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Forefoot Fractures

Understand forefoot fractures involving toes, metatarsals, and sesamoid bones. Learn types, mechanisms of injury, treatment goals, rehabilitation objectives, expected healing times, and treatment methods for phalangeal, metatarsal, and sesamoid fractures. Follow bone healing phases and special considerations for optimal recovery.

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Forefoot Fractures

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  1. Forefoot Fractures Marie Bamer

  2. What is a Forefoot Fx? • Those fractures involving the great toe or any of the lesser toes, metatarsals, or sesamoid bones.

  3. 3 Types of Forefoot Fractures • Phalangeal • Metatarsal • Sesamoid

  4. Types of Forefoot Fractures • Phalangeal Fractures: can involve the neck, shaft, or base of the bone • MOI:Results from a direct trauma or avulsion mechanism *fx of 1st from being hit with an axe

  5. Types of Forefoot Fractures • Metatarsal Fractures: Fx of a metatarsal • MOI: fractures of the 1st- 4th usually result in direct trauma. 2nd -5th may occur as result of a twisting injury * Jones Fx- proximal 5th metatarsal shaft

  6. Types of Forefoot Fractures • SesamoidFractures: splitting or fragmentation of one or both of the two small bones contained within the tendon of the flexor hallicus longus • MOI: often secondary to the impact of the foot on a hard surface while toes are dorsiflexed. *A) Comminuted fx B) Post-op resection of bone

  7. OrthopaedicObjectives Anatomical alignment of the great toe, phalanx, metatarsal and sesamoid is essential in weight bearing and load distribution on the foot. Alignment of the 2nd- 5th metatarsals is important to minimize problematic gait and painful fitting of shoes Forefoot stability is important to maintain stable and pain-free gait Treatment Goals

  8. Treatment Goals Rehabilitation Objectives • Range of Motion-restore and maintain all ROM • Muscle Strength- improve and restore strength of extensors, flexors, invertors, and evertors in foot • Functional Goals- normalize gait to pre-injury pattern

  9. Lesser Phalanx Fx: 4 to 6 weeks 2nd, 3rd and 4th Metatarsal Fx: 4 to 6 weeks 5th Metatarsal Fx ( Jones Fx): 6 to 8 weeks Great Toe Phalanx Fx: 4 to 6 weeks 1st Metatarsal Fx: 6 to 8 weeks Sesamoid Fx: 4 to 8 weeks Expected time of bone healing

  10. Lesser Phalanx Fx: 2 to 6 weeks 2nd, 3rd and 4th Metatarsal Fx: 4 to 6 weeks 5th Metatarsal Fx (Jones): 4 to 6 weeks (acute), 6 to 10 for delayed union, nonunion, or stress fx Great Toe Phalanx Fx: 4 to 6 weeks 1st Metatarsal Fx: 4 to 6 weeks Sesamoid Fx: 8 to 12 weeks, possibly longer after sesamoidectomy Expected Time of Rehabilitation

  11. Methods of Treatment Lesser Phalanx Fx • Splints or Buddy Taping • Open Reduction and Percutaneous Pinning K –wires and short leg cast for 2-3 weeks *distal phalanx of 5th

  12. Methods of Treatment 2nd, 3rd, 4th Metatarsal Fx • Cast-short leg walking *if undisplaced or minimally displaced • Closed Reduction and Percutaneous Pinning *closed, displaced or angulated fx- NWB cast for 2-3 weeks • Open Reduction and Internal Fixation *open, displaced- NWB cast for 2-3 weeks * 2nd MT

  13. Methods of Treatment 5th Metatarsal Fx (Jones) • Cast/Splint • Acute avulsion=walking boot if displacement is less than 2 mm • Jones of proximal end= NWB cast • Open Reduction and Internal Fixation • Avulsion of greater than 2 mm= tension-band wire or lag screw • Delayed or non-union require intramedullary screw • NWB cast approx 6 weeks

  14. Methods of Treatment Great Toe Phalanx Fx • Cast- NWB extended to toes • Closed Reduction and Percutaneous Pinning or Open Reduction and Internal Fixation

  15. Methods of Treatment 1st Metatarsal Fx • Cast • Open Reduction and Internal Fixation

  16. Methods of Treatment Sesamoid Fx • Cast/ Splint • Sesamoidectomy

  17. Phase of Bone Healing Day of injury to 1 week • Stability of fx site: None • Stage of Bone Healing: Inflammatory phase • Radiograph: No callus * NWB, check cap refill, no deformities, radiograph,

  18. Phase of Bone Healing Two Weeks • Stability of fx site: None to minimal • Stage of bone healing: Begins reparative phase • Radiograph: No change or early callus

  19. Phase of Bone Healing Four to Six Weeks • Stability of fx site: Bridging callus and fx usually stable (acute fx) • Stage of bone healing: reparative phase • Radiograph: Bridging callus visible

  20. Phase of Bone Healing Six to Eight Weeks • Stability of fx site: Fx stable with bridging callus • Stage of bone healing: reparative phase • Radiograph: Bridging callus visible w/ increased ridgidity. Fx line less distinct

  21. Phase of Bone Healing Eight to Twelve Weeks • Stability of fx site: Stable • Stage of bone healing: Remodeling Phase • Radiograph: abundant callus

  22. Special Considerations of the Fracture • Age – elderly at higher risks for joint stiffness • Articular Involvement- any fx in forefoot requires anatomic reduction • Location • Open Fractures- all must be treated aggressively with irrigation, debridement, and intravenous antibiotics

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