Dan Preece DPM, PGY-1
Stress Fx Frequency /Distribution:
-second metatarsal 52%
-third metatarsal 35%
-first metatarsal 8%
-fourth and fifth metatarsals 5%
**shorter first metatarsal of Morton's foot leads to a higher
risk of second metatarsal stress fractures
1: Drez D Jr, Young J, Johnston R, Parker W: Metatarsal stress fractures. Am J Sports Med 8:123-125, 1980
2: Leabhart J: Stress fractures of the calcaneus. J Bone Joint Surg Am 41:1285-1290, 1959.
Factors that can increase the risk of fractures
(and stress fractures:
-cavus foot conformation
-long second metatarsal (e.g. Morton's foot)
-metatarsus adductus
-amenorrhea (hypoestrogenism)
-hyperthyroidism
-osteoporosis
-medications
-tobacco
-alcohol abuse
-nutritional problems
-anemic disorders
-training errors
-poor footwear
-improper athletic technique
3: Daffner R, Pavlov H: Stress fractures: Current concepts. Am J Radiol 159:245-252, 1992.
Etiology and Description of Stress Fractures:
- Microfractures  Stress Reactions  Cortical Fracture.
- Stress fxs occur by cyclic loading that does not exceed the ultimate
breaking limits of plastic deformation of bone.
- One possible cause of stress fracture is muscle fatigue, which decreases
shock-absorbing capacity of the extremity.
- Repetitive force exerted by a muscle on bone
3: Daffner R, Pavlov H: Stress fractures: Current concepts. Am J Radiol 159:245-252, 1992.
Biomechanical Causes of Metatarsal Stress Fxs:
-Dorsal strains are significantly reduced by
contraction of the plantar flexory
musculature.
- Fatigue of these muscles during strenuous or
prolonged running may result in decreased
dissipation of forces by the musculature
and increased exposure of the metatarsals
to stress.
4: Brukner P, Bradshaw C, Khan KM, et al. Stress fractures: a review of 180 cases. Clin J Sport Med. 1996;6(2):85–9.
Clinical Presentation of Stress Fxs:
- Metatarsal stress fxs have a much faster onset than similar injuries of the tibia and
fibula.
- The average time to presentation ranges from 2 to 6 weeks
- Can occur with a single training event or military exercise.
- Pain to direct palpation and through ROM, also pain, redness, swelling present.
5: Milgrom C, Finestone A, Sharkey N, et al: Metatarsal strains are sufficient to cause fracture during cyclic loading. Foot Ankle Int 23(3):230-235, 2002
Stress Fractures:
- Imaging:
-Plain films may not show changes for > 10 days. Changes may be evident
in only 30% to 70% of cases.
-Bone Scan: 99Tc bone scan is extremely sensitive, and uptake may be
evident within 24 hours of injury (not specific however) .
-MRI is highly sensitive and specific, particularly to identifying location.
-CT is helpful to define a fx line and to determine whether the fx is
complete or incomplete.
6: Matheson G, Clements D, McKenzie D, et al: Stress fractures in athletes: A study of 320 cases. Am J Sports Med 15:46-58, 1987.
US in Dx of Stress Fractures:
-Forty-one feet were analyzed with US and dedicated MRI from 37 patients.
-MRI detected 13 fractures in 12 patients.
-US was 83% sensitive, 76% specific. Positive predictive value 59%,
and negative predictive value 92%.
-In cases of normal radiographs, US is indicated in the diagnosis of
metatarsal bone stress fractures, as it is a low cost, noninvasive,
rapid, and easy technique with good sensitivity and specificity.
7: F Banal, F Etchepare, B Rouhier, C Rosenberg, V Foltz, S Rozenberg. Ultrasound ability in early diagnosis of stress fracture of metatarsal bone. Ann Rheum Dis. 2006 July; 65(7): 977–978.
Stress Fx Treatment:
-Activity restriction 4-8+ weeks.
-Immobilization: depends on the duration of symptoms before the patient
presenting for treatment. Longer duration: more severe injury.
-Serial radiography used to document bony union.
-Correct contributing factors : training techniques and footwear.
-Return to activity is allowed when radiographic healing is noted and tenderness has
completely resolved.
-Recurrent stress fractures are uncommon in the absence of metabolic or endocrine
disorders, and they rarely recur at the same site
8: K, Hahn S, Chung M, et al: A clinical study of stress fractures in sports activities. Orthopedics 15:1089-1095, 1991.
Metatarsal Fx’s:
-Frequency: 5th  3rd  2nd  1st  4th (different frequency than stress fx’s)
-MCC:
-Direct force: crushing, blunt trauma, penetrating wounds.
-Indirect force: twisting injury (forepart of the foot is fixed as the pt turns)
-Who?
Most commonly: athletes, diabetics
(worse with longer duration), men.
-Diabetic neuropathy: has been associated
with osteopenia in both hands
and feet as well as metatarsal fxs.
16: Cundy, TF, Edmonds, ME, Watkins, PJ. Osteopenia and metatarsal fractures
in diabetic neuropathy. Diabet Med 1985; 2:461.
9: Sammarco GJ: The Jones fracture. Instr Course Lect 42:201-205, 1993.
10: DeLee JC, Evans JP, Julian J. Stress fracture of the fifth metatarsal. Am J Sports Med 1983;11:349-353.
 A 6-month study showed that metatarsal fractures
accounted for (majority are 1st and 5th met fx):
 35% of foot fractures,
 6% of foot injuries,
 5% of skeletal fractures,
 0.2% of emergency department visits.
11: SPECTOR FC, KARLIN JM, SCURRAN BL, ET AL: Lesser metatarsal fractures: incidence, management, and review. JAPA 74: 259, 1984.
Unstable Foot Types Leads to Stress Overload: hypermobile 1st and/or 5th rays
causes overload of the lesser mets.
GRF
GRF
Surgical Approach: consider the complex soft tissue
anatomy that surrounds, inserts or originates from
each of the central metatarsals.
-Fractures of the proximal shaft
and base must be evaluated for
ligamentous disruption.
- Manipulation under anesthesia
while monitoring with
fluoroscopy is recommended.
Fracture Treatment Options:
-Non-dislocated fractures w/o ligament damage of the
second, third, and fourth metatarsal bases rarely
need treatment other than solid-soled shoe or, if
painful, a cast.
-Met fxs are often held in good alignment by surrounding
ligamentous structures, with exception of met
neck and shaft fractures that displace easily.
-3 to 4 mm of medial or lateral transverse plane deformity
and 10° or less of angulation are well tolerated and
need not undergo surgical corrective measures.
-Healing time may be as much as 3 months from injury.
-Weight bearing is advanced as tolerated.
12: Armagan OE, Shereff MJ. Injuries to the toes and metatarsal. Foot Ankle Trauma. 2001;32:1–10.
Fracture Tx Options:
-ORIF is indicated in metatarsal fractures that are irreducible, involve a joint, or are
significantly displaced.
Fixation options:
-crossed K-wires,
-percutaneous pinning,
-circlage wire,
-interfrag screw,
-plate and screw fixation,
-external fixation,
-intramedullary fixation using a
Steinmann pin or doublethreaded compression screw .
13:Rammelt S, Heineck J, Zwipp H. Metatarsal fractures. Injury. 2004;35:S-B77–S-B86.
14: Pendarvis JA, Mandracchia VJ, Haverstock BD, et al. A new fixation technique for metatarsal fractures. Clin Podiatr Med Surg. 1999;16:643–657
Evidence for which type of fixation is best in lesser met fractures:
-None
-Didley Squat
-Zilch
*Best evidence available is “author’s experience”.
*Most authors recommend k-wire/steinman pins or other types of intramed fixation.
Evidence from osteotomies similar to met fractures:
-40 bone models were divided equally into 4 groups: a control group consisting of
intact lesser rays; and Weil osteotomies that were fixated with 2 crossed Kirschner
wires (0.045-in K-wires), 2.0-mm cortical screws, or cannulated 2.4-mm cortical
screws.
Result: There was no statistical difference in structural stiffness among the
3 groups of fixation methods.
20: Craig T. Jex, DPM,1 Chanda J. Wan, DPM,2 Steve Rundell, MS. Analysis of Three Types of Fixation of the Weil Osteotomy.
The Journal of Foot & Ankle Surgery 45(1):13–19, 2006.
K-Wire Pinning Technique:
(same idea as hammertoe
fixation)
K-Wire
Fixation:
Fixation Options: k-wires
Comminuted Fxs:
-Kirschner wire for
provisional stability.
-Application of mini
external fixation devices to
the fourth and fifth
metatarsal fractures.
15: I, Mosheiff R, Zelgowski A, et al. Crush injuries of the foot
with compartment syndrome: immediate one-stage
management. Foot Ankle. 1989;9(4):185–189
.
IM Rod Fixation
Fixation
Options:
Fixation
Options: plate
and screws.
Fixation Options: k-wires, plate and screws.
Complications to be aware of:
 Significant shortening or angular deviation of mets
-may result in transfer lesions/pressure points/new stress fx
Early weight bearing with unstable fixationnon unions
Pin tract infection vs irritation, hematoma, seroma etc.

References:

1: Drez D Jr, Young J, Johnston R, Parker W: Metatarsal stress fractures. Am J Sports Med 8:123-125, 1980.

2: Leabhart J: Stress fractures of the calcaneus. J Bone Joint Surg Am 41:1285-1290, 1959.

3: Daffner R, Pavlov H: Stress fractures: Current concepts. Am J Radiol 159:245-252, 1992.

4: Brukner P, Bradshaw C, Khan KM, et al. Stress fractures: a review of 180 cases. Clin J Sport Med. 1996;6(2):85–9.

5: Milgrom C, Finestone A, Sharkey N, et al: Metatarsal strains are sufficient to cause fracture during cyclic loading. Foot Ankle Int 23(3):230-235, 2002

6: Matheson G, Clements D, McKenzie D, et al: Stress fractures in athletes: A study of 320 cases. Am J Sports Med 15:46-58, 1987.

7: F Banal, F Etchepare, B Rouhier, C Rosenberg, V Foltz, S Rozenberg. Ultrasound ability in early diagnosis of stress fracture of metatarsal bone. Ann Rheum
Dis. 2006 July; 65(7): 977–978.

8: Ha K, Hahn S, Chung M, et al: A clinical study of stress fractures in sports activities. Orthopedics 15:1089-1095, 1991.

9: Sammarco GJ: The Jones fracture. Instr Course Lect 42:201-205, 1993.

10: DeLee JC, Evans JP, Julian J. Stress fracture of the fifth metatarsal. Am J Sports Med 1983;11:349-353.

11: Spector FC, Karlin JM, Scurran BL, et al: Lesser metatarsal fractures: incidence, management, and review. JAPA 74: 259, 1984.

12: Armagan OE, Shereff MJ. Injuries to the toes and metatarsal. Foot Ankle Trauma. 2001;32:1–10

13: Rammelt S, Heineck J, Zwipp H. Metatarsal fractures. Injury. 2004;35:S-B77–S-B86.

14: Pendarvis JA, Mandracchia VJ, Haverstock BD, et al. A new fixation technique for metatarsal fractures. Clin Podiatr Med Surg. 1999;16:643–657

15: I, Mosheiff R, Zelgowski A, et al. Crush injuries of the foot with compartment syndrome: immediate one-stage management. Foot Ankle. 1989;9(4):185–189.

16: Cundy, TF, Edmonds, ME, Watkins, PJ. Osteopenia and metatarsal fractures in diabetic neuropathy. Diabet Med 1985; 2:461.

17: Wolf, SK. Diabetes mellitus and predisposition to athletic pedal fracture. J Foot Ankle Surg 1998; 37:16.

18: S Papp, R Sanders. Fractures of the Midfoot and Forefoot. Surgery of the Foot and Ankle. 8th edition. Ch 41 pg 2215.

19: Craig T. Jex, DPM,1 Chanda J. Wan, DPM,2 Steve Rundell, MS. Analysis of Three Types of Fixation of the Weil Osteotomy.. JFAS 45(1):13–19, 2006.