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 WOMAC All 3 components worse with foot injury These publications emphasize the importance of foot trauma as it relates to patient outcomes. After healing of all of their other complex injuries, associated foot injuries are associated with worse overall results as measured by a variety of outcomes measures. So, as tempting as it may be to minimize the attention and treatment of associated foot injuries in the multiply injured patient, don’t! While these injuries may not take priority in the initial hours or days of treatment, they should be treated aggressively and with the same attention. 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, deceleration Midfoot: Controls relationship between hindfoot and forefoot Forefoot: Platform for standing and lever for push off The forefoot is primarily important as a platform to allow standing; and as a lever used for push off. The exact anatomical relationships between the various osseus structures determine the stability and function of the forefoot.

Platform for weight bearing Forefoot Function Platform for weight bearing Lever for propulsion This pressure diagram demonstrates the high pressures associated with the forefoot. It is not surprising that small alterations in the anatomy of this region can translate into symptomatic foot problems for the patient.

Anatomy First Metatarsal Lesser Metatarsals 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)

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

Biomechanics Metatarsal heads in contact with floor 60-80% of stance phase Toes in contact with floor 75% of stance phase Once again emphasizing the importance of the forefoot with regards to stance phase. Cavanagh, PR, F&A, 1987 Hughes, J, JBJS[Br], 1990

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

Mechanisms of Injury: Forefoot Industrial accidents MVA (airbags) Indirect (twisting injuries) Other Obviously, a variety of mechanisms are associated with forefoot injuries. Often, they are low energy injuries associated with falls or twisting injuries. However, high energy accidents associated with motor vehicle crashes, motorcycle crashes, and industrial accidents may occur. Airbags certainly protect patients and potentially decrease mortality rates. However, this may be associated with even worse foot trauma as patients survive higher and higher energy motor vehicle crashes.

Physical Examination Gross deformity Dislocations Sensation Capillary refill Foot Compartments

Radiographs Foot trauma series AP/lat/oblique Don’t forget oblique Sesamoid view Tangential view (MT heads) Contralateral foot films (comparison) CT Scan (occasionally) The foot trauma series consists of three views for the initial evaluation of forefoot injuries. The oblique view is particularly helpful for identifying midfoot and forefoot displacements and subtle injuries. Additional views can be obtained if there is suspicion of injury in certain locations. This can include sesamoid and tangential views. Comparison views of the contralateral foot can be quite helpful. CT scans are typically not required by may be helpful in some complex injury patterns.

Treatment Principles: Foot Hindfoot: Protect subtalar, ankle and talonavicular joints Midfoot: restore length and alignment of medial and lateral “columns” Forefoot: Even weight distribution Some basic overall treatment principles exist for foot injuries. With respect to the forefoot, allowing for even weight distribution during stance and push off is critical. This requires an accurate restoration of the anatomy following injury.

Treatment Border Rays First metatarsal Fifth metatarsal Dislocations Multiple metatarsal shafts Intraarticular fractures With regards to the metatarsals, the border rays tolerate displacement and shortening much less than the central three metatarsals. Particular attention much be paid to first and fifth metatarsal injuries. Central metatarsal injuries may be partially controlled due to the intermetatarsal ligaments. However, multiple metatarsal shaft fractures may require a more aggressive approach. These injuries will be specifically discussed in the slides that follow.

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 For displaced first metatarsal shaft fractures, most require operative fixation. This is due to the strong muscular attachments, the amount of load that the first bears with walking, and the fact that it is a border ray. An accurate reduction (length, alignment, rotation) is necessary. If necessary, the first MTP joint may be crossed to enhance fixation for proximal fractures. This may be temporary. ORIF Plate and screws Anatomically reduce May cross first MTP joint (temp)

First MT Base Fractures Articular injuries Frequently require ORIF Fixation: Spans TMT Doesn’t span TMT Temporarily Spans TMT Most articular fractures at the base of the first metatarsal require operative treatment. This is due to the tendency for displacement, as well as the importance of that particular articulation. The fracture location at the base of the first metatarsal determines the location and type of fixation necessary. Plates are frequently required. Small locking plates may offer some advantage for proximal fixation. It may be necessary to span the the first TMT joint onto the medial cuneiform. This may be temporary or permanent.

36 year old male s/p MVC Active Case example of a comminuted fracture at the base of the first metatarsal. Note the displacement and the instability of the first TMT joint. Note articular comminution

Direct ORIF of comminuted Temporary spanning across After ORIF 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.

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

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

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.

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 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 MTs Exit wire distally through the proximal phalanx Plantar wire exit may produce a hyperextension deformity of the MTP Ideally, when “pinning” a lesser metatarsal neck fracture, the K-wire should exit though the base of the proximal phalanx. This maintains the relationship between the metatarsal and the proximal phalanx. If the k-wire exits plantar to the proximal phalanx, a hyperextension deformity can be produced as demonstrated. ST Hansen, Skeletal Trauma

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. Compliments: Daphne Beingessner, MD

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

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 - 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

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

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

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

Metatarsal Head Fractures Unusual Articular injuries May require ORIF (especially if first MT) This is an unusual injury. In the example shown, the patient sustained an injury due to a circular saw cut of the distal aspect of the first metatarsal. Following reduction and healing, the avascular changes of the articular segment are obvious. However, collapse did not occur. Circular saw injury to the 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 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

Fifth Metatarsal Blood Supply Smith et al, Foot Ankle 1993

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

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 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

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 Operative Treatment Medullary Screw Stabilization Bone Graft Stabilization 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 Treatment Tuberosity fractures: Non-displaced treated non-operatively If displaced >2mm or with >30% of the cubometatarsal joint, operative treatment Shaft fractures: 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 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

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

Comminuted fracture of the base of the fifth metatarsal

After ORIF of the fifth metatarsal

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

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)

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

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

Sesamoiditis Acute fractures Stress fractures in dancers and runners Sesamoid Injuries Sesamoiditis Acute fractures Stress fractures in dancers and runners Treatment 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 Trauma

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

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. Compliments: Steve Benirschke, MD

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

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

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 is an example of a crushed foot that could not be salvaged. Treatment consisted of primary amputation.

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. 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, 2002. 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.

Harborview Medical Center University of Washington 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

Thank You Questions? 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 e-mail to ota@aaos.org E-mail OTA about Questions/Comments Return to Lower Extremity Index