Metatarsals are the five long bones of the foot. Metatarsal fractures are amongst the most common injuries in the foot. These long bones help maintain the alignment and anatomy of the arches in our feet. Metatarsals are held in place with various ligaments and tendons. For anatomical purposes, the metatarsals are divided into three sections- the head (near the toes), shaft and base. Two mechanisms of injury to the metatarsals are either direct or indirect forces. Direct forces are usually from a crush injury which may also involve soft tissue compromise. Indirect forces are when the forefoot is in a fixed position with the leg or rearfoot rotating which may also cause ligamentous and tendon damage. It is important to categorize fractures based on displacement and angulation since those characteristics dictates conservative vs surgical treatment. The most common metatarsal to become injured is the fifth metatarsal bone. A specific area on the fifth metatarsal which has decreased blood flow is most famously known as a Jones fracture and needs to be treated with extra care. Stress fractures of the metatarsals are also fairly common which can occur from repeated trauma, fragile bone from metabolic deficiency or an associated foot deformity. Stress fractures are the most common in the second metatarsal head.
Clinically, metatarsal fractures will appear as pain and swelling mostly to the top of the foot. There are several ways to aid in the diagnosis of metatarsal fractures. Plain film radiographs are usually the first line imaging used in the office. It is always important to obtain three views as one view alone may present as a false negative result. Another helpful diagnostic imaging device is a C-arm or fluoroscopy which is key when examining joints under dynamic range of motion under X-ray technology. Ultrasounds can also be utilized to rule out fractures and are fairly convenient as they can be done at the bedside. Though ultrasounds are more often used to evaluate for soft tissue abnormalities, fractures can be diagnosed using this modality with no radiation. At Advanced Podiatry, we are fully equipped with X-rays, C arm and ultrasound to help with accurate diagnosis and get our patients back on their feet as soon as possible. CT scans can also be ordered to check for displacement of multiple joints when a serious injury is suspected. MRI is helpful in diagnosing stress fractures as they do not initially appear on X-rays.
Treatment for metatarsal fractures is driven by the type of fracture (i.e. displacement, angulation, joint involvement). Nonoperative treatment usually consists of a walking or CAM boot which has a stiff sole and prevents the propulsive cycle of gait. Such treatment is only effective when a fracture is non displaced or minimally displaced in isolation. Stress fractures are also treated with walking boots to inhibit the fracture from worsening. Bone typically takes about 6-8 weeks to heal so a patient can expect to be in a walking for about that time. Surgical treatment becomes necessary when displacement/angulation is involved or when multiple metatarsal fractures are involved. In surgery, the fracture part of the bone is realigned into normal position and can be fixated with a pin/wire, screws or a combination of plates and screws depending on the nature of the fracture.