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Emergency Med - Exam 2 > 20 - Metatarsal Fractures > Flashcards

20 - Metatarsal Fractures Flashcards

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1
Q

Metatarsal fracture locations

A
  • Metatarsal neck/head fractures (metaphyseal: Intra-articular vs. non-intra-articular)
  • Metatarsal shaft fractures (diaphyseal)
  • Metatarsal base fractures (metaphyseal: Intra-articular vs. non-intra-articular, Jones Fracture - 5th metatarsal base fracture)
  • Avulsion fracture of fifth metatarsal
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2
Q

Fracture patterns (ANY bone – especially long bone)

A
  • Simple/Transverse (transverse fractures are very difficult to fixate)
  • Oblique/Spiral
  • Comminuted/Crush
  • Displaced
  • Non-Displaced
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3
Q

Notes on fracture patterns

A

o He tends to focus on how you fixate the different types of fractures rather than the specific bone that you are fixating
o If you focus on fracture types and fixations to use for them, you will be fine

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4
Q

Clinical diagnosis

A
  • History and mechanism of injury (MOI)
  • Direct palpation
  • Pain
  • Swelling
  • Compartment syndrome (only with crush MOI)
  • Bruising
  • ROM? (sometimes don’t do ROM based on physical exam, wait for vasculature)
  • Check neurovasculature (EXTREMELY IMPORTANT)
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5
Q

Notes on clinical diagnosis

A

o Students don’t usually delve into the history deep enough
o Especially with stress fracture, you need to know the history
o If there is a stress fracture, there is a reason for it – either physiologically (bone strength) or activity related

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6
Q

Diagnosis via radiographs

A
  • Usually confirms diagnosis
  • Assess in three planes (frontal, sagittal, transverse)
  • Sagittal most important (dorsal or plantar dislocation)
  • May need contralateral views in pediatric patients because you may be seeing a growth plate (it is very easy to “talk yourself into a fracture” when there isn’t one
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7
Q

Diagnosis via CT scan

A
  • Metatarsal base fractures (tarsometatarsal joint), intra-articular fractures
  • Surgical planning for complex fractures (displaced and comminuted)
  • Can get 3D recreation of a CT scan – shows you more of the displacement that you couldn’t pick up on an x-ray (allows you to predict what ligaments are ruptured due to displacement)
  • Can see how comminuted the bone fracture is and how many pieces there are, which you are not able to see on x-ray
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8
Q

Diagnosis via bone scan

A
  • Stress fractures
  • If the patient has pain and the history aligns with stress fracture, you may want to do a bone scan so you don’t let them walk on it for 2 weeks before you can see callus formation
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9
Q

Metatarsal head fractures

A
  • MOI – direct trauma or impaction (kick or jam a toe so that proximal phalanx is driven back into the metatarsal head leading to fracture)
  • Angulation/rotation possible
  • Intra-articular involvement possible
  • Dislocation possible
  • Often transverse fractures
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10
Q

Metatarsal neck fractures

A
  • Often displaced
  • Shearing force or direct trauma
  • Fractures can be oblique or transverse
  • Often MULTIPLE metatarsals involved (drop something, get fractures in 2, 3 and 4)
  • Vassal principle
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11
Q

Vassal principle

A
  • If you put one back, the rest will go too – If you repair one, it will pull the other ones back
  • If all the fractured metatarsals (2, 3 and 4) are deviated laterally, you would want to relocate 2 and then 3 and 4 would relocate back naturally
  • If all the fractured metatarsals (2, 3 and 4) are deviated medially, you would want to relocate 4 and then 2 and 3 would relocate back naturally
  • If metatarsals are not going in same direction, you probably tore the deep metatarsal ligament
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12
Q

Metatarsal shaft fractures

A
  • Direct trauma, blunt force and torsional injuries (spiral)
  • Usually oblique, transverse (stress), spiral and comminuted fractures noted
  • Multiple metatarsal involved (direct and blunt trauma)
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13
Q

Metatarsal base fractures

A
  • Result of direct trauma (MVA, fall)
  • Often associated with tarsometatarsal fracture-dislocation (except 5th metatarsal)
  • Often need CT for metatarsal base fractures
  • X-ray and CT** (NEED TO GET A CT)
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14
Q

Fifth metatarsal BASE fractures

A

A WHOLE separate topic

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15
Q

5th metatarsal base fractures

A
  • Tuberosity fractures (tend to be avulsion fracture)
  • Acute metaphyseal-diaphyseal fractures (Jones fracture)
  • Proximal diaphyseal stress fractures (Acute, Delayed union, Nonunion)
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16
Q

Tuberosity fracture of the 5th metatarsal base

A

Tends to be an avulsion fracture

o Mechanism of avulsion fracture is pulling off, typically the tendon or ligament pulls a part of the bone

17
Q

Acute metaphyseal-diaphyseal fracture (Jones fracture)

A

o We often hear “Jones fractures don’t heal very well” but cute Jones fx actually heal fine
o A lot of the fractures that take a long time to heal are STRESS FRACTURES
o You will know if it is a stress fracture because of the history – if they have had prodromal symptoms for an extended period of time (had slight pain for months and months), not just one injury that brought them into your office
o How does this change treatment? Most people are going to fixate a fracture, regardless of whether or not it is a stress fracture or acute fracture because stress fractures can take up to 20 weeks to heal without fixation

18
Q

Proximal diaphyseal stress fractures

A
  • Acute
  • Delayed union
  • Nonunion
19
Q

Stewart Classification – NEED TO KNOW – TEST QUESTION ***

A
  • Type 1
  • Type 2
  • Type 3
  • Type 4
  • Type 5

5th metatarsal fractures - Class is based on location and whether or not it is intra-articular

20
Q

Type 1 Stewart Classification

A

o Fracture at the metaphyseal-diaphyseal junction

o This is the CLASSIC “Jones fracture”

21
Q

Type 2 Stewart Classification

A

o Intra-articular tuberosity fracture without comminution

o Look for picture on exam, needs to go INTO the joint

22
Q

Type 3 Stewart Classification

A

o Extra-articular tuberosity fracture

o Look for picture on exam, does NOT go into the joint

23
Q

Type 4 Stewart Classification

A

o Intra-articular, comminuted tuberosity fracture

o Look for picture on exam, needs to go INTO the joint ***

24
Q

Type 5 Stewart Classification

A

o Fracture of the epiphysis

o ONLY seen in pediatric patients

25
Q

5th metatarsal tuberosity fracture

A
  • One of the things you need to figure out when you have a tuberosity fracture is whether or not it is intra-articular, meaning within the 5th metatarsal – cuboid joint
26
Q

5th metatarsal tuberosity fractures in children

A
  • KNOW THIS
  • Fracture vs apophysis
  • A lot of times an ER doctor will see the growth plate at the neck of the 5th metatarsal, so they thing the apophysis is a fracture
  • The 5th metatarsal has two growth centers, so there is more than one growth plate
  • The way you know if it an avulsion fracture or not is if it is displaced perpendicular to the structure that attaches there
  • Note that the fracture is located perpendicular to the PB tendon
27
Q

Jones fracture on x-ray

A
  • Located at the proximal metaphyseal-diaphyseal junction
  • Will not always see a full fracture through the shaft of 5th met
  • May just see a small line on lateral aspect
  • Most of the time, acute stress fractures actually do heal well, it’s the stress fractures that end up leading to non-unions or mal-unions typically
28
Q

Stress fracture

A
  • The typical non-union Jones fracture is actually a stress fracture, not an acute fracture
  • The treatment for acute fracture and stress fracture may be different
  • If you see a patient with complaints of pain on the 5th metatarsal base and a Jones fracture on x-ray, do a thorough history and see if there has been pain there for a while (before event that brought them in) or if it was actually acute onset
29
Q

Acute-on-chronic fracture

A
  • Acute on chronic is when there was a long standing stress fracture that weakened the bone and then an injury led to an actual fracture
  • It doesn’t need to be a stress fracture that was the chronic part, could have just been increased stress on the bone leading to bone marrow edema and pain in the area
  • This is a more complex fracture than just an acute Jones fracture
  • More commonly leads to a non-union or mal-union and may need fixation to heal
30
Q

Jones/stress fractures – factors influencing outcome

A
  • Vascular Supply (watershed area with void of vascularity)
  • Mechanical Forces (area of bone that is under a lot of stress)
  • Treatment Inconsistencies (some take to surgery right away, some try casting first)
  • Population Involved
31
Q

Jones/stress fractures – when to operate

A
  • Jones fractures in athletes*** (this is pretty much everyone since most people are active and want to be able to keep moving)
  • Stress fractures (take a long time to heal, so fixate it)
  • Based on patient’s activity
32
Q

Torg classification on treatment (probably not on exam, but need to know for rotations)

A

Torg type I
o Same as Jones fracture treatment

Torg type II
o Also need inlay bone graft
o Use intramedullary screw

Torg type III
o Also need inlay bone graft
o Use intramedullary screw

33
Q

Treatment options for Jones fractures

A
  • WB in stiff-soled shoe or orthotic device (for sedentary, elderly, comorbid patients – 20 weeks to healing)
  • NWB immobilization
  • Inlay bone grafting
  • Intramedullary screw fixation (standard of care)
  • You may come across studies that use either a plate or ex-fix with mini-rail
  • With a plate, you need to strip the periosteum, much more tissue dissection and the sural nerve is nearby (risk for injury)
34
Q

Cannulated screws

A
  • Gold standard for Jones fractures
  • This can be tricky – what you do is initially take a c-arm image of the foot (AP) and you mark on the skin the top of the 5th metatarsal
  • Then you take a lateral radiograph and make a mark on the side of the foot
  • You then run your wire down and try to stay parallel to the line on the side and top of the foot
  • This is “metatarsal mapping” which can help, but it is not always 100%
  • Sometimes it takes a few tries driving the screw
  • Often times, you will need to measure the width of the internal canal of the 5th metatarsal, so that you do not cause additional fracture
  • If you have a lot of bowing of the 5th metatarsal (lateral deviation angle), you may not be able to use a very long screw because it will be got through the far cortex
35
Q

Cancellous screw

A
  • Shows that a cannulated guidewire and screw down the middle
  • Can see the medullary canal on x-ray – you will measure this in planning for surgery
36
Q

CASE STUDY

A

o Patient presents to clinic complaining of pain in the right foot. Pt. started training for a half marathon 3 weeks ago. Pain started last week and pt. applied ice after his run and took Advil without improvement. Pt. also noticed some swelling on the top of the foot. Pt. rates pain as 8/10 when running and 4/10 when walking.

37
Q

Physical exam

A

o PE reveals neurovascular status intact. Swelling on top of right foot. Pain on palpation over the 2nd and 3rd metatarsals at midshaft region. Muscle strength and joint ROM right lower extremity normal.
o Do vibratory sense over the area of pain, if there is a fracture, the patient will have pain from the vibration over the stress fracture, making you more confident in stress fracture

38
Q

Radiographs

A

o Initial radiographs show small stress fracture on lateral aspect of the 2nd metatarsal shaft

39
Q

Treatment and follow up

A

o Stop running
o Either NWB or use CAM boot
o Patient returns to clinic in 2 weeks after wearing post-op shoe and x-ray reveals large callus formation over midshaft of second metatarsal – sign of healing which is good
o Either we fix the callus phase or don’t get callus formation with a fracture
o Patient returns to clinic 4 weeks after diagnosis and x-ray reveals larger callus, which is more of an organized callus with actual formation of bone which will decrease over time

Emergency Med - Exam 2 (11 decks)

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