Metatarsal Fractures Research Articles

Surgical Intervention for 5th Metatarsal Fracture in the Athlete: A Systematic Review

Category:Midfoot/Forefoot; SportsIntroduction/Purpose:To provide an overview and evaluation of the available evidence on surgical intervention for 5th metatarsal fractures in the athletic population.Methods:PubMed, Cochrane, and Embase databases were systematically reviewed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The level and quality of evidence (LOE and QoE) were recorded and assessed. Return to sport/play (RTS/RTP), radiographic outcomes, complications, reoperations, and revisions were also evaluated.Results:Twenty-eight studies were included in this review spanning a total of 761 patients and 765 fractures. The weighted mean age of the study population was 24 years, and the mean follow-up was 33.8 months. Surgical techniques and fracture types varied across the studies, but the majority (18) used internal fixation. Nonunion occurred in 5.8% (11/190) of patients who received a surgical treatment other than internal fixation, but only in 2.3% (11/480) of patients who received surgical treatment with internal fixation. Patients presenting with acute 5th MTP fractures returned to play significantly faster than those with delayed union 5th MTP fractures (7.6 weeks vs. 11.2 weeks) (p<.001). However, reoperation/revision rates were highest in patients who received surgery for acute 5th MTP fracture, of which 8.3% (16/192) of patients with acute fracture underwent reoperation or revision after surgical management.Conclusion:The current systematic review showed favorable outcomes for the surgical treatment of 5th MTP fractures in the athletic population. Athletes who underwent surgical treatment for an acute 5th MTP fracture returned to play at a faster rate compared to other fracture types but were associated with a high complication rate and a higher reoperation and revision rate.

Between 2000 and 2020, Reimbursement for Orthopaedic Foot and Ankle Surgery Decreased by 30%

PurposeTo examine and analyze Medicare reimbursement rates from 2000 to 2020 for orthopaedic foot and ankle procedures.MethodsThe 20 most used orthopaedic foot and ankle surgical procedures were gathered from the Centers for Medicare & Medicaid Services website using the Medicare Provider Utilization and Payment Data Public Use File 2017. The reimbursement data for each code were gathered from The Physician Fee Schedule Look-Up Tool from Centers for Medicare & Medicaid Services. The reimbursement values were adjusted for inflation to 2020 U.S. dollars using the consumer price index.ResultsThe average inflation-adjusted reimbursement for included procedures decreased by 30% from 2000 to 2020. The greatest mean decreases were observed for “correction of hallux valgus” (–47%) and “partial excision of foot bone” (–41%). The procedures with the smallest mean decreases were observed in “treatment of “Amputation of toe” (–19%) and “closed treatment of metatarsal fracture” (–7%).ConclusionsFrom 2000 to 2020, Inflation-adjusted Medicare reimbursement for foot and ankle surgery decreased by 30%.Level of EvidenceIV; economic analysis.

Screw Length Associated With Fracture Gapping of Fifth Metatarsal Base Fracture With Intramedullary Screw Fixation: A Cadaveric Study

Intramedullary screw fixation is a well-established surgical treatment for fifth metatarsal Jones fractures, due to its minimally invasive nature, and potential early return to activity. Due to the curvature of the fifth metatarsal, optimal length of the screw is needed to prevent gapping at the fracture site. The placement of a straight screw induces straightening of a naturally curved bone. The purpose of this study was to aid surgeons in determining an appropriate screw length for intramedullary fixation of a fifth metatarsal Jones fracture in order to prevent fracture gapping. A transverse osteotomy of the fifth metatarsal was made in 10 cadaver specimens at the level of a traditional Jones fracture. Inserted screws were sequentially increased in length until plantar gapping at the fracture site was noted. The angle (degree) of plantar gapping was measured with each increase in screw length and diameter. The mean length of the cadaveric fifth metatarsals was 73.76 mm (range 67.42-81.73). The mean screw length that caused gapping at the fracture site was 49.89 mm (range 44-55), representing 67.05% (range 61.26-75.35) of the fifth metatarsal length. The correlation coefficient revealed that gapping of the fracture site is most likely to occur when the screw length is 66% the length of the metatarsal length (rs = 0.66; 95% confidence interval: 0.06-0.91; p = .04). The angle of the initial gapping was 2.85° (range 2°-4°). With an incremental increase in screw length, the angle was 3.85° (range 3°-6°), and with an incremental increase in screw diameter, the angle was 3.70° (range 2°-5°). Our study demonstrated that screw lengths exceeding 66% of the metatarsal length lead to plantar fracture gapping. Additionally, gapping was accentuated with larger diameter screws due to angle variance.

What is the diagnostic accuracy of ultrasound versus x-ray for closed metatarsal fractures?

Family Medicine Residency Program at Wesley Medical Center, Wichita, KS The corresponding author is Kari Nilsen; [email protected]. The authors declare no conflicts of interest.

Post-Traumatic Hallux Valgus: A Modified Surgical Technique

Post-traumatic hallux valgus, a turf toe variant, is a rare, yet limiting injury. According to the literature, the deformity has been associated with acute medial collateral ligament tears, turf toe variant injuries, Lisfranc injury patterns, and first metatarsal fractures. There have been few documented cases of post-traumatic hallux valgus secondary to medial collateral ligament tears, and the treatment has been variable. Some authors have described direct end-to-end repair of the ligament to address the deformity, while others have described a modified McBride bunionectomy involving a Silver bunionectomy, lateral soft tissue release, and medial capsular and ligamentous repair. We propose a modified technique similar to the modified McBride bunionectomy, however, with the use of an all-suture anchor in the medial capsular and ligamentous repair. Our belief is that the all-suture anchor will allow for a stronger repair that will meet the physical demands of everyday ambulation and athletic participation. We used this technique in an individual who had evidence of a medial ligamentous complex injury of the hallux on MRI and failed conservative management. Postoperatively, the patient is immobilized until they can begin working on range of motion, strengthening, and finally to achieve return to full activity and sports.

Tarsal tunnel syndrome: current rationale, indications and results.

Tarsal tunnel syndrome (TTS) is a neuropathy due to compression of the posterior tibial nerve and its branches.It is usually underdiagnosed and its aetiology is very diverse. In 20% of cases it is idiopathic.There is no test that diagnoses it with certainty. The diagnosis is usually made by correlating clinical history, imaging tests, nerve conduction studies (NCSs) and electromyography (EMG).A differential diagnosis should be made with plantar fasciitis, lumbosacral radiculopathy (especially S1 radiculopathy), rheumatologic diseases, metatarsal stress fractures and Morton’s neuroma.Conservative management usually gives good results. It includes activity modification, administration of pain relief drugs, physical and rehabilitation medicine, and corticosteroid injections into the tarsal tunnel (to reduce oedema).Abnormally slow nerve conduction through the posterior tibial nerve usually predicts failure of conservative treatment.Indications for surgical treatment are failure of conservative treatment and clear identification of the cause of the entrapment. In these circumstances, the results are usually satisfactory. Surgical success rates vary from 44% to 96%.Surgical treatment involves releasing the flexor retinaculum from its proximal attachment near the medial malleolus down to the sustentaculum tali. Ultrasound-guided tarsal tunnel release is possible.A positive Tinel’s sign before surgery is a strong predictor of surgical relief after decompression.Surgical treatment achieves the best results in young patients, those with a clear aetiology, a positive Tinel’s sign prior to surgery, a short history of symptoms, an early diagnosis and no previous ankle pathology. Cite this article: EFORT Open Rev 2021;6:1140-1147. DOI: 10.1302/2058-5241.6.210031

Less Invasive Surgery With Autologous Bone Grafting for Proximal Fifth Metatarsal Diaphyseal Stress Fractures

Surgery with autologous bone grafting for proximal fifth metatarsal diaphyseal stress fracture has a potential to decrease nonunion, but it is not performed widely as the primary surgery because of donor-site morbidity. We have devised and performed a less invasive surgical procedure with autologous bone grafting and aimed to investigate the clinical and radiologic outcomes of this procedure. The data for 73 patients who underwent primary intramedullary screw fixation with autologous bone grafting from the fifth metatarsal base for proximal fifth metatarsal diaphyseal stress fractures were investigated retrospectively. The clinical and radiologic outcomes were evaluated. The mean time to bone union, starting running, and return to play was 11.8, 6.3, and 13.4 weeks, respectively. Bone union was achieved in 76 of the 78 cases. Intramedullary screw fixation with autologous bone grafting from the fifth metatarsal base showed good outcomes. It may be a useful surgical option for patients with proximal fifth metatarsal diaphyseal stress fractures.

Comparison of the rate of delayed/nonunion in fifth metatarsal fractures receiving anti-inflammatory medications

PurposeControversy exists regarding the acute effect of non-steroidal anti-inflammatory drugs (NSAIDs) on early fracture healing. The purpose of this study was to analyze the rate of nonunion or delayed union in patients with fifth metatarsal (5th MT) fractures. We hypothesize that the use of NSAIDs would increase the rate of nonunion/delayed union in 5th MT fractures.MethodsUsing PearlDiver, a national insurance database was analyzed. ICD codes were used to identify patients diagnosed with 5th MT fracture from 2007-2018. Patients were grouped by initial management (nonoperative vs. open reduction and internal fixation (ORIF) or non/malunion repair within 60 days) and sub-grouped by whether they had been prescribed at least one pre-defined NSAID. Subsequent ORIF or nonunion/malunion repair operative intervention was used as a surrogate for fracture nonunion/delayed union.ResultsOf the 10,991 subjects with a diagnosis of 5th MT, 10,626 (96.7%) underwent initial nonoperative treatment, 1,409 of which (13.3%) received prescription NSAIDS within 60 days of diagnosis. 16/1,409 (1.14%) subjects who received anti-inflammatory prescriptions underwent ORIF or repair of non/malunion at least 60 days after diagnosis while 46/9,217 (0.50%; P=0.003483) subjects who did not receive anti-inflammatory prescriptions underwent ORIF or repair of non/malunion at least 60 days after diagnosis. In the 365 subjects who underwent early repair/ORIF (within 60 days), there was no significant difference in the rate of nonunion/delayed union.ConclusionThe rate of nonunion/delayed union of 5th MT fractures was significantly higher in subjects receiving NSAIDs within 60 days of initial diagnosis in patients managed non-operatively.Level of evidenceLevel III

Functional Effects of 3 Cases of Functional Fifth Metatarsal Fracture Treatment in Athletes

Functional Effects of 3 Cases of Functional Fifth Metatarsal Fracture Treatment in Athletes

Short leg cast versus orthotic removable support for the management of pseudo-Jones avulsion fracture: A systematic review and meta-analysis

BackgroundThe fifth metatarsal base avulsion fracture (i.e., Pseudo-Jones fracture) is one of the most common foot fractures. The management of pseudo-Jones fractures could be carried out surgically or conservatively. This systematic review and meta-analysis aimed to provide an update about the efficacy of orthotic removable support compared to short-leg casting for individuals with pseudo-Jones fracture. MethodsWe searched Embase, Medline, and Cochrane Central register of Controlled Trials (CENTRAL) for randomized controlled trials (RCTs) that compared the clinical outcomes of orthotic removable support and short-leg cast for adult individuals with a fifth metatarsal base avulsion fracture. We used 95% as a confidence level and P <0.05 as a threshold. The standardized mean difference (SMD) was used for the continuous outcomes, and the risk ratio (RR) was used for the dichotomous outcomes. ResultsA total of 6 RCTs incorporating 403 individuals out were deemed eligible. There was no significant difference between orthotic removable support and short-leg casting regarding AOFAS score (standardized mean difference (SMD)= 0.31, 95% CI -0.17 to 0.8), pain on VAS score (SMD= -0.08, 95% CI -0.39 to 0.22), VAS-FA score (SMD= 0.22, 95% CI -0.19 to 0.62) EQ-5D VAS score, and non-union rate (RR=0.37, 95% CI 0.05 to 2.74). ConclusionThe current meta-analysis reveals that there is no difference between orthotic removable support and short-leg casting for the conservative management of individuals sustaining pseudo-Jones fracture.

The Fifth Metatarsal Shaft Fracture Is Well Treated With Benign Neglect.

Background. Spiral fifth metatarsal fractures have been studied previously in professional dancers. However, little has been reported about outcomes of these injuries in the general population. The objective of this study was to examine patient demographics of those who sustain this injury and their functional outcomes, as stratified by treatment type. Methods. A total of 186 "nonprofessional dancer" patients with a fifth metatarsal fracture who were treated by one orthopaedic surgeon at our academic medical center were identified through chart review. All patients were allowed to weight bearing as tolerated (WBAT). Time to healing, persistence of pain, range of motion, and complications were recorded. Independent samples t tests, 1-way analysis of variance, and Fisher exact tests were used for analysis. Results. Thirty-seven of the 186 patients with fifth metatarsal fractures reviewed were identified as having a spiral fifth metatarsal fracture with appropriate follow-up. The cohort was 78.4% female with a mean age of 50.3 years. Twenty-two were initially treated in a controlled ankle motion (CAM) boot, 14 in a postoperative shoe, and 1 continued in their own shoes. All patients were allowed to WBAT. All fractures healed by a mean of 3.1 months. By the end of the follow-up period, 67.6% of patients had full range of ankle motion, with 5.4% reporting feeling stiff, 27.0% reporting mild persistent pain, and 2.7% reporting significant persistent pain. Conclusion. Fifth metatarsal shaft ("Dancer's") fractures occur within the general population, not only among professional dancers. Without operative fixation and regardless of nonoperative treatment selected, these fractures heal reliably and do so without clinically relevant complication.Level of Evidence: Level III: Retrospective comparative study.

In-Situ Fracture Tolerance of the Metatarsals During Quasi-Static Compressive Loading of the Human Foot.

Accidental foot injuries including metatarsal fractures commonly result from compressive loading. The ability of personal protective equipment to prevent these traumatic injuries depends on the understanding of metatarsal fracture tolerance. However, the in situ fracture tolerance of the metatarsals under direct compressive loading to the foot's dorsal surface remains unexplored, even though the metatarsals are the most commonly fractured bones in the foot. The goal of this study was to quantify the in situ fracture tolerance of the metatarsals under simulated quasi-static compressive loading. Fresh-frozen cadaveric feet (n = 10) were mounted into a testing apparatus to replicate a natural stance and loaded at the midmetatarsals with a cylindrical bar to simulate a crushing-type injury. A 900 N compressive force was initially applied, followed by 225 N successive load increments. Specimens were examined using X-ray imaging between load increments to assess for the presence of metatarsal fractures. Descriptive statistics were conducted for metatarsal fracture force and deformation. Pearson correlation tests were used to quantify the correlation between fracture force with age and body mass index (BMI). The force and deformation at fracture were 1861 ± 642 N (mean ± standard deviation) and 22.6 ± 3.4 mm, respectively. Fracture force was correlated with donor BMI (r = 0.90). Every fractured specimen experienced a transverse fracture in the second metatarsal. New biomechanical data from this study further quantify the metatarsal fracture risk under compressive loading and will help to improve the development and testing of improved personal protective equipment for the foot to avoid catastrophic injury.

The Metatarsal Cortical Index as an Indicator of Insufficiency Fracture of the Foot

The diagnosis of metatarsal stress fractures is challenging. Standard imaging often shows false-negative results. The aim of this study was to create reliable radiologic outcome parameters to predict insufficiency fractures of the metatarsals. We performed an age- and sex-matched case-control study of patients with (n = 18) and without insufficiency fracture (n = 18) of the foot. The metatarsal cortical index (MCI) for each metatarsal was developed to predict an insufficiency fracture. The MCI of each metatarsal was significantly decreased in the insufficiency fracture group compared with the control group (p < .01). The MCI of the fourth ray yielded the highest area under the curve among the analyzed MCI values (area under the curve, 0.79; 95% confidence interval, 0.61-0.90). A cut-off value of 1.62 for the MCI of the fourth ray yielded a sensitivity of 78% and a specificity of 78% to predict insufficiency fracture of the foot (odds ratio, 12.25; 95% confidence interval, 2.54-58.97), and enabled accurate allocation to the insufficiency fracture group versus the control group in 74% of cases. In conclusion, a decreased MCI is associated with metatarsal insufficiency fractures and enables an accurate diagnosis in 3 out of 4 cases. The MCI might aid clinicians in identifying insufficiency fracture, and raise the suspicion of the diagnosis without additional imaging studies.

A problem-based approach in musculoskeletal ultrasonography: central metatarsalgia.

Ultrasonography (US) is a useful diagnostic method that can be easily applied to identify the cause of metatarsalgia. The superficial location of structures in the foot, dynamic capability of US, and the ability to perform direct real-time evaluations of the pain site are also strong advantages of US as a modality for examining the foot. Moreover, knowing the possible pain sources to investigate when a patient has a specific site of pain will enhance the diagnostic quality of US, and will help radiologists to perform US efficiently and effectively. The purpose of this article is to review the common etiologies of metatarsalgia including Morton’s neuroma, plantar plate injury, synovitis, tenosynovitis, bursitis, and metatarsal fractures, and to discuss their US features.

Conservative management of Jones fractures with immediate weight-bearing in a walking boot demonstrates healing

Jones fractures, or proximal metatarsal fractures at the level of the fourth and fifth intermetatarsal junction, have a high risk for nonunion due to a vascular watershed region. Classically, treatment consists of weight bearing restrictions in a cast or surgical fixation. Some studies have assessed immediate weight bearing following a Jones fracture. Due to conflicting results, the most appropriate treatment method remains unclear. This study analyzes outcomes after treating adults with acute Jones fractures non-operatively without weight bearing restrictions in a walking boot. This study hypothesizes that patients will not require future operative intervention following functional treatment.A retrospective review of 55 adult patients who sustained acute, closed Jones fractures was conducted. 47 were treated weight bearing as tolerated (WBAT) in a walking boot and eight were treated non-weight bearing (NWB) in a cast. They were followed radiographically by an orthopedic surgeon for an average of 6.4 and 15.5 months, respectively.Three patients in each group (6.4% WBAT, 37.5% NWB) developed painful nonunion leading to surgical fixation. Thirty (66.7%) patients in the WBAT group demonstrated radiographic union on final radiographs. Only two (13.3%) of the 15 patients with partial union were seen at least six months from time of injury, one of whom had ongoing pain but declined surgery. The remaining 13 patients were asymptomatic at their final clinic appointment.Controversy still exists as to the best treatment methodology for acute Jones fractures. Due to a lack of clear guidelines, it can be difficult for the multiple medical specialties involved to evaluate and treat this injury. Our study suggests that non-operative management of minimally displaced Jones fractures, in the adult, low demand population, without weight bearing restrictions in a walking boot offers similar outcomes to cast immobilization with weight bearing restrictions, resulting in bony union or asymptomatic fibrous nonunion.

The Effectiveness of Intramedullary Screw Fixation Using the Herbert Screw for Fifth Metatarsal Stress Fractures in High-Level Athletes

Background: Intramedullary screw fixation is the most common operative procedure used for treatment of fifth metatarsal stress fractures in athletes. However, the optimal implant in intramedullary screw fixation is still being investigated. Purpose: To review experiences with intramedullary screw fixation using the Herbert screw for fifth metatarsal stress fractures in high-level athletes. Study Design: Case series; Level of evidence, 4. Methods: The authors retrospectively analyzed 37 high-level athletes (Tegner activity score ≥7) who underwent intramedullary screw fixation using the Herbert screw for fifth metatarsal stress fractures between August 2005 and August 2017. The minimum follow-up period of the patients was 2 years. In assessing the surgical results, time to obtain bone union, time to return to original level of sport participation, and treatment failures/complications were reviewed. Additionally, the effect of intraoperative plantar gap widening caused by the screw insertion was analyzed. The surgical results of the 2 groups, the no-gap group (intraoperative plantar gap widening, <1 mm) and the gap group (intraoperative plantar gap widening, ≥1 mm), were compared, while correlations between intraoperative plantar gap widening and the surgical results were statistically analyzed. Results: Bone union and return to the original sport were attained in all patients without treatment failures/complications such as delayed union, nonunion, or refracture. The mean time to obtain bone union was 10.1 weeks, and the mean time to return to sport was 10.9 weeks. In comparing the no-gap group (n = 16) and the gap group (n = 21), no significant differences in the time to obtain bone union (P = .392) or to return to sport (P = .399) were noted. Additionally, there was no correlation between intraoperative plantar gap widening and the time to obtain bone union (r = 0.131; P = .428) or to return to sport (r = 0.160; P = .331). Conclusion: The use of the Herbert screw for intramedullary screw fixation to treat fifth metatarsal stress fractures in high-level athletes provided satisfactory results enabling all the athletes to return to the original sport without treatment failures/complications. Additionally, intraoperative plantar gap widening does not affect the surgical results using this technique.

Comparison between Conservative and Surgical Treatment of Base of Fifth Metatarsal Fracture

Comparison between Conservative and Surgical Treatment of Base of Fifth Metatarsal Fracture

Management of Compound Metatarsal Fractures under Tamil Nadu Accident and Emergency Care Initiative

Management of Compound Metatarsal Fractures under Tamil Nadu Accident and Emergency Care Initiative

Jones type fifth metatarsal fracture fixation in athletes: A review and current concept.

Jones type fifth metatarsal fracture is a common occurrence among athletes at all levels. These fractures may occur due to several mechanisms, but inversions and twisting injuries are considered some of the leading causes in sports. However, while Jones fracture incidences are frequent in the sporting world, there is still a lack of consensus on how such fractures should be effectively managed. There are numerous treatment options for patients with fifth metatarsal Jones fractures. The role of nonoperative treatment remains controversial, with concerns about delayed union and nonunion. Surgical stabilization of metatarsal Jones fractures is therefore often recommended for athletes, as it is often associated with a low number of complications and a higher rate of union than nonoperative management. This review will focus on literature regarding the prevalence of Jones type fifth metatarsal fracture, alongside the efficacy of both conservative and surgical treatment within this population.

Fifth Metatarsal Fracture–A Systematic Review of the Treatment of Fractures of the Base of the Fifth Metatarsal Bone.

Metatarsal fractures are among the most common foot and ankle injuries, with an annual incidence of 6.7 per 100 000 persons. Approximately 30% of metatarsal fractures affect the base of the fifth metatarsal bone. Nevertheless, no evidence-based treatment recommendations are available to date. The three fracture localizations according to Lawrence and Botte (zone I, proximal to the intermetatarsal joint between the fourth and fifth metatarsal bones; zone II, in the area of the joint; zone III, at the distal end of the joint) are analyzed on the basis of a systematic literature search. Studies were included that compared the treatment of two types of fracture in the same manner, or that compared two different treatments for a single type of fracture. Nine studies compared different treatments of zone I fractures. Two of these were randomized controlled trials (RCTs); in one RCT, patients given functional therapy returned to work much sooner than those treated with immobilization (11 vs. 28 days; p = 0.001), with otherwise similar outcomes. The non-randomized studies revealed a faster return to full function (33 vs. 46 days; p<0.05) with early functional therapy, and similar outcomes for immobilization and surgery. One RCT that compared functional therapy with immobilization for zone II fractures revealed no statistically significant difference. Five studies compared fractures in zones I and II that were treated in the same manner, revealing similar outcomes. One RCT compared surgery and immobilization for zone III fractures: surgery led to statistically significant improvement of the outcome in all of the measured parameters. Fractures in zones I and II should be treated with early functional therapy. There seems to be no reason to consider zone I and II fractures as two separate entities, as the outcomes in the two groups are similar. In contrast, fractures in zone III should primarily be treated surgically.