A look at foot fractures – which can be splinted and which may need the OR.
Audrey Bree Tse, MD
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Foot_Fractures.mp3
Download
Leave a Comment
Tags: Orthopedics
Show Notes
Episode Produced by Audrey Bree Tse, MD
Why do we care about Jones fractures?Propensity for poor healing due to watershed area of blood supplyFifth metatarsal fractures account for 68% of metatarsal fractures in adultsProximal 5th metatarsal fractures are divided into 3 zones (93% zone 1, 4% zone 2, 3% zone 3)Zone 1 (pseudo-Jones):Tuberosity avulsion fractureTypically avulsion type injuries due to acute episode of forefoot supination with plantar flexionTypical fracture pattern is transverse to slightly obliqueZone 2 (Jones fracture):Fracture at the metaphyseal-diaphyseal junction of the fifth metatarsalTypically acute episode of large adduction force applied to forefoot with the ankle plantar flexedZone 3:Proximal diaphyseal stress fractureTypically results from a fatigue or stress mechanismHistory of acute or repetitive trauma to forefootFracture type / pattern closely related to injury locationFoot often swollen, ecchymotic, very tender to fifth metatarsal +/- crepitus, inability to hear weightClinical exam:Evaluate skin integrityCheck neurovascular statusEvaluate toes/ feet/ ankles/ tib fib/ knees/ hips, involved tendon function, associated adjacent structures (Achilles, ankle ROM/ function, etc)3 XR views: lateral, anteroposterior, 45* oblique Acute stress fractures are typically not detected on the standard 3 views; therefore, repeat XRs 10-14d after onset of sx (may see radiolucent reabsorption gap around fracture)For more complex mid foot trauma, consider CT to r/o LisfrancConsider classification of fracture, patient demographics & activity level when deciding on treatmentTertiary care centers that have access to Orthopedics/Podiatry servicesConsider consultation for “true” Jones fractures, as some cases may be operatively managed acutely and/or for expedited follow-up to be arrangedIf working in community/rural locations: other than patients that present with “open” injuries, concerns for compartment syndrome (almost never), and “high-end”/professional athletes, there are generally no other circumstances that would require expedited transfer to a tertiary care center for immediate further evaluation.Less favorable outcomes associated with certain patient factors: female gender, DM, obesityDifferent modalities of surgery:Intramedullary screwBone graftClosed reduction and fixation with K-wireORIF (all +/- need for bone graft)Surgery likely recommended for displacement >10 degrees of plantar angulation or 3-4 mm of translation in any planeIndications for OR:Neck and shaft fractures with >10 degrees plantar angulation or 3mm of displacement in any plane with insufficient closed reductionAvulsion fractures (zone one) with >3 mm of displacement or comminutedZone two fractures: displaced zone two fractures require operative management. For acute non displaced Jones fractures, consider early intramedullary screw fixation in athletes (studies have shown return to sport ~ 8 weeks, weight bearing within 1-2 weeks)Zone three fractures (diaphyseal stress fractures) in athletesAll non displaced fifth metatarsal fractures can be treated non operativelyNon displaced zone 1 fractures: protected weight bearing/ symptomatic care in short leg walking cast, air-boot, posterior splint, or compression wrap/ rigid shoe until discomfort subsidesZone 2 and 3 fractures are more complex because they often result in prolonged healing time and potential for delayed/ nonunionAcute zone 2 fractures: nonweightbearing in short leg cast for 6-8 weeksAcute zone 3 fractures: nonweightbearing in short leg cast for up to 20 weeksWith respect to athletes: repeat fracture after surgical treatment of Jones fracture can occur after healing and screw removal; thus it is recommended that the screw be left in until the end of the athlete’s careerBowes J, Buckley R. Fifth metatarsal fractures and current treatment. World J Orthop. 2016;7(12):793–800. Published 2016 Dec 18. doi:10.5312/wjo.v7.i12.793
Petrisor BA, Ekrol I, Court-Brown C. The epidemiology of metatarsal fractures. Foot Ankle Int. 2006 Mar; 27(3): 172-4.
Rammelt S, Heineck J, Zwipp H. Metatarsal fractures. Injury. 2004;35 Suppl 2:SB77–SB86.
Tham W, Sng S, Lum YM, Chee YH. A Look Back in Time: Sir Robert Jones, ‘Father of Modern Orthopaedics’. Malays Orthop J. 2014;8(3):37–41. doi:10.5704/MOJ.1411.009
Thomas JL, Davis BC. Three-wire fixation technique for displaced fifth metatarsal base fractures. J Foot Ankle Surg. 2011;50:776–779.
THANKS TO DANNY PURCELL, MD and MAY LI, MD
Read More
