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

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Presentation on theme: "Forefoot Fractures Sean E. Nork, MD Sean E. Nork, MD Created March 2004; revised March 2006 & 2011."— Presentation transcript:

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

2 Foot Trauma and Outcomes Turchin et al, JOT, patients: Polytrauma +/- foot injury Age, gender, ISS matched Results: SF-365/8 components worse with foot injury WOMACAll 3 components worse with foot injury Jurkovich et al, JT, 1995 Highest Sickness Impact Profile 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 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 Lesser Metatarsals More mobile medial to lateral Bear 1/6 weight each Intermetatarsal ligaments (2-3, 3-4, 4-5)

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 intermediate FDL/EDL distal

8 Biomechanics Metatarsal heads in contact with floor % 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 male s/p MVC Active 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 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.

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 Compliments: Daphne Beingessner, MD 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.

30 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.

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

32 Stress Fractures of Metatarsals 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 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

39 Proximal Fifth Metatarsal Fractures Dameron, TB, JAAOS, 1995 Relative Frequency Zone 193% Zone 24% Zone 33%

40 Fifth Metatarsal Blood Supply 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 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

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: Tuberosity Weiner, et al, F & A Int, 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: Tuberosity Egol et al, F & A Int, 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 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

51 Recent Review: Zwitser and Breederveld, Injury, 2009 Fracture of the fifth metatarsal: Diagnosis and Treatment “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

52 Recent Review: Zwitser and Breederveld, Injury, 2009 Fracture of the fifth metatarsal: Diagnosis and Treatment “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

53 Comminuted fracture of the base of the fifth metatarsal

54 After ORIF of the fifth metatarsal

55 MTP Joint Injuries Sprains “Turf Toe”: hyperextension with injury to thee plantar plate Hyperflexion sprains Dislocations

56 First MTP Dislocations Jahss, F&A, 1980 Type I: Hallux dislocation without disrupting sesamoid Irreducible closed! MT incarcerated by conjoined tendons and intact sesamoid Open reduction required (dorsal, plantar, or medial approach) 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)

57 Lesser MTP Dislocations Uncommon Dorsal vs Lateral Usually stable post reduction Rarely require open reduction If unstable post reduction, consider k-wire fixation

58 Fractures of the Great Toe Proximal Phalanx Fractures ORIF for transverse & displaced (?) ORIF intraarticular fractures (?) Interphalangeal Joint Fractures Nonoperative treatment usually Distal Phalanx Fractures Taping usually adequate Hard shoe

59 Sesamoid Injuries Sesamoiditis Acute fractures Stress fractures in dancers and runners Treatment Acute:padding strap 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.

60 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 Trauma

61 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

62 Compliments: Steve Benirschke, MD 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.

63 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.

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

65 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

66 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

67 Compliments: Steve Benirschke, MD 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.

68 Recommended Readings Cavanaugh, PR, et al. Pressure Distribution Patterns under Symptom-free Feet during barefoot standing. Foot Ankle, 7: , 1987 Dameron, TB, Fractures of the Proximal Fifth Metatarsal: Selecting the Best Treatment Option. J Acad Orthop Surg, 3(2): , 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), , Smith, JW, et al. The Intraosseus Blood Supply of the Fifth Metatarsal: Implications for Proximal Fracture Healing. Foot & Ankle, 13(3), , 1992

69 Recommended Readings Adelaar, RS: Complications of forefoot and midfoot fractures. Clin Orthop Relat Res, (391): 26-32, Armagan, OE, and Shereff, MJ: Injuries to the toes and metatarsals. Orthop Clin North Am, 32(1): 1-10, Griffin, NL, and Richmond, BG: Cross-sectional geometry of the human forefoot. Bone, 37(2): , Mittlmeier, T, and Haar, P: Sesamoid and toe fractures. Injury, 35 Suppl 2: SB87-97, 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.

70 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): , Dalal, R., and Mahajan, R. H.: Single transverse, dorsal incision for lesser metatarsophalangeal exposure. Foot Ankle Int, 30(3): 226-8, Den Hartog, B. D.: Fracture of the proximal fifth metatarsal. J Am Acad Orthop Surg, 17(7): , 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, 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): , 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): , 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, Zwitser, E. W., and Breederveld, R. S.: Fractures of the fifth metatarsal; diagnosis and treatment. Injury, 2009.

71 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, Taitsman

72 Questions? Return to Lower Extremity Index OTA about Questions/Comments If you would like to volunteer as an author for the Resident Slide Project or recommend updates to any of the following slides, please send an to Thank You


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