common consequence [33, 36, 47, 48].
ten times as frequent as Lisfranc fracture-dislocations [41]. In children, 61% of all fractures of the foot are located in the metatarsal bones [45]. Because of their anatomical exposure, most metatarsal fractures in children occur at the fifth (41%) and the first (19%) ray [45]. In a review of industrial injuries, the fifth metatarsal (including fractures at the base) was the most commonly fractured (23%) followed by the third metatarsal [15]. Furthermore, the metatarsals are the most common site of stress fractures in the human skeleton, the most commonly affected being the second, third, and fifth at their proximal third [6, 9, 25, 40].
Epidemiology Fractures of the metatarsal bones are among the most common injuries to the foot. They are about
1
Abstracts in German, French, Italian, Spanish, Japanese, and Russian are printed at the end of this supplement.
Mechanism of injury Metatarsal fractures may result either from direct or indirect violence, and they display a wide variety of injuries ranging from isolated, simple fractures
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of one metatarsal to crush injuries with serial fractures and severe soft tissue compromise [47]. Direct trauma is common in industrial workers who have a heavy object fall on the foot. Indirect trauma occurs when the leg and hindfoot are twisted with the forefoot fixed. The base of the fifth metatarsal is the end point of the “supination fracture line” as described by Hellpap [12]. Therefore, avulsion fractures of the fifth metatarsal base (“tennis fracture”) may occur as a result of supination (inversion) injuries to the foot [1, 4, 28]. The appealing theory that these fractures result from the pull of the peroneus brevis tendon during rapid inversion has not been reproduced in cadaveric experiments. Rather, the lateral band of the plantar aponeurosis has been identified as a possible cause of avulsion fractures of the tuberosity, since it inserts right at the tip [32]. The peroneus brevis tendon has a broad lateral insertion and may contribute to further dislocation [4, 39]. Stress fractures result from repetitive force, as seen in athletes, ballet dancers, and soldiers (especially recruits), hence the historical term “march fracture” [2]. Several risk factors have been reported for stress fractures of the second metatarsal including a hyperload syndrome secondary to a short or unstable first ray, eg, after a Keller-Brandes procedure or in Morton’s foot, amenorrhea, anorexia nervosa, and prolonged hypoestrogenism [25, 42].
Assessment Patients with metatarsal fractures complain about pain on ambulation or the impossibility of weight bearing. The forefoot is swollen and tender to palpation. Gross deformities are only seen with complex injury patterns including serial fractures and additional toe dislocations. Radiographic assessment includes three standard views of the foot in anteroposterior, 45° oblique, and lateral projection. For the diagnosis of metatarsal overload in posttraumatic deformities anteroposterior and lateral weight-bearing x-rays of the whole
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foot as well as a tangential view of the metatarsal heads under weight bearing is helpful (Fig. 1). Acute stress fractures are frequently not detected with standard x-rays. Repeated films about 10—14 days after the onset of symptoms show a radiolucent resorption gap around the fracture that confirms the diagnosis [6, 9]. Alternatively, Technetium scans and MRI have a high sensitivity in detecting stress fractures. In cases of serial fractures of the metatarsal bases, CT scanning is advised to rule out a Lisfranc fracture-dislocation. Ligamentous instability at the Lisfranc joint is revealed on stress x-rays (passive abduction and adduction of the forefoot) under local anesthesia. When interpreting x-rays, anatomical variants such as the os peroneum (within the peroneus longus tendon), the os vesalianum (within the peroneus brevis tendon), the os intermetatarseum, and the os cuneometatarsale have to be borne in mind as well as the apophysis at the base of the fifth metatarsal that is visible between 9 and 11 years in girls and between 11 and 14 years in boys [4].
Classification Topographically, metatarsal fractures are subdivided into fractures of the metatarsal head, subcapital, midshaft, and basal fractures. Fractures of the fifth metatarsal have been classified by Dameron [4] and later Quill [28] as tuberosity avulsion fractures (zone 1), metaphyseal-diaphyseal junction fractures (zone 2), and proximal shaft stress fractures (zone 3). This classification is aimed at avoiding the imprecise and indiscriminate use of the term “Jones fracture”. This fracture, first described by Sir Robert Jones in 1902 in four cases including his own foot [16], was defined by Stewart [38] as a transverse fracture at the metaphyseal/diaphyseal junction that is characterized by a watershed in blood supply [37]. The AO-ICI classification of the foot discriminates between extraarticular fractures (type A), intraarticular fractures (type B), and fracture-dislocations (type C). Pure dislocations, such as the “floating metatarsal” are
Fig. 1: Technique (a) for obtaining the tangential view (b) of the metatarsal heads under weight bearing.
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classified as type D. The exact extent of the injury is classified in subgroups (see article by Zwipp et al in this issue for details). Torg et al [40] classified fractures at the fifth metatarsal base proximal to the tuberosity into three types according to their healing potential and radiographic appearance. The authors distinguished between acute fractures without signs of intramedullary sclerosis (representing early stress fractures with a periosteal reaction), delayed fracture healing with a widened fracture line and intramedullary sclerosis, and manifest nonunions with complete obliteration of the intramedullary canal.
Treatment indications In general, all undisplaced metatarsal fractures including stress fractures can be treated nonoperatively. Stress fractures in professional athletes have to be addressed individually, depending on the functional demand of the patient to avoid prolonged courses of immobilization or protection. Fractures of the second to fourth metatarsal that are only displaced in the frontal plane without shortening of the respective ray can also be treated nonoperatively [33, 47]. Fractures of the first and fifth metatarsal with displacement in the transverse (horizontal) plane should be corrected to avoid secondary deformities with altered load distribution such as posttraumatic hallux valgus and digitus quintus varus [33, 47]. Metatarsal fractures that are displaced in the sagittal plane may lead to an altered weight distribution under the metatarsal heads resulting in painful callosities, mechanical metatarsalgia, and even neuroma formation and should therefore be treated surgically [47]. Shereff [36] recommends reduction of any fracture with displacement of more than 3—4 mm and angulation of more than 10 degrees.
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Fractures of the fifth metatarsal base have good healing potential because they are located in cancellous bone. However, malunions at the base of the fifth metatarsal adversely affect the function of the Lisfranc joint complex, which exerts the greatest range of motion at its lateral aspect. It is recommended that these fractures be treated with open reduction and internal fixation if displaced more than 2 mm and with more than 30% of the joint involved [11, 31].
Nonoperative treatment Numerous modalities of nonoperative treatment have been described for undisplaced metatarsal fractures. In general, immobilization and unloading of the metatarsals are recommended for 3—5 weeks. Treatment options include adhesive strapping or compression dressing in combination with a wooden sole or a stiff-soled boot for 3—5 weeks [15], weight bearing as tolerated in a medial longitudinal arch support with unloading of the metatarsal heads [23], a short leg walking cast for 4—6 weeks [36] or a non weight-bearing cast for 3 weeks followed by a walking cast for another 3 weeks [5]. In the authors’ practice, a split lower leg cast is applied for 3—5 days and antiphlogistic drugs are administered [11, 47]. When the soft tissue swelling has subsided, a well-fitting plastic cast shoe (“Lopresti slipper”) is applied to support the foot arch (Fig. 2). This shoe is worn for 3—5 weeks under weight bearing as tolerated. Recommendations for nonoperative treatment of avulsion fractures at the base of the fifth metatarsal range from elastic dressing only to lower leg cast [8, 13, 43, 44]. In our practice, minimally or nondisplaced fractures are treated with initial casting until the swelling subsides followed by application of an ankle orthosis (Caligamed®) that prevents supination for 6 weeks [11]. Shereff [36] describes closed reduction with the use of Chinese fingertraps and subsequent immobilization in a short leg cast from the tibial Tubercule de Chaput to the tips of the toes. However, maintaining the reduction of a completely dislocated metatarsal neck fracture has been reported to be highly uncertain [22]. If the postreduction x-rays show residual displacement, surgical treatment is advocated.
Operative treatment Fig. 2: Hard plastic cast shoe allowing free movement of the ankle.
Open metatarsal fractures are treated according to general guidelines that include debridement, lavage, external fixation or minimal internal fixation,
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the use of antibiotics, and planned second-look surgery. In severe crush injuries with closed soft tissue damage, acute compartment syndrome of the foot has to be ruled out. Most displaced closed metatarsal fractures can be reduced by closed means but remain unstable after reduction thus requiring internal fixation for retention. A variety of implants is employed, ranging from percutaneous K-wires to plates and screws from the AO small fragment system (3.5 mm), the AO Foot Set (2.7 mm) or several minifragment systems
(AO, Leibinger, Mondeal). Most of these osteosyntheses only allow partial weight bearing and need additional protection for the time of bone healing as described above.
Fig. 3: Midshaft fracture of the first metatarsal (a, b) treated with closed reduction and crossed K-wires (c, d).
Fig. 4: Technique of percutaneous pinning of metatarsal shaft fractures (technique recommended by the AO, adapted from [46]). The K-wire should be inserted through the base of the proximal phalanx to avoid dorsal subluxation of the distal fragment and the toe.
First metatarsal The first metatarsal bone carries twice the load of each of the lateral four during the stance phase of gait [36] and must therefore be carefully reconstructed. Closed reduction of displaced fractures may be attempted. Due to the pull of the intrinsic and extrinsic muscles, fractures of the first metatarsal are difficult to retain after closed reduction and frequently require internal fixation. In midshaft fractures, stable fixation can be achieved with two crossed K-wires of 1.8—2 mm diameter (Fig. 3). These implants cause only minimal additional damage to the soft tissues, especially in fractures with severe soft tissue compromise. Fractures with multiple fragments are best fixed with plates via a straight lateral approach [10]. Plates should be applied to the medial-plantar aspect of the first metatarsal because of the thin and vulnerable soft tissue layer on the dorsal aspect. Fractures of the base, neck, and head of the first metatarsal that involve the tarsometatarsal and metatarsophalangeal joint should be carefully reconstructed with anatomically shaped plates of the minifragment system to prevent painful joint incongruities and posttraumatic arthritis. Care should also be taken to correct displacement in the transverse (horizontal) plane to avoid consecutive deformities such as a posttraumatic hallux valgus or varus [47].
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Second to fourth metatarsal The rigid ligamentous anchoring between the heads of these bones provides protection against displacement of simple fractures [22]. With higher forces of displacement these fractures tend to be multiple and frequently displaced [1]. In subcapital fractures, the head tends to move plantarly and oblique fractures of the shaft tend to shorten with the pull of the intrinsic muscles. The aim of treatment is to reconstruct the length and axis in the sagittal plane, while dislocation in the transverse plane can be tolerated to a certain degree. Retrograde percutaneous pinning is the treatment of choice for simple fractures of the second to fourth metatarsal [33, 46]. K-wires should be inserted percutaneously and distally through the base of the proximal phalanx (Fig. 4) under fluoroscopic guidance [46]. When inserting the K-wire through the metatarsal head, plantarflexion of the distal fragment and dorsiflexion of the adjacent toe will result. For better control of the distal fragment and the toe, holding the head of the proximal phalanx
Fig. 5: Serial fracture of the second to fourth metatarsal base with subluxation in the lateral Lisfranc joint complex and severe damage to the soft tissue (a). Wound debridement, open reduction of the displaced third to fifth metatarsal, and internal fixation with K-wires was carried out (b). Temporary wound closure was achieved with skin substitute, fixed with wound staples over the second metatarsal.
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with a sharp reduction clamp percutaneously is recommended. Small distal or proximal fragments, multiple fragmentation of the shaft or intervening soft tissue reduction may render closed reduction impossible (Fig. 5). If open reduction becomes necessary, the K-wire should be inserted in an antegrade fashion through the fracture into the distal fragment and proximal phalanx and then way back over the fracture into the proximal fragment [10]. Alternatively, in fractures of the metatarsal head or neck with small or multiple fragments, minifragment plates may be used.
Fifth metatarsal The fifth metatarsal bone has the widest range of motion of all metatarsals and, except for the base, only loose ligamentous connections to the fourth metatarsal. Therefore fractures of the shaft should be treated by internal fixation because nonsurgical treatment will regularly result in displacement. In contrast to the second to fourth metatarsals, K-wires
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can be inserted through the tuberosity into the distal fragment. Heim and Pfeiffer [10] recommended plating rather than pinning because of the easy access to the bone and the more stable fixation of this rather mobile metatarsal bone (Fig. 6). The typically nondisplaced “Jones fracture”, a transversal fracture between the proximal metaphysis and the diaphysis (Fig. 7), has a reputation for
Fig. 6: Displaced midshaft fracture of the fifth metatarsal (a, b) treated by open reduction and internal fixation with an AO minifragment plate (c, d).
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protracted fracture healing due to the poor vascular supply and instability of this fracture between the fixed base and the loose shaft [17, 21, 37]. Acute, nondisplaced Jones fractures are usually treated with restricted weight bearing and immobilization for 6—8 weeks (20, 28). Radiographic bone healing occurs medially to laterally and lags behind clinical healing by weeks to months [24]. Surgical treatment should be considered in high-performance athletes or in cases of delayed fracture healing beyond ten weeks [20, 28, 40]. Quill [28] has advocated early surgical intervention with medullary screw fixation or bone grafting because he observed from the literature that about one third of these fractures went on to closed refracture if followed long enough. When approaching fractures of the proximal shaft one has to differentiate between acute traumatic injuries, early stress fractures, delayed healing, and nonunion [40]. These four entities have approximately the same incidence at first presentation
Fig. 7: Jones fracture at the metaphyseal-diaphyseal junction proximal to the fifth metatarsal.
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Fig. 8: Nonunion after a Jones fracture (a, b) treated with curettage, bone grafting, and compression from a 4-hole LC-DCP from the AO modular foot set with 3.5 mm cortex screws (c, d).
[43]. Trauma history, medullary sclerosis, periosteal reaction, and the width of the fracture gap have to be considered when making the diagnosis. Acute stress fractures can be treated nonsurgically [4, 17, 21, 40]. In cases of delayed healing, a medullary screw or inlay bone grafting is recommended by some authors, especially in professional athletes [18, 21, 40]. The choice of treatment for nonunions depends on the periosteal reaction. If there is a strong periosteal reaction, sufficient stability is achieved with either medullary screw or plate fixation. If there is considerable intramedullary sclerosis and no periosteal reaction, curettage of the sclerotic bone and autogenous corticocancellous bone grafting is advocated [21, 40]. Glasgow et al [7] analyzed failed surgical management of fractures at the fifth metatarsal base in eleven cases. They concluded that inadequate screw size, undersized corticocancellous grafts, and incomplete reaming of the medullary canal correlated with failure. In addition, early return to vigorous physical activity was believed to have played a role in delayed union and refracture. In biomechanical studies, maximizing the screw diameter did not appear to be critical for a stable fixation but it increased the risk of intra or postoperative fracture [19, 35]. The newly designed 4-hole low contact dynamic compression plate from the AO modular foot set represents an alternative to the intramedullary screw for managing metatarsal nonunions (Fig. 8). Displaced fractures of the base of the fifth metatarsal are treated with open reduction and internal fixation. Care is taken to realign the joint surface
to the cuboid. Our treatment of choice is tension band wiring (Fig. 9), but fixation with a small fragment screw appears to be equally effective. A 4.0 mm partially threaded cancellous screw engaging two cortices provided significantly superior fixation strength over tension banding in a biomechanical study [14]. The clinical relevance of these findings is not clear because the functional results appear to be equal and small fragments may not be amenable
Fig. 9: Avulsion fracture of the fifth metatarsal base with joint displacement (a) treated by open reduction and tension band wiring (b).
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to screw fixation without risking further fragmentation. Aftertreatment is the same as in the nonsurgical procedure [9, 26].
Results Apart from the fifth metatarsal, no systematic outcome studies report results after metatarsal fractures. In general, fractures of the fifth metatarsal tuberosity have a good prognosis. Bauer and Zeithammel [3] reported 23 good to excellent results in 25 patients treated operatively. We have observed no nonunions and no residual pain in a preliminary series of ten patients treated with tension band wiring at an average 29 months of follow-up [11]. Dameron [4] saw only one nonunion in 100 patients with fractures of the “flare” of the tuberosity with the apophysis still being visible who were treated with an elastic bandage and weight bearing as tolerated. However, in 20 patients with fractures of the proximal shaft (Jones fractures), 25% nonunions requiring bone grafting were seen. Kavanaugh et al (18) even observed delayed union in twelve of 18 conservatively treated Jones fractures (66.7%). In their whole series of 23 fractures, 13 (56.5%) were eventually treated operatively. Torg et al [40] noted one delayed union in 15 acute Jones fractures when treated with non weight bearing, while six of ten patients treated with a weight-bearing cast developed delayed union or nonunion. Of ten patients with delayed union, seven healed in a mean of 15 months and three required bone grafting for nonunion. The authors concluded that immobilization without weight bearing is the treatment of choice and that given enough time most of the delayed unions will heal if vigorous activity is avoided. This level of inactivity will be unacceptable to active patients, particularly to athletes. Josefsson et al [17] noted that late surgery was required for delayed unions and refractures in 12% after acute and in 50% of chronic Jones fractures. The functional results were uniformly good at a 5-year follow-up, irrespective of the initial treatment. Recently, more aggressive treatment of Jones fractures has been advocated to avoid prolonged immobilization [27, 28]. Portland et al [27] reported a 100% union rate in 22 patients treated with immediate screw fixation. The average time to union was 6.2 weeks in acute fractures and 8.3 weeks in stress fractures with intramedullary sclerosis. When treating avulsion fractures of the fifth metatarsal base nonoperatively, Wiener et al [44] saw an earlier return to work and superior clinical scores in patients treated with a soft dressing compared to a short leg cast without union being compromised, which amounted to 100% in this
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series of 60 patients. Saxena et al [34] reported five fractures of the proximal fourth metatarsal in athletes. The authors reported similar long healing times and residual symptoms as with proximal fifth metatarsal fractures. O’Malley et al [25] followed 51 professional dancers with 64 stress fractures of the second metatarsal that were treated symptomatically except for six patients. The dancers returned to performance in an average of 6.2 weeks. 14% still had occasional pain with dancing and 12% had a refracture at an average of 4.3 years.
Posttraumatic deformities Deformities in the sagittal plane and in length will result in overload of the affected metatarsal if the distal fragment is fixed in plantar flexion. Overload of the adjacent metatarsals will occur if the formerly fractured metatarsal is shortened and/or dorsiflexed. Displacement in the transverse plane in the first and fifth ray will result in toe deformities (eg, hallux valgus and digitus quintus varus). Preoperative planning includes dorsoplantar and lateral weight-bearing x-rays of the foot and tangential weight-bearing views of the metatarsals. The treatment of choice is a corrective osteotomy at the site of the former fracture [48]. These may be difficult to perform especially in malunited fractures of the metatarsal head or neck because of disuse osteopenia. In these cases, a standard oblique sliding osteotomy as described by Reikeras [30] is a good alternative.
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8. Gösele A, Schulenburg J, Ochsner PE (1997) [Early functional treatment of a 5th metatarsal fracture using an orthopedic boot.] Swiss Surg; 3(2):81—84. 9. Harrington T, Crichton KJ, Anderson IF (1993) Overuse ballet injury of the base of the second metatarsal: a diagnostic problem. J Sports Med Am; 21(4):591—598. 10. Heim U, Pfeiffer KM (1988) Periphere Osteosynthesen. Berlin, Heidelberg, New York: Springer. 11. Heineck J, Liebscher T, Zwipp H (2001) [Fifth metatarsal base avulsion fractures] Orthop Traumatol; 9:141—147. 12. Hellpap W (1963) [The neglected lower ankle. The ”fracture“ line of supination.] Arch Orthop Unfallchir; 55:289—300. 13. Holzach P, Staubli B, Gerber B (1983) Die Behandlung der Basisfraktur des Os metatarsale V. Helv Chir Acta; 50:69—72. 14. Husain ZS, DeFronzo DJ (2000) Relative stability of tension band versus two-cortex screw fixation for treating fifth metatarsal base avulsion fractures. J Foot Ankle Surg; 39(2):89—95. 15. Johnson VS (1976) Treatment of fractures of the forefoot in industry. In: Bateman JE. Foot science. Philadelphia: W B Saunders. 16. Jones R (1902) Fracture of the base of the fifth metatarsal bone by indirect violence. Ann Surg; 35:697—700. 17. Josefsson PO, Karlsson M, Redlund-Johnell I, et al. (1994) Jones fracture. Surgical versus nonsurgical treatment. Clin Orthop:252—255. 18. Kavanaugh JH, Brower TD, Mann RV (1978) The Jones fracture revisited. J Bone Joint Surg Am; 60(6):776—782. 19. Kelly IP, Glisson RR, Fink C, et al. (2001) Intramedullary screw fixation of Jones fractures. Foot Ankle Int; 22:585—589. 20. Lawrence SJ, Botte MJ (1983) Jones‘ fractures and related fractures of the proximal fifth metatarsal. Foot Ankle; 14:358—365. 21. Lehman RC, Torg JS, Pavlov H, et al. (1987) Fractures of the base of the fifth metatarsal distal to the tuberosity: a review. Foot Ankle; 7:245—252. 22. Lindholm R (1961) Operative treatment of dislocated simple fracture of the neck of the metatarsal bone. Ann Chir Gynecol Tenn; 50:328—331.
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tures.] Arch Orthop Unfallchir; 72(2):139—155. 30. Reikeras O (1983) Metatarsal osteotomy for relief of metatarsalgia. Arch Orthop Trauma Surg; 101(3):177—178. 31. Rettig AC, Shelbourne KD, Wilckens J (1992) The surgical treatment of symptomatic nonunions of the proximal (metaphyseal) fifth metatarsal in athletes. Am J Sports Med; 20(1):50—54. 32. Richli WR, Rosenthal DI (1984) Avulsion fracture of the fifth metatarsal: experimental study of pathomechanics. AJR Am J Roentgenol; 143(4):889—891. 33. Sanders R (1999) Fractures of the midfoot and forefoot. In: Mann RA, Coughlin MJ. Surgery of the foot and ankle. St Louis: Mosby:1574—1605. 34. Saxena A, Krisdakumtorn T, Erickson S (2001) Proximal fourth metatarsal injuries in athletes: similarity to proximal fifth metatarsal injury. Foot Ankle Int; 22(7):603-608. 35. Shah SN, Knoblich GO, Lindsey DP, et al. (2001) Intramedullary screw fixation of proximal fifth metatarsal fractures: a biomechanical study. Foot Ankle Int; 22:581-584. 36. Shereff MJ (1990) Fractures of the forefoot. Instr Course Lect; 39:133—140. 37. Smith JW, Arnoczky SP, Hersh A (1992) The intraosseous blood supply of the fifth metatarsal: implications for proximal fracture healing. Foot Ankle; 13(3):143—152. 38. Stewart IM (1960) Jones’s fracture: fracture of the base of the fifth metatarsal. Clin Orthop; 16:190—198. 39. Theodorou DJ, Theodorou SJ, Kakitsubata Y, et al. (2003) Fractures of proximal portion of fifth metatarsal bone: anatomic and imaging evidence of a pathogenesis of avulsion of the plantar aponeurosis and the short peroneal muscle tendon. Radiology; 226:857—865. 40. Torg JS, Balduini FC, Zelko RR, et al. (1984) Fractures of the base of the fifth metatarsal distal to the tuberosity. Classification and guidelines for non-surgical and surgical management. J Bone Joint Surg Am; 66:209—214. 41. Vuori JP, Aro HT (1993) Lisfranc joint injuries: trauma mechanisms and associated injuries. J Trauma; 35(1):40—45.
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44. Wiener BD, Linder JF, Giattini JF (1997) Treatment of fractures of the fifth metatarsal: a prospective study. Foot Ankle Int; 18(5):267—269.
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27. Portland G, Kelikian A, Kodros S (2003) Acute surgical management of Jones‘ fractures. Foot Ankle Int; 24(11):829—833. 28. Quill GEJ (1995) Fractures of the proximal fifth metatarsal. Orthop Clin North Am; 26:353—361. 29. Reichelt A, Derkmann G (1972) [Therapy of metatarsal frac-
46. Zwipp H (1994) Chirurgie des Fußes. Wien - New York: Springer-Verlag. 47. Zwipp H, Rammelt S (2002) Frakturen und Luxationen. In: Wirth CJ. Orthopädie und Orthopädische Chirurgie. Fuß. Stuttgart, New York: Georg Thieme Verlag:531—618. 48. Zwipp H, Rammelt S (2003) [Posttraumatic deformity correction at the foot.] Zentralbl Chir; 128:218—226.
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Correspondence address: Dr. med. Stefan Rammelt Klinik und Poliklinik für Unfall- und Wiederherstellungschirurgie Universitätsklinikum “Carl Gustav Carus” Fetscherstr. 74 01307 Dresden phone: +49 (351) 458 3777 fax: +49 (351) 458 4307 email: [email protected]
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Metatarsal fractures Stefan Rammelt, Jan Heineck, Hans Zwipp Department of Trauma and Reconstructive Surgery, University Hospital “Carl Gustav Carus”, Dresden, Germany
KEYWORDS: Metatarsal fractures; Stress fractures; Nonoperative treatment; Internal fixation; Corrective osteotomy.
Summary1 Metatarsal fractures are relatively common and if malunited, a frequent source of pain and disability. Nondisplaced fractures and fractures of the second to fourth metatarsal with displacement in the horizontal plane can be treated conservatively with protected weight bearing in a cast shoe for 4—6 weeks. In most displaced fractures, closed reduction can be achieved but maintenance of the reduction needs internal fixation. Percutaneous pinning is suitable for most fractures of the lesser metatarsals. Fractures with joint involvement and multiple fragments frequently require open reduction and plate fixation. Transverse fractures at the metaphyseal-diaphyseal junction of the fifth metatarsal (“Jones fractures”) require an individualized approach tailored to the level of activity and time to union. Avulsion fractures of the fifth metatarsal bone are treated by open reduction and tension-band wiring or screw fixation if displaced more than 2 mm or with more that 30% of the joint involved. The metatarsals are the most common site of stress fractures, most of which are treated nonoperatively. Symptomatic posttraumatic deformities need adequate correction, in most cases by osteotomy across the former fracture site.
Metatarsal fractures are frequent injuries to the foot that may lead to prolonged disability in cases of malunion or nonunion. If adequately assessed, these fractures are easy to treat and have a generally favorable prognosis [1, 3, 8, 11, 17, 29, 43, 44]. Treatment aims to restore alignment of the five metatarsals, thus preserving the longitudinal and transverse arch of the forefoot and a normal weight distribution under the metatarsal heads. If these goals are not achieved, disabling metatarsalgia is a common consequence [33, 36, 47, 48].
ten times as frequent as Lisfranc fracture-dislocations [41]. In children, 61% of all fractures of the foot are located in the metatarsal bones [45]. Because of their anatomical exposure, most metatarsal fractures in children occur at the fifth (41%) and the first (19%) ray [45]. In a review of industrial injuries, the fifth metatarsal (including fractures at the base) was the most commonly fractured (23%) followed by the third metatarsal [15]. Furthermore, the metatarsals are the most common site of stress fractures in the human skeleton, the most commonly affected being the second, third, and fifth at their proximal third [6, 9, 25, 40].
Epidemiology Fractures of the metatarsal bones are among the most common injuries to the foot. They are about
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Mechanism of injury Metatarsal fractures may result either from direct or indirect violence, and they display a wide variety of injuries ranging from isolated, simple fractures
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of one metatarsal to crush injuries with serial fractures and severe soft tissue compromise [47]. Direct trauma is common in industrial workers who have a heavy object fall on the foot. Indirect trauma occurs when the leg and hindfoot are twisted with the forefoot fixed. The base of the fifth metatarsal is the end point of the “supination fracture line” as described by Hellpap [12]. Therefore, avulsion fractures of the fifth metatarsal base (“tennis fracture”) may occur as a result of supination (inversion) injuries to the foot [1, 4, 28]. The appealing theory that these fractures result from the pull of the peroneus brevis tendon during rapid inversion has not been reproduced in cadaveric experiments. Rather, the lateral band of the plantar aponeurosis has been identified as a possible cause of avulsion fractures of the tuberosity, since it inserts right at the tip [32]. The peroneus brevis tendon has a broad lateral insertion and may contribute to further dislocation [4, 39]. Stress fractures result from repetitive force, as seen in athletes, ballet dancers, and soldiers (especially recruits), hence the historical term “march fracture” [2]. Several risk factors have been reported for stress fractures of the second metatarsal including a hyperload syndrome secondary to a short or unstable first ray, eg, after a Keller-Brandes procedure or in Morton’s foot, amenorrhea, anorexia nervosa, and prolonged hypoestrogenism [25, 42].
Assessment Patients with metatarsal fractures complain about pain on ambulation or the impossibility of weight bearing. The forefoot is swollen and tender to palpation. Gross deformities are only seen with complex injury patterns including serial fractures and additional toe dislocations. Radiographic assessment includes three standard views of the foot in anteroposterior, 45° oblique, and lateral projection. For the diagnosis of metatarsal overload in posttraumatic deformities anteroposterior and lateral weight-bearing x-rays of the whole
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foot as well as a tangential view of the metatarsal heads under weight bearing is helpful (Fig. 1). Acute stress fractures are frequently not detected with standard x-rays. Repeated films about 10—14 days after the onset of symptoms show a radiolucent resorption gap around the fracture that confirms the diagnosis [6, 9]. Alternatively, Technetium scans and MRI have a high sensitivity in detecting stress fractures. In cases of serial fractures of the metatarsal bases, CT scanning is advised to rule out a Lisfranc fracture-dislocation. Ligamentous instability at the Lisfranc joint is revealed on stress x-rays (passive abduction and adduction of the forefoot) under local anesthesia. When interpreting x-rays, anatomical variants such as the os peroneum (within the peroneus longus tendon), the os vesalianum (within the peroneus brevis tendon), the os intermetatarseum, and the os cuneometatarsale have to be borne in mind as well as the apophysis at the base of the fifth metatarsal that is visible between 9 and 11 years in girls and between 11 and 14 years in boys [4].
Classification Topographically, metatarsal fractures are subdivided into fractures of the metatarsal head, subcapital, midshaft, and basal fractures. Fractures of the fifth metatarsal have been classified by Dameron [4] and later Quill [28] as tuberosity avulsion fractures (zone 1), metaphyseal-diaphyseal junction fractures (zone 2), and proximal shaft stress fractures (zone 3). This classification is aimed at avoiding the imprecise and indiscriminate use of the term “Jones fracture”. This fracture, first described by Sir Robert Jones in 1902 in four cases including his own foot [16], was defined by Stewart [38] as a transverse fracture at the metaphyseal/diaphyseal junction that is characterized by a watershed in blood supply [37]. The AO-ICI classification of the foot discriminates between extraarticular fractures (type A), intraarticular fractures (type B), and fracture-dislocations (type C). Pure dislocations, such as the “floating metatarsal” are
Fig. 1: Technique (a) for obtaining the tangential view (b) of the metatarsal heads under weight bearing.
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classified as type D. The exact extent of the injury is classified in subgroups (see article by Zwipp et al in this issue for details). Torg et al [40] classified fractures at the fifth metatarsal base proximal to the tuberosity into three types according to their healing potential and radiographic appearance. The authors distinguished between acute fractures without signs of intramedullary sclerosis (representing early stress fractures with a periosteal reaction), delayed fracture healing with a widened fracture line and intramedullary sclerosis, and manifest nonunions with complete obliteration of the intramedullary canal.
Treatment indications In general, all undisplaced metatarsal fractures including stress fractures can be treated nonoperatively. Stress fractures in professional athletes have to be addressed individually, depending on the functional demand of the patient to avoid prolonged courses of immobilization or protection. Fractures of the second to fourth metatarsal that are only displaced in the frontal plane without shortening of the respective ray can also be treated nonoperatively [33, 47]. Fractures of the first and fifth metatarsal with displacement in the transverse (horizontal) plane should be corrected to avoid secondary deformities with altered load distribution such as posttraumatic hallux valgus and digitus quintus varus [33, 47]. Metatarsal fractures that are displaced in the sagittal plane may lead to an altered weight distribution under the metatarsal heads resulting in painful callosities, mechanical metatarsalgia, and even neuroma formation and should therefore be treated surgically [47]. Shereff [36] recommends reduction of any fracture with displacement of more than 3—4 mm and angulation of more than 10 degrees.
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Fractures of the fifth metatarsal base have good healing potential because they are located in cancellous bone. However, malunions at the base of the fifth metatarsal adversely affect the function of the Lisfranc joint complex, which exerts the greatest range of motion at its lateral aspect. It is recommended that these fractures be treated with open reduction and internal fixation if displaced more than 2 mm and with more than 30% of the joint involved [11, 31].
Nonoperative treatment Numerous modalities of nonoperative treatment have been described for undisplaced metatarsal fractures. In general, immobilization and unloading of the metatarsals are recommended for 3—5 weeks. Treatment options include adhesive strapping or compression dressing in combination with a wooden sole or a stiff-soled boot for 3—5 weeks [15], weight bearing as tolerated in a medial longitudinal arch support with unloading of the metatarsal heads [23], a short leg walking cast for 4—6 weeks [36] or a non weight-bearing cast for 3 weeks followed by a walking cast for another 3 weeks [5]. In the authors’ practice, a split lower leg cast is applied for 3—5 days and antiphlogistic drugs are administered [11, 47]. When the soft tissue swelling has subsided, a well-fitting plastic cast shoe (“Lopresti slipper”) is applied to support the foot arch (Fig. 2). This shoe is worn for 3—5 weeks under weight bearing as tolerated. Recommendations for nonoperative treatment of avulsion fractures at the base of the fifth metatarsal range from elastic dressing only to lower leg cast [8, 13, 43, 44]. In our practice, minimally or nondisplaced fractures are treated with initial casting until the swelling subsides followed by application of an ankle orthosis (Caligamed®) that prevents supination for 6 weeks [11]. Shereff [36] describes closed reduction with the use of Chinese fingertraps and subsequent immobilization in a short leg cast from the tibial Tubercule de Chaput to the tips of the toes. However, maintaining the reduction of a completely dislocated metatarsal neck fracture has been reported to be highly uncertain [22]. If the postreduction x-rays show residual displacement, surgical treatment is advocated.
Operative treatment Fig. 2: Hard plastic cast shoe allowing free movement of the ankle.
Open metatarsal fractures are treated according to general guidelines that include debridement, lavage, external fixation or minimal internal fixation,
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the use of antibiotics, and planned second-look surgery. In severe crush injuries with closed soft tissue damage, acute compartment syndrome of the foot has to be ruled out. Most displaced closed metatarsal fractures can be reduced by closed means but remain unstable after reduction thus requiring internal fixation for retention. A variety of implants is employed, ranging from percutaneous K-wires to plates and screws from the AO small fragment system (3.5 mm), the AO Foot Set (2.7 mm) or several minifragment systems
(AO, Leibinger, Mondeal). Most of these osteosyntheses only allow partial weight bearing and need additional protection for the time of bone healing as described above.
Fig. 3: Midshaft fracture of the first metatarsal (a, b) treated with closed reduction and crossed K-wires (c, d).
Fig. 4: Technique of percutaneous pinning of metatarsal shaft fractures (technique recommended by the AO, adapted from [46]). The K-wire should be inserted through the base of the proximal phalanx to avoid dorsal subluxation of the distal fragment and the toe.
First metatarsal The first metatarsal bone carries twice the load of each of the lateral four during the stance phase of gait [36] and must therefore be carefully reconstructed. Closed reduction of displaced fractures may be attempted. Due to the pull of the intrinsic and extrinsic muscles, fractures of the first metatarsal are difficult to retain after closed reduction and frequently require internal fixation. In midshaft fractures, stable fixation can be achieved with two crossed K-wires of 1.8—2 mm diameter (Fig. 3). These implants cause only minimal additional damage to the soft tissues, especially in fractures with severe soft tissue compromise. Fractures with multiple fragments are best fixed with plates via a straight lateral approach [10]. Plates should be applied to the medial-plantar aspect of the first metatarsal because of the thin and vulnerable soft tissue layer on the dorsal aspect. Fractures of the base, neck, and head of the first metatarsal that involve the tarsometatarsal and metatarsophalangeal joint should be carefully reconstructed with anatomically shaped plates of the minifragment system to prevent painful joint incongruities and posttraumatic arthritis. Care should also be taken to correct displacement in the transverse (horizontal) plane to avoid consecutive deformities such as a posttraumatic hallux valgus or varus [47].
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Second to fourth metatarsal The rigid ligamentous anchoring between the heads of these bones provides protection against displacement of simple fractures [22]. With higher forces of displacement these fractures tend to be multiple and frequently displaced [1]. In subcapital fractures, the head tends to move plantarly and oblique fractures of the shaft tend to shorten with the pull of the intrinsic muscles. The aim of treatment is to reconstruct the length and axis in the sagittal plane, while dislocation in the transverse plane can be tolerated to a certain degree. Retrograde percutaneous pinning is the treatment of choice for simple fractures of the second to fourth metatarsal [33, 46]. K-wires should be inserted percutaneously and distally through the base of the proximal phalanx (Fig. 4) under fluoroscopic guidance [46]. When inserting the K-wire through the metatarsal head, plantarflexion of the distal fragment and dorsiflexion of the adjacent toe will result. For better control of the distal fragment and the toe, holding the head of the proximal phalanx
Fig. 5: Serial fracture of the second to fourth metatarsal base with subluxation in the lateral Lisfranc joint complex and severe damage to the soft tissue (a). Wound debridement, open reduction of the displaced third to fifth metatarsal, and internal fixation with K-wires was carried out (b). Temporary wound closure was achieved with skin substitute, fixed with wound staples over the second metatarsal.
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with a sharp reduction clamp percutaneously is recommended. Small distal or proximal fragments, multiple fragmentation of the shaft or intervening soft tissue reduction may render closed reduction impossible (Fig. 5). If open reduction becomes necessary, the K-wire should be inserted in an antegrade fashion through the fracture into the distal fragment and proximal phalanx and then way back over the fracture into the proximal fragment [10]. Alternatively, in fractures of the metatarsal head or neck with small or multiple fragments, minifragment plates may be used.
Fifth metatarsal The fifth metatarsal bone has the widest range of motion of all metatarsals and, except for the base, only loose ligamentous connections to the fourth metatarsal. Therefore fractures of the shaft should be treated by internal fixation because nonsurgical treatment will regularly result in displacement. In contrast to the second to fourth metatarsals, K-wires
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can be inserted through the tuberosity into the distal fragment. Heim and Pfeiffer [10] recommended plating rather than pinning because of the easy access to the bone and the more stable fixation of this rather mobile metatarsal bone (Fig. 6). The typically nondisplaced “Jones fracture”, a transversal fracture between the proximal metaphysis and the diaphysis (Fig. 7), has a reputation for
Fig. 6: Displaced midshaft fracture of the fifth metatarsal (a, b) treated by open reduction and internal fixation with an AO minifragment plate (c, d).
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protracted fracture healing due to the poor vascular supply and instability of this fracture between the fixed base and the loose shaft [17, 21, 37]. Acute, nondisplaced Jones fractures are usually treated with restricted weight bearing and immobilization for 6—8 weeks (20, 28). Radiographic bone healing occurs medially to laterally and lags behind clinical healing by weeks to months [24]. Surgical treatment should be considered in high-performance athletes or in cases of delayed fracture healing beyond ten weeks [20, 28, 40]. Quill [28] has advocated early surgical intervention with medullary screw fixation or bone grafting because he observed from the literature that about one third of these fractures went on to closed refracture if followed long enough. When approaching fractures of the proximal shaft one has to differentiate between acute traumatic injuries, early stress fractures, delayed healing, and nonunion [40]. These four entities have approximately the same incidence at first presentation
Fig. 7: Jones fracture at the metaphyseal-diaphyseal junction proximal to the fifth metatarsal.
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Fig. 8: Nonunion after a Jones fracture (a, b) treated with curettage, bone grafting, and compression from a 4-hole LC-DCP from the AO modular foot set with 3.5 mm cortex screws (c, d).
[43]. Trauma history, medullary sclerosis, periosteal reaction, and the width of the fracture gap have to be considered when making the diagnosis. Acute stress fractures can be treated nonsurgically [4, 17, 21, 40]. In cases of delayed healing, a medullary screw or inlay bone grafting is recommended by some authors, especially in professional athletes [18, 21, 40]. The choice of treatment for nonunions depends on the periosteal reaction. If there is a strong periosteal reaction, sufficient stability is achieved with either medullary screw or plate fixation. If there is considerable intramedullary sclerosis and no periosteal reaction, curettage of the sclerotic bone and autogenous corticocancellous bone grafting is advocated [21, 40]. Glasgow et al [7] analyzed failed surgical management of fractures at the fifth metatarsal base in eleven cases. They concluded that inadequate screw size, undersized corticocancellous grafts, and incomplete reaming of the medullary canal correlated with failure. In addition, early return to vigorous physical activity was believed to have played a role in delayed union and refracture. In biomechanical studies, maximizing the screw diameter did not appear to be critical for a stable fixation but it increased the risk of intra or postoperative fracture [19, 35]. The newly designed 4-hole low contact dynamic compression plate from the AO modular foot set represents an alternative to the intramedullary screw for managing metatarsal nonunions (Fig. 8). Displaced fractures of the base of the fifth metatarsal are treated with open reduction and internal fixation. Care is taken to realign the joint surface
to the cuboid. Our treatment of choice is tension band wiring (Fig. 9), but fixation with a small fragment screw appears to be equally effective. A 4.0 mm partially threaded cancellous screw engaging two cortices provided significantly superior fixation strength over tension banding in a biomechanical study [14]. The clinical relevance of these findings is not clear because the functional results appear to be equal and small fragments may not be amenable
Fig. 9: Avulsion fracture of the fifth metatarsal base with joint displacement (a) treated by open reduction and tension band wiring (b).
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to screw fixation without risking further fragmentation. Aftertreatment is the same as in the nonsurgical procedure [9, 26].
Results Apart from the fifth metatarsal, no systematic outcome studies report results after metatarsal fractures. In general, fractures of the fifth metatarsal tuberosity have a good prognosis. Bauer and Zeithammel [3] reported 23 good to excellent results in 25 patients treated operatively. We have observed no nonunions and no residual pain in a preliminary series of ten patients treated with tension band wiring at an average 29 months of follow-up [11]. Dameron [4] saw only one nonunion in 100 patients with fractures of the “flare” of the tuberosity with the apophysis still being visible who were treated with an elastic bandage and weight bearing as tolerated. However, in 20 patients with fractures of the proximal shaft (Jones fractures), 25% nonunions requiring bone grafting were seen. Kavanaugh et al (18) even observed delayed union in twelve of 18 conservatively treated Jones fractures (66.7%). In their whole series of 23 fractures, 13 (56.5%) were eventually treated operatively. Torg et al [40] noted one delayed union in 15 acute Jones fractures when treated with non weight bearing, while six of ten patients treated with a weight-bearing cast developed delayed union or nonunion. Of ten patients with delayed union, seven healed in a mean of 15 months and three required bone grafting for nonunion. The authors concluded that immobilization without weight bearing is the treatment of choice and that given enough time most of the delayed unions will heal if vigorous activity is avoided. This level of inactivity will be unacceptable to active patients, particularly to athletes. Josefsson et al [17] noted that late surgery was required for delayed unions and refractures in 12% after acute and in 50% of chronic Jones fractures. The functional results were uniformly good at a 5-year follow-up, irrespective of the initial treatment. Recently, more aggressive treatment of Jones fractures has been advocated to avoid prolonged immobilization [27, 28]. Portland et al [27] reported a 100% union rate in 22 patients treated with immediate screw fixation. The average time to union was 6.2 weeks in acute fractures and 8.3 weeks in stress fractures with intramedullary sclerosis. When treating avulsion fractures of the fifth metatarsal base nonoperatively, Wiener et al [44] saw an earlier return to work and superior clinical scores in patients treated with a soft dressing compared to a short leg cast without union being compromised, which amounted to 100% in this
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series of 60 patients. Saxena et al [34] reported five fractures of the proximal fourth metatarsal in athletes. The authors reported similar long healing times and residual symptoms as with proximal fifth metatarsal fractures. O’Malley et al [25] followed 51 professional dancers with 64 stress fractures of the second metatarsal that were treated symptomatically except for six patients. The dancers returned to performance in an average of 6.2 weeks. 14% still had occasional pain with dancing and 12% had a refracture at an average of 4.3 years.
Posttraumatic deformities Deformities in the sagittal plane and in length will result in overload of the affected metatarsal if the distal fragment is fixed in plantar flexion. Overload of the adjacent metatarsals will occur if the formerly fractured metatarsal is shortened and/or dorsiflexed. Displacement in the transverse plane in the first and fifth ray will result in toe deformities (eg, hallux valgus and digitus quintus varus). Preoperative planning includes dorsoplantar and lateral weight-bearing x-rays of the foot and tangential weight-bearing views of the metatarsals. The treatment of choice is a corrective osteotomy at the site of the former fracture [48]. These may be difficult to perform especially in malunited fractures of the metatarsal head or neck because of disuse osteopenia. In these cases, a standard oblique sliding osteotomy as described by Reikeras [30] is a good alternative.
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Correspondence address: Dr. med. Stefan Rammelt Klinik und Poliklinik für Unfall- und Wiederherstellungschirurgie Universitätsklinikum “Carl Gustav Carus” Fetscherstr. 74 01307 Dresden phone: +49 (351) 458 3777 fax: +49 (351) 458 4307 email: [email protected]
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