Forefoot Fractures - Orthopaedic Trauma Association by yaofenji

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									           Forefoot Fractures
                    Sean E. Nork, MD

Created March 2004; revised March 2006 & 2011
        Foot Trauma and Outcomes
                  Turchin et al, JOT, 1999
                28 patients: Polytrauma +/- foot injury
                       Age, gender, ISS matched
          SF-36           5/8 components worse with foot injury
          WOMAC          All 3 components worse with foot injury

                  Jurkovich et al, JT, 1995

       Highest Sickness Impact Profile (SIP) @ 6 & 12 months
Patients with foot trauma (compared to other lower extremity injuries)
           Foot Function

  Hindfoot: Shock absorption, propulsion,

  Midfoot: Controls relationship between
           hindfoot and forefoot

Forefoot: Platform for standing and lever for
                  push off
         Forefoot Function
• Platform for weight

• Lever for propulsion
     First Metatarsal                    Lesser Metatarsals

      Shorter & wider                    More mobile medial to
   Bears 1/3 body weight
                                         Bear 1/6 weight each
 Tendon attachments: (Tibialis
      Anterior & Peroneus Longus)
                                        Intermetatarsal ligaments
Tibialis Anterior: varus, supination,          (2-3, 3-4, 4-5)
     Peroneus Longus: valgus,
          pronation, depression
          Anatomy: Sesamoids
       Medial (tibial) & Lateral (fibular)
             Within FHB tendons
         Articulate with 1st MT head
       Weight bearing through sesamoids

Tibial Sesamoid:    Tibial FHB
                    Abductor Hallucis
Fibular Sesamoid: Fibular FHB
                    Adductor Hallucis
                    Deep Tverse MT ligament
           Anatomy: Phalanges
       Great toe (2)

    Lesser toes (3 each)

FDB attaches @ intermediate

FDL/EDL attaches @ distal
Metatarsal heads in
contact with floor 60-
 80% of stance phase

Toes in contact with
 floor 75% of stance
 Cavanagh, PR, F&A, 1987
 Hughes, J, JBJS[Br], 1990
  Cross-sectional Geometry of the Human
       Griffin & Richmond, Bone, 2005

Examines the relationship between external
  loads during walking & running and the
    geometrical properties of the human

  Metatarsals 2-4 are the weakest in most cross-sectional
                     geometric properties

Metatarsal 2 (and 3 to a lesser extent) experience high peak
Mechanisms of Injury: Forefoot

   Industrial accidents

     MVA (airbags)

Indirect (twisting injuries)

        Physical Examination
 Gross deformity



  Capillary refill

Foot Compartments
        Foot trauma series

       Don’t forget oblique

        Sesamoid view
   Tangential view (MT heads)

Contralateral foot films (comparison)

     CT Scan (occasionally)
Treatment Principles: Foot

 Hindfoot: Protect subtalar, ankle and
          talonavicular joints

Midfoot: restore length and alignment of
     medial and lateral “columns”

  Forefoot: Even weight distribution
      Border Rays
      First metatarsal
      Fifth metatarsal


Multiple metatarsal shafts

 Intraarticular fractures
           First MT Shaft Fractures
    Consider conservative treatment
     Immobilization with toe plate

            Most require ORIF
       Strong muscle forces (TA, PL)
            Deformity common
           Bears 2/6 body weight

 Plate and screws
 Anatomically reduce
 May cross first MTP joint (temp)
    First MT Base Fractures

   Articular injuries

Frequently require ORIF

      Spans TMT
   Doesn’t span TMT
 Temporarily Spans TMT
                 36 year old male
                     s/p MVC

Note articular

   Fixation Strategy

Direct ORIF of comminuted
    first MT base fractre

Temporary spanning across
     first TMT joint
               43 year old male injured in a MVC
 Observe the articular segment impaction of the base of the first.
The first MT is shortened and dorsally displaced while the plantar
                   ligaments remain attached.
The patient underwent ORIF of the base of
  the first metatarsal with spanning of the
first TMT, given the level of comminution
     observed. Additionally, temporary
    spanning external fixation was used.
appearance at 3 months
  after removal of the
  external fixator and
metatarsal neck k-wire
  Non-displaced Metatarsal Fractures 2-4

 Single metatarsal fractures (non-displaced)
       Treatment usually nonoperative
  Symptomatic: hard shoe vs AFO vs cast vs
               elastic bandage

Multiple metatarsal fractures (non-displaced)
 Usually symptomatic treatment (as above)
    May require ORIF if other associated
    Minimally Displaced Lesser Metatarsal
          Zenios et al, Injury 2005

      Prospective and randomized (n=50)
        Case vs elastic support bandage

Higher AOFAS mid-foot scores at 3 months and
    less pain if treated with an elastic support
     Displaced Metatarsal Shaft Fractures
Sagittal plane displacement & angulation is most important.
         Reestablish length, rotation, & declination

        Dorsal deformity can produce transfer metatarsalgia
 Plantar deformity can produce increased load at affected metatarsal

                     Treatment Options

                      Closed Reduction
    Intramedullary pinning with k-wire (0.054” or 0.062”)
      Pinning of distal segment to adjacent metatarsal
               ORIF with dorsal plate fixation
    This patient sustained an open
second metatarsal fracture in a crush
 injury. Given the soft tissue injury
and continued pressure on the dorsal
skin, operative fixation was elected.
Fixation consisted of a dorsal
2.0 mm plate application after
 appropriate irrigation of the
        open fracture.
This patient was treated
 with ORIF of multiple
  metatarsal fractures
(3,4,5) through a dorsal
  approach. Fixation
 consisted of a 2.7 mm
DCP on the fifth and 2.0
 mm plates on the third
and fourth metatarsals.
    Medullary K-wires in Lesser
Exit wire distally through the
      proximal phalanx

Plantar wire exit may produce
  a hyperextension deformity
          of the MTP

                                 ST Hansen, Skeletal
This patient sustained multiple metatarsal neck fractures (2, 3, 4) and a
 dislocation of the fifth MTP joint. Note the lateral translation, lateral
      angulation, and the displacement on the lateral radiograph.

                                                 Compliments: Daphne Beingessner, MD
Stabilization consisted of closed reduction and percutaneous pin fixation
of the multiple metatarsal fractures and closed reduction of the fifth MTP
       dislocation. Note the location and trajectory of the K-wires.

                                                Compliments: Daphne Beingessner, MD
Following healing and removal of the pins, good alignment of the forefoot
          is demonstrated on the multiple radiographic views.

                                               Compliments: Daphne Beingessner, MD
Stress Fractures of Metatarsals 2
              Identify Cause
             First ray hypermobility
                  Short first ray
              Tight gastrocnemius
                Long metatarsal

             Treat cause if identifiable
          If overuse, activity restriction
       Reserve ORIF for displaced fractures
    Metatarsal Neck Fractures
Usually displace plantarly

May require reduction and

   Closed reduction and pinning
   Open reduction and pinning
       ORIF (dorsal plate)
 This patient sustained
multiple metatarsal neck
 fractures after an MVA.
Note additional fractures
   at the first and fifth
                                 Medullary wire fixation
                                  of metatarsal neck
                                    fractures 2, 3, 4

Compliments of S.K. Benirschke
   Metatarsal Head Fractures

Articular injuries

May require ORIF
                              Circular saw injury to the
 (especially if first   articular surface of the first MT head

      Fifth Metatarsal Fractures
     Mid diaphyseal fractures

Stress fractures (proximal diaphysis)

Jones fractures (metadiaphyseal jxn)

        Tuberosity fractures
    Proximal Fifth Metatarsal Fractures
               Dameron, TB, JAAOS, 1995

   Zone 1 cancellous tuberosity
           insertion of PB & plantar fascia
            involves metatarsocuboid joint

    Zone 2 distal to tuberosity
             extends to 4/5 articulation

Zone 3 distal to proximal ligaments
               usually stress fractures
           extends to diaphysis for 1.5 cm
Proximal Fifth Metatarsal Fractures
       Dameron, TB, JAAOS, 1995
        Relative Frequency
              Zone 1 93%

              Zone 2 4%

              Zone 3 3%
      Fifth Metatarsal Blood Supply
  Smith, J et al, F&A, 1992              Shereff, M et al, F&A,
Cadaver Arterial Injection Study (n
                = 10)                    Fresh leg specimens (after
                                                 BKA) (n = 15)
 Nutrient artery with intramedullary
      branches (retrograde flow to
       proximal fifth metatarsal)         Extraosseus circulation:
                                            dorsal metatarsal artery
    Multiple metaphyseal arteries           plantar metatarsal artery
                                         fibular plantar marginal artery
 Conclusions: Fracture distal to the
    tuberosity disrupts the nutrient      Intraosseus circulation:
  arterial supply and creates relative         Nutrient artery
                                             Metaphyseal vessels
                                             Periosteal complex
Fifth Metatarsal Blood Supply

         Smith et al, Foot Ankle 1993
     Zone 1 Fractures: Tuberosity

Avulsion from lateral plantar aponeurosis
             (Richli & Rosenthal, AJR, 1984)   Lawrence, SL, Foot
                                                  Ankle, 1993

               Hard shoe
       Healing usually uneventful
          Zone 1 Fractures: Tuberosity
               Weiner, et al, F & A Int, 1997

                         60 patients
     Randomized to short leg cast vs soft dressing only
             Weight bearing in hard shoe in all
            Healing in 44(average) - 65(all) days
Soft dressing only: shorter recuperation (33 vs 46 days) and
                 similar foot score (92 vs 86)

Conclusions: Faster return to function without compromising
  radiographic union or clinical outcome in patients treated
                       without casting.
          Zone 1 Fractures: Tuberosity
                Egol et al, F & A Int, 2007

                 50 fractures in 49 patients
Prospective outcomes study of fifth metatarsal base avulsion
     Protocol: hard shoe, weight bearing as tolerated
            Average of 22 days lost from work
86% to pre-injury status at 6 months (only 20% at 3 months)

Conclusions: Fifth metatarsal base fractures associated with
    loss of work productivity. Return is expected but takes
 significant time, with recovery of 6 months or longer in some
Zone 2 Fractures: Metadiaphyseal
         Zone 2 Fractures: Metadiaphyseal
             Treatment Controversial
                   Union frequently a concern
 Early weight bearing associated with increased nonunion (Torg,
                   Ortho, 1990; Zogby, AJSM, 1987)

        Nondisplaced Fractures: Treatment
               Cast with non weight bearing
(Shereff, Ortho, 1990; Heckman, 1984; Hens, 1990; Lawrence, 1993)

                  Cast with weight bearing
               (Kavanaugh, 1978; Dameron, 1975)
Zone 2 Fractures: Metadiaphyseal
      Operative Treatment
      Medullary Screw Stabilization
 (Delee, 1983; Kavanaugh, 1978; Dameron, 1975)

          Bone Graft Stabilization
    (Dameron, 1975; Hens, 1990; Torg, 1984)
Zone 2 Fractures: Metadiaphyseal

              Medullary Screw

                  Bone Graft

             Lehman, Foot Ankle 1987
           Zone 2 Fractures: Metadiaphyseal
                      Operative Treatment
                Biomechanical Comparison of Screws
                     (Sides et al, Foot & Ankle Int, 2006)

    Compared 6.5 mm cancellous screw and variable pitch, tapered screw

CONCLUSIONS: Headless, tapered, variable pitch compression screws of the
      size tested are not entirely comparable to 6.5-mm lag screws in this
 application. They are effective in resisting bending but do not offer equivalent
                           resistance to thread pull-out.
                 Recent Review:
       Zwitser and Breederveld, Injury, 2009
Fracture of the fifth metatarsal: Diagnosis and

                Tuberosity fractures:
            Non-displaced treated non-operatively
If displaced >2mm or with >30% of the cubometatarsal joint,
                      operative treatment

                   Shaft fractures:
           Non-displaced treated non-operatively
If displaced >3 or 4mm or >10 degrees angulation, consider
                     operative treatment
                 Recent Review:
       Zwitser and Breederveld, Injury, 2009
Fracture of the fifth metatarsal: Diagnosis and
               “Jones Fractures”
 Torg classification based on radiographic appearance and
                       healing potential

Type I: narrow fracture line and no intramedullary sclerosis
  Type II: widening of the fracture line with evidence of
                   intramedullary sclerosis
Type III: complete obliteration of the medullary canal with
                        sclerotic bone
                  Recent Review:
        Zwitser and Breederveld, Injury, 2009
Fracture of the fifth metatarsal: Diagnosis and
               “Jones Fractures”
  Torg classification based on radiographic appearance and
                        healing potential

              Type I: non-operative treatment

Type II: treatment dependent on activity level (op vs non-op)

           Type III: operative treatment indicated
Comminuted fracture of the
base of the fifth metatarsal
After ORIF of the fifth
        MTP Joint Injuries
“Turf Toe”: hyperextension with injury to thee plantar

                Hyperflexion sprains

    First MTP Dislocations
              Jahss, F&A, 1980

Type I:       Hallux dislocation without disrupting sesamoid
                            Irreducible closed!
           MT incarcerated by conjoined tendons and intact
           Open reduction required (dorsal, plantar, or medial

Type II:      Disruption of intersesamoid ligament (type A)
           Transverse fracture of one of the sesamoids (type B)

                      Usually stable after reduction
           Treatment usually conservative and symptomatic
                        (hard shoe for 4-6 weeks)
   Lesser MTP Dislocations

            Dorsal vs Lateral

      Usually stable post reduction

      Rarely require open reduction

If unstable post reduction, consider k-wire
  Fractures of the Great
 Proximal Phalanx Fractures
  ORIF for transverse & displaced (?)
   ORIF intraarticular fractures (?)

Interphalangeal Joint Fractures
    Nonoperative treatment usually

   Distal Phalanx Fractures
       Taping usually adequate
             Hard shoe
             Sesamoid Injuries
                  Acute fractures
     Stress fractures in dancers and runners
Acute:            padding
            strap MTP @ neutral or slight flexion
            immobilization in cast/shoe
Chronic:    consider bone grafting
            sesamoidectomy: not a simple
  procedure,                   assoc with hallux drift
  and transfer                 lesions, requires
  tendon (FHB) repair.
      Fractures of the LesserToes
 Correct alignment & rotation

 Attempt taping to adjacent toe

May require open reduction and
  pinning if adequate reduction
          not obtained

                                  ST Hansen, Skeletal
            Newer Implants
                Locking plates
 May be useful in patients with osteoporosis or
  comminuted fractures that require spanning
  fixation from the metatarsals to the midfoot.
  Not needed in routine fractures of the foot.
               Anatomic plates
Cuboid specific plates
Navicular specific plates
 both may be useful for complex fractures of
 these bones
This patient sustained a complex constellation of injuries to the midfoot and the
metatarsals. Additionally, there are associated fractures of the cuboid. This has
                  resulted in lateral translation of the forefoot.

                                                      Compliments: Steve Benirschke, MD
 Stabilization consisted of fixation of all components of the injury including the
cuboid fracture, the multiple LisFranc joint dislocations, and fixation of the third
  metatarsal base fracture. Because of the comminution at the base of the third
                     metatarsal, a locking implant was used.

                                                        Compliments: Steve Benirschke, MD
This patient was referred after temporary stabilization of a
        comminuted first metatarsal base fracture

                                        Compliments: Steve Benirschke, MD
   Because of the significant intraarticular involvement of the base of the first,
  fixation consisted of a direct reduction of the articular surface combined with
spanning of the first TMT joint. A locking plate was used to ensure maintenance
   of length of the medial column given the limited fixation possibilities in the
                                  medial cuneiform

                                                       Compliments: Steve Benirschke, MD
                      The Crushed Foot
  Soft Tissue Evaluation
      Assess whether salvageable
    – sensate, perfused, adequate plantar tissue

           Wash open wounds

Reposition bone deformity that threatens
                 the skin

          Reduce dislocations

   Release compartments as needed
This patient’s multiple and complex fractures of the midfoot (and calcaneus; and
 pilon) were sequentiallly fixed. Because of the significant comminution of the
                   fourth metatarsal, a locking plate was used.

                                                     Compliments: Steve Benirschke, MD
          Recommended Readings
 Cavanaugh, PR, et al. Pressure Distribution Patterns under Symptom-free
        Feet during barefoot standing. Foot Ankle, 7:262-276, 1987

Dameron, TB, Fractures of the Proximal Fifth Metatarsal: Selecting the Best
        Treatment Option. J Acad Orthop Surg, 3(2): 110-114, 1995.

 Holmes, James. AAOS Monograph “The Traumatized Foot”, pages 55-75,

 Lawrence, SJ, and Botte, MJ. Foot Fellow’s Review: Jones’ Fractures and
   Related Fractures of the Proximal Fifth Metatarsal. Foot & Ankle, 14(6),
                                358-365, 1987.

  Smith, JW, et al. The Intraosseus Blood Supply of the Fifth Metatarsal:
   Implications for Proximal Fracture Healing. Foot & Ankle, 13(3), 143-
                                  152, 1992
         Recommended Readings
Adelaar, RS: Complications of forefoot and midfoot fractures. Clin Orthop
                      Relat Res, (391): 26-32, 2001.

Armagan, OE, and Shereff, MJ: Injuries to the toes and metatarsals. Orthop
                   Clin North Am, 32(1): 1-10, 2001.

 Griffin, NL, and Richmond, BG: Cross-sectional geometry of the human
                    forefoot. Bone, 37(2): 253-60, 2005.

Mittlmeier, T, and Haar, P: Sesamoid and toe fractures. Injury, 35 Suppl 2:
                               SB87-97, 2004.

  Zenios, M; Kim, WY; Sampath, J et al.: Functional treatment of acute
  metatarsal fractures: a prospective randomised comparison of management
   in a cast versus elasticated support bandage. Injury, 36(7): 832-5, 2005.
                            Recent Literature
 1. Blundell, C. M.; Nicholson, P.; and Blackney, M. W.: Percutaneous screw fixation for fractures of
                 the sesamoid bones of the hallux. J Bone Joint Surg Br, 84(8): 1138-41, 2002.
   2. Dalal, R., and Mahajan, R. H.: Single transverse, dorsal incision for lesser metatarsophalangeal
                                 exposure. Foot Ankle Int, 30(3): 226-8, 2009.
 3. Den Hartog, B. D.: Fracture of the proximal fifth metatarsal. J Am Acad Orthop Surg, 17(7): 458-
                                                    64, 2009.
   4. Egol, K.; Walsh, M.; Rosenblatt, K.; Capla, E.; and Koval, K. J.: Avulsion fractures of the fifth
              metatarsal base: a prospective outcome study. Foot Ankle Int, 28(5): 581-3, 2007.
5. Leumann, A.; Pagenstert, G.; Fuhr, P.; Hintermann, B.; and Valderrabano, V.: Intramedullary screw
      fixation in proximal fifth-metatarsal fractures in sports: clinical and biomechanical analysis. Arch
                                 Orthop Trauma Surg, 128(12): 1425-30, 2008.
 6. Raikin, S. M.; Slenker, N.; and Ratigan, B.: The association of a varus hindfoot and fracture of the
     fifth metatarsal metaphyseal-diaphyseal junction: the Jones fracture. Am J Sports Med, 36(7): 1367-
                                                    72, 2008.
7. Sides, S. D.; Fetter, N. L.; Glisson, R.; and Nunley, J. A.: Bending stiffness and pull-out strength of
      tapered, variable pitch screws, and 6.5-mm cancellous screws in acute Jones fractures. Foot Ankle
                                            Int, 27(10): 821-5, 2006.
  8. Zwitser, E. W., and Breederveld, R. S.: Fractures of the fifth metatarsal; diagnosis and treatment.
                                                  Injury, 2009.
                     Sean E. Nork, MD
                 Harborview Medical Center
                  University of Washington

                         HMC Faculty
Barei, Beingessner, Bellabarba, Benirschke, Chapman, Dunbar,
   Hanel, Hanson, Henley, Krieg, Routt, Sangeorzan, Smith,
                                    Thank You


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