March Fracture

Abstract

“March fracture” is a term applied to a fracture occurring typically in infantry recruits during training periods involving a great deal of marching. In contrast to the usual fracture, a march fracture does not result from a single definite traumatism. Formerly thought to be limited to the metatarsal bones, march fractures have now been reported by various authors in most of the weight-bearing bones of the lower extremity and pelvis (3). The terms “fatigue fracture,” “stress fracture,” “strain fracture,” “insufficiency fracture,” and “skaters' fracture” are synonymous with “march fracture.” In civilians the condition is said to occur with some frequency in waitresses, shop attendants, and nurses as a result of the prolonged walking and standing in their respective occupations (4); a similar fracture has been reported in children (5). Etiological Considerations The war program of infantry training was extremely strenuous, being planned to condition physically and train the recruit as a soldier within a period of a few months. The introduction of “speed marches” and prolonged hikes up to twenty-five miles placed a severe burden on the physique of the soldier in training. Practically every soldier was subject to much greater physical stress in the army than he had been as a civilian. As a result, march fractures were of common occurrence in the infantry troops undergoing training. In our experience these fractures are confined to no particular type of individual. We believe that they occur in a bone which is unused to strenuous activity and which has not accommodated itself quickly enough to accept the increased stress placed upon it. March fractures are at a minimum in well seasoned troops, in whom conditioning has apparently added tensile strength to bone and related structures. The exact mechanism of the fracture has not been proved. Recently Breck and Higinbotham (2) have popularized the theory that the fracture occurs as a result of a molecular rearrangement of the bone, due to multiple small traumata; this rearrangement is thought to render the bone brittle and liable to fracture. Watson-Jones (6) describes the fracture as a simple crack fracture, which is so fine in character that it is frequently missed; it is not until new callus appears that the typical roentgen findings are present. Symptomatology and Findings The typical complaint is pain following a march, during which the soldier had been unable to keep up with his company. The pain is usually well localized to the affected area, which is tender on palpation. Gross swelling is evident on examination in case of the subcutaneous bones of the foot and leg. Motion of the adjacent joints in their extreme ranges may produce slight pain. In contrast to traumatic fractures, the ecchymosis due to soft-tissue injury is absent. By far the most frequent site of march fracture is the shaft of a metatarsal, particularly the second or third (Fig. 1).