Metatarsal Stress Fracture

Abstract

HISTORY: B.B. is a 15 year-old male with a 4 week history of left foot pain. The pain was mostly noted when running. He was participating in country, soccer and track where he was currently running the 400 m. He was exercising on a high level of intensity for 12–15 hours weekly. There were no constitutional symptoms including no fever or night sweats. He had no previous history of similar pain. He could not recall any specific event or trauma. The symptoms improved by non-weight bearing conditioning (stationary bike) and intermittently icing but did not resolve. The medical and family histories were normal. PHYSICAL EXAMINATION: 15 y/o male in good health and well nourished Gait: Weight bearing without limp Foot: Normal sensation, FROM with good strength. Provocative Test: Toe raise with mild discomfort 5 hop test decreased due to pain. Palpation: 4th and 5th metatarsal discomfort midshaft Hip, Knee normal exam with good axis alignment DIFFERENTIAL DIAGNOSIS: Metatarsal stress fracture Neuroma Peroneus brevis avulsion fracture TEST AND RESULTS: Plain radiographs Initial: Healing stress fracture of the midshaft of the fourth metatarsal with no displacement or angulation. FINAL WORKING DIAGNOSIS: 4th metatarsal midshaft stress fracture TREATMENT AND OUTCOMES: NSAID's as needed for pain No high impact activity (jumping, running) for next 3 weeks until good bony healing achieved Weight bearing allowed with stiff sole shoes as long as foot remains pain free. Follow up visit showed clinical and radiological evidence of continued fracture therefore treatment in a walking boot was initiated. Patient developed over next 6 weeks delayed union of the fracture site. Eventually good healing of fracture after a prolonged time of CAM walker treatment and non weight bearing exercise for three months. Remote follow-up at 6 months after initial presentation, outpatient physical therapy to rehabilitate deconditioning from immobilization. Patient is biomechanically sound and able to run pain free. DISCUSSION:It is well known that 5th metatarsal fracture has a propensity for delayed union, non union and has a high risk of refracture whereas the 3rd usually runs an uncomplicated course. Treatment option includes non-weight-bearing cast immobilization for 6 weeks or intramedullary screw fixation.Although the 4th metatarsal stress fractures is general considered as a low risk stress fracture similar to the 3rd a review of the literature showed very few articles of suggested treatment, outcome and complication of 4th metatarsal fractures.