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Forefoot Fractures

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 Results: SF-36 5/8 components worse with foot injury

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Forefoot Fractures

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  1. Forefoot Fractures • Sean E. Nork, MD Created March 2004; revised March 2006 & 2011

  2. Foot Trauma and Outcomes • Turchin et al, JOT, 1999 • 28 patients: Polytrauma +/- foot injury • Age, gender, ISS matched • Results: • 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)

  3. Foot Function • Hindfoot: Shock absorption, propulsion, deceleration • Midfoot: Controls relationship between hindfoot and forefoot • Forefoot: Platform for standing and lever for push off

  4. Forefoot Function • Platform for weight bearing • Lever for propulsion

  5. Anatomy Lesser Metatarsals More mobile medial to lateral Bear 1/6 weight each Intermetatarsal ligaments (2-3, 3-4, 4-5) • First Metatarsal • Shorter & wider • Bears 1/3 body weight • Tendon attachments: (Tibialis Anterior & Peroneus Longus) • Tibialis Anterior: varus, supination, elevation • Peroneus Longus: valgus, pronation, depression

  6. 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

  7. Anatomy: Phalanges • Great toe (2) • Lesser toes (3 each) • FDB attaches @ intermediate • FDL/EDL attaches @ distal

  8. Biomechanics • Metatarsal heads in contact with floor 60-80% of stance phase • Toes in contact with floor 75% of stance phase Cavanagh, PR, F&A, 1987 Hughes, J, JBJS[Br], 1990

  9. Cross-sectional Geometry of the Human Forefoot • Griffin & Richmond, Bone, 2005 • Examines the relationship between external loads during walking & running and the geometrical properties of the human forefoot • Metatarsals 2-4 are the weakest in most cross-sectional geometric properties • Metatarsal 2 (and 3 to a lesser extent) experience high peak pressures; this may explain the preponderance of stress fractures in these metatarsals

  10. Mechanisms of Injury: Forefoot • Industrial accidents • MVA (airbags) • Indirect (twisting injuries) • Other

  11. Physical Examination • Gross deformity • Dislocations • Sensation • Capillary refill • Foot Compartments

  12. Radiographs • Foot trauma series • AP/lat/oblique • Don’t forget oblique • Sesamoid view • Tangential view (MT heads) • Contralateral foot films (comparison) • CT Scan (occasionally)

  13. Treatment Principles: Foot • Hindfoot: Protect subtalar, ankle and talonavicular joints • Midfoot: restore length and alignment of medial and lateral “columns” • Forefoot: Even weight distribution

  14. Treatment • Border Rays • First metatarsal • Fifth metatarsal • Dislocations • Multiple metatarsal shafts • Intraarticular fractures

  15. First MT Shaft Fractures • Nondisplaced • Consider conservative treatment • Immobilization with toe plate • Displaced • Most require ORIF • Strong muscle forces (TA, PL) • Deformity common • Bears 2/6 body weight ORIF Plate and screws Anatomically reduce May cross first MTP joint (temp)

  16. First MT Base Fractures • Articular injuries • Frequently require ORIF • Fixation: • Spans TMT • Doesn’t span TMT • Temporarily Spans TMT

  17. 36 year old males/p MVCActive Note articular comminution

  18. After ORIF Fixation Strategy Direct ORIF of comminuted first MT base fractre Temporary spanning across first TMT joint

  19. 43 year old male injured in a MVCObserve the articular segment impaction of the base of the first.The first MT is shortened and dorsally displaced while the plantar ligaments remain attached.

  20. 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.

  21. Radiographic appearance at 3 months after removal of the external fixator and metatarsal neck k-wire fixations.

  22. 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 injuries

  23. Minimally Displaced Lesser Metatarsal Fractures • Zenios et al, Injury 2005 • Prospective and randomized (n=50) • Case vs elastic support bandage • MINIMALLY DISPLACED fractures • Higher AOFAS mid-foot scores at 3 months and less pain if treated with an elastic support bandage.

  24. 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

  25. 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.

  26. Fixation consisted of a dorsal 2.0 mm plate application after appropriate irrigation of the open fracture.

  27. 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.

  28. Medullary K-wires in Lesser MTs • Exit wire distally through the proximal phalanx • Plantar wire exit may produce a hyperextension deformity of the MTP ST Hansen, Skeletal Trauma

  29. 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

  30. 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

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

  32. Stress Fractures of Metatarsals 2 - 4 • Identify Cause • First ray hypermobility • Short first ray • Tight gastrocnemius • Long metatarsal • Treatment • Treat cause if identifiable • If overuse, activity restriction • Reserve ORIF for displaced fractures

  33. Metatarsal Neck Fractures • Usually displace plantarly • May require reduction and fixation: • Closed reduction and pinning • Open reduction and pinning • ORIF (dorsal plate)

  34. This patient sustained multiple metatarsal neck fractures after an MVA. Note additional fractures at the first and fifth metatarsals

  35. Medullary wire fixation of metatarsal neck fractures 2, 3, 4 Compliments of S.K. Benirschke

  36. Metatarsal Head Fractures • Unusual • Articular injuries • May require ORIF • (especially if first MT) Circular saw injury to the articular surface of the first MT head

  37. Fifth Metatarsal Fractures • Mid diaphyseal fractures • Stress fractures (proximal diaphysis) • Jones fractures (metadiaphyseal jxn) • Tuberosity fractures

  38. Proximal Fifth Metatarsal FracturesDameron, 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

  39. Proximal Fifth Metatarsal FracturesDameron, TB, JAAOS, 1995 • Relative Frequency • Zone 1 93% • Zone 2 4% • Zone 3 3%

  40. Fifth Metatarsal Blood Supply Shereff, M et al, F&A, 1991 Fresh leg specimens (after BKA) (n = 15) Extraosseus circulation: dorsal metatarsal artery plantar metatarsal artery fibular plantar marginal artery Intraosseus circulation: Nutrient artery Metaphyseal vessels Periosteal complex • Smith, J et al, F&A, 1992 • Cadaver Arterial Injection Study (n = 10) • Nutrient artery with intramedullary branches (retrograde flow to proximal fifth metatarsal) • Multiple metaphyseal arteries • Conclusions: Fracture distal to the tuberosity disrupts the nutrient arterial supply and creates relative avascularity

  41. Fifth Metatarsal Blood Supply Smith et al, Foot Ankle 1993

  42. Zone 1 Fractures: Tuberosity • Etiology • Avulsion from lateral plantar aponeurosis • (Richli & Rosenthal, AJR, 1984) • Treatment • Symptomatic • Hard shoe • Healing usually uneventful • (Dameron, T, JBJS, 1975) Lawrence, SL, Foot Ankle, 1993

  43. Zone 1 Fractures: TuberosityWeiner, 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.

  44. Zone 1 Fractures: TuberosityEgol et al, F & A Int, 2007 • 50 fractures in 49 patients • Prospective outcomes study of fifth metatarsal base avulsion fractures • 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 patients

  45. Zone 2 Fractures: Metadiaphyseal

  46. 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)

  47. Zone 2 Fractures: Metadiaphyseal • Operative Treatment • Medullary Screw Stabilization • (Delee, 1983; Kavanaugh, 1978; Dameron, 1975) • Bone Graft Stabilization • (Dameron, 1975; Hens, 1990; Torg, 1984)

  48. Zone 2 Fractures: Metadiaphyseal • Operative Treatment • Medullary Screw Stabilization • Bone Graft Stabilization Lehman, Foot Ankle 1987

  49. 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.

  50. Recent Review:Zwitser and Breederveld, Injury, 2009 • Fracture of the fifth metatarsal: Diagnosis and Treatment • 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

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