20 - Metatarsal Fractures Flashcards
(39 cards)
Metatarsal fracture locations
- Metatarsal neck/head fractures (metaphyseal: Intra-articular vs. non-intra-articular)
- Metatarsal shaft fractures (diaphyseal)
- Metatarsal base fractures (metaphyseal: Intra-articular vs. non-intra-articular, Jones Fracture - 5th metatarsal base fracture)
- Avulsion fracture of fifth metatarsal
Fracture patterns (ANY bone – especially long bone)
- Simple/Transverse (transverse fractures are very difficult to fixate)
- Oblique/Spiral
- Comminuted/Crush
- Displaced
- Non-Displaced
Notes on fracture patterns
o He tends to focus on how you fixate the different types of fractures rather than the specific bone that you are fixating
o If you focus on fracture types and fixations to use for them, you will be fine
Clinical diagnosis
- History and mechanism of injury (MOI)
- Direct palpation
- Pain
- Swelling
- Compartment syndrome (only with crush MOI)
- Bruising
- ROM? (sometimes don’t do ROM based on physical exam, wait for vasculature)
- Check neurovasculature (EXTREMELY IMPORTANT)
Notes on clinical diagnosis
o Students don’t usually delve into the history deep enough
o Especially with stress fracture, you need to know the history
o If there is a stress fracture, there is a reason for it – either physiologically (bone strength) or activity related
Diagnosis via radiographs
- Usually confirms diagnosis
- Assess in three planes (frontal, sagittal, transverse)
- Sagittal most important (dorsal or plantar dislocation)
- May need contralateral views in pediatric patients because you may be seeing a growth plate (it is very easy to “talk yourself into a fracture” when there isn’t one
Diagnosis via CT scan
- Metatarsal base fractures (tarsometatarsal joint), intra-articular fractures
- Surgical planning for complex fractures (displaced and comminuted)
- Can get 3D recreation of a CT scan – shows you more of the displacement that you couldn’t pick up on an x-ray (allows you to predict what ligaments are ruptured due to displacement)
- Can see how comminuted the bone fracture is and how many pieces there are, which you are not able to see on x-ray
Diagnosis via bone scan
- Stress fractures
- If the patient has pain and the history aligns with stress fracture, you may want to do a bone scan so you don’t let them walk on it for 2 weeks before you can see callus formation
Metatarsal head fractures
- MOI – direct trauma or impaction (kick or jam a toe so that proximal phalanx is driven back into the metatarsal head leading to fracture)
- Angulation/rotation possible
- Intra-articular involvement possible
- Dislocation possible
- Often transverse fractures
Metatarsal neck fractures
- Often displaced
- Shearing force or direct trauma
- Fractures can be oblique or transverse
- Often MULTIPLE metatarsals involved (drop something, get fractures in 2, 3 and 4)
- Vassal principle
Vassal principle
- If you put one back, the rest will go too – If you repair one, it will pull the other ones back
- If all the fractured metatarsals (2, 3 and 4) are deviated laterally, you would want to relocate 2 and then 3 and 4 would relocate back naturally
- If all the fractured metatarsals (2, 3 and 4) are deviated medially, you would want to relocate 4 and then 2 and 3 would relocate back naturally
- If metatarsals are not going in same direction, you probably tore the deep metatarsal ligament
Metatarsal shaft fractures
- Direct trauma, blunt force and torsional injuries (spiral)
- Usually oblique, transverse (stress), spiral and comminuted fractures noted
- Multiple metatarsal involved (direct and blunt trauma)
Metatarsal base fractures
- Result of direct trauma (MVA, fall)
- Often associated with tarsometatarsal fracture-dislocation (except 5th metatarsal)
- Often need CT for metatarsal base fractures
- X-ray and CT** (NEED TO GET A CT)
Fifth metatarsal BASE fractures
A WHOLE separate topic
5th metatarsal base fractures
- Tuberosity fractures (tend to be avulsion fracture)
- Acute metaphyseal-diaphyseal fractures (Jones fracture)
- Proximal diaphyseal stress fractures (Acute, Delayed union, Nonunion)
Tuberosity fracture of the 5th metatarsal base
Tends to be an avulsion fracture
o Mechanism of avulsion fracture is pulling off, typically the tendon or ligament pulls a part of the bone
Acute metaphyseal-diaphyseal fracture (Jones fracture)
o We often hear “Jones fractures don’t heal very well” but cute Jones fx actually heal fine
o A lot of the fractures that take a long time to heal are STRESS FRACTURES
o You will know if it is a stress fracture because of the history – if they have had prodromal symptoms for an extended period of time (had slight pain for months and months), not just one injury that brought them into your office
o How does this change treatment? Most people are going to fixate a fracture, regardless of whether or not it is a stress fracture or acute fracture because stress fractures can take up to 20 weeks to heal without fixation
Proximal diaphyseal stress fractures
- Acute
- Delayed union
- Nonunion
Stewart Classification – NEED TO KNOW – TEST QUESTION ***
- Type 1
- Type 2
- Type 3
- Type 4
- Type 5
5th metatarsal fractures - Class is based on location and whether or not it is intra-articular
Type 1 Stewart Classification
o Fracture at the metaphyseal-diaphyseal junction
o This is the CLASSIC “Jones fracture”
Type 2 Stewart Classification
o Intra-articular tuberosity fracture without comminution
o Look for picture on exam, needs to go INTO the joint
Type 3 Stewart Classification
o Extra-articular tuberosity fracture
o Look for picture on exam, does NOT go into the joint
Type 4 Stewart Classification
o Intra-articular, comminuted tuberosity fracture
o Look for picture on exam, needs to go INTO the joint ***
Type 5 Stewart Classification
o Fracture of the epiphysis
o ONLY seen in pediatric patients
