Introduction
Metatarsal fractures are common injuries that usually result from
direct blow of a heavy object dropped onto the forefoot. Such a direct
force can result in fracture of metatarsal at any point. Indirect
forces, particularly twisting the body with the toes fixed, apply
torque to the foot, producing fractures of metatarsal shafts, particularly
spiral fractures of middle three metatarsals. Despite the relative
insignificance usually relegated to metatarsal injuries they can lead
to significant limitations if ignored.
The orthopaedic trauma association groups metatarsal fractures under
the heading of 81 with 81-3 being the designation for fractures of
distal metaphyseal and articular surfaces. We present a similar case
of closed fractures of distal metaphyseal and articular surfaces.
We present a similar case of closed fracture of head of fourth metatarsal
with complete rotation of the articular surface. Such a injury is
very rare and requires a high index of suspicion for correct diagnosis
and management.
Case Report
This is a case report of a 22 year old male who sustained injury to
his right foot. He sustained his injury while running, when his foot
accidentally struck against a pavement. The patient presented with
a closed injury, with significant pain and swelling of his right foot.
On examination there was tenderness over the heads of second and fourth
metatarsals. Roentgenograms of the right foot, anteroposterior and
oblique views showed a chip fracture of the second metatarsal head
and a transverse fracture of fourth metatarsal head with complete
rotation of the articular surface.
To restore back the alignment of the fourth metatarsal head an attempt
of closed reduction under anaesthesia was done but we were unsuccessful
in completely aligning the head back to its normal position, due to
severity of injury and complete rotation of the head. Hence an open
reduction was performed and the fracture was fixed with a K wire after
aligning the head to its normal position.
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Fig.
1 : X-ray of the right foot showing chip fracture of
the second metatarsal head and a transverse fracture of fourth
metatarsal head with complete rotation of the articular surface
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Fig.
2 : Post operative X-ray of the right foot showing restoration
of the head of fourth metatarsal and fixation of the fracture
with a k-wire |
Post operatively
a below knee cast was given for 4 wks followed by gradual weight bearing
and mobilization. There was no residual pain three months, hence,
and the patient had
returned to his routine daily activities with ease.
Discussion
The four lesser metatarsals each provide only one contact point on
the plantar weight bearing surface.1 There are significant
ligamentous structures that link each of the bones to their adjacent
neighbours. There is the thick transverse metacarpal ligament distally
which connects the metatarsals indirectly by linking the plantar surfaces
of adjacent metatarsophalangeal joints. This also allows a cascade
of allowable increase in motion through the tarsometatarsal joint
beginning at the second and going out to the fifth. It is this increase
in motion in the sagittal plane that allows significant adaptability
to terrain by the metatarsal heads.
Fractures of the central metatarsals are much more common than first
metatarsal fractures and can be isolated or part of more significant
injury pattern.
The emphasis of treatment in metatarsal fractures is on the resulting
position of the metatarsal head. The problems of transfer metatarsalgia
and shoe wear are well known in fractures that allow significant changes
in normal position of metatarsal head.1 The criterion most
often mentioned is that any fracture displaying more than 10 degrees
of deviation in the dorsal plantar plane or 3-4 mm translation in
any plane should be actively corrected.2
Individual head or neck fractures that appreciably deviate either
dorsal or plantar in the sagittal plane are treated with closed reduction
using finger trap distraction to restore alignment. A method of closed
reduction and repositioning of metatarsal fractures using K wire manipulation
is also described in the literature.3
However great care must be taken during reduction to avoid dorsiflexion
or plantar flexion of the distal fragment causing a malalignment of
metatarsal head with its neighbours. Inability to correct any appreciable
deviation in the metatarsal head position by closed means, as in this
case should be addressed with open reduction and K wire fixation to
maintain normal forefoot alignment. Urgent reduction and fixation
is also required to decrease the risk of devascularisation which might
have occurred after such a significant displacement.
The above presented case emphasizes the importance of prompt diagnosis,
open reduction and internal fixation to achieve an acceptable final
outcome by preventing damage to the blood supply of metatarsal head
and gaining achieving good alignment of the articular surfaces.
References
1. Early JS. Fractures and dislocations of the midfoot and forefoot.
In: Bucholz RW, Heckman JD, Ed. Rockwood and Green’s fractures
in adults. Philadelphia : Lippincott Williams and Wilkins 2001 : 2221-5.
2. Shereff M. Fractures of forefoot. Instructional course lectures
1990; 39 : 133-40.
3. Braun C, Bauer M, Rose S, Buhren B. Aktuelle Traumatol 1992 June;
22 (3) : 129-31.
*Senior Resident, **Consultant
Orthopaedic Surgeon, ***Ex-Resident, Department of Orthopaedic Surgery;
+Senior Resident, Department of General Surgery; Sri Sayaji General
Hospital and Medical College, Baroda - 390 001, Gujarat.
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