Forefoot Fractures

1. Forefoot Fractures Sean E. Nork, MD Harborview Medical Center

2. 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

3. Foot Function Hindfoot: Shock absorption, propulsion, deceleration Midfoot: Controls relationship between hindfoot and forefoot Forefoot: Platform for standing and lever for push off

4. Forefoot Function Platform for weight bearing Lever for propulsion

5. Anatomy First Metatarsal Shorter & wider Bears 1/3 body weight Tendon attachments: (Tibialis Anterior & Peroneus Longus) Tibialis Anterior: varus, supination, elevation Peroneus Longus: valgus, pronation, depression

6. Sesamoids Medial (tibial) & Lateral (fibular) Within FHB tendons Articulate with 1st MT head Weight bearing through sesamoids

7. Phalanges Great toe (2) Lesser toes (3) FDB attaches @ intermediate FDL/EDL attaches @ distal

8. Biomechanics Metatarsal heads in contact with floor 60-80% of stance phase Toes in contact with floor 75% of stance phase

9. 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

10. Mechanism Industrial accidents MVA (airbags) Indirect (twisting injuries) Other

11. Physical Examination Gross deformity Dislocations Sensation Capillary refill Foot Compartments

12. Radiographs Foot trauma series AP/lat/oblique Don�t forget oblique Sesamoid view Tangential view (MT heads) Contralateral foot films (comparison) CT Scan (occasionally)

13. Treatment Principles Hindfoot: Protect subtalar, ankle and talonavicular joints Midfoot: restore length and alignment of medial and lateral �columns� Forefoot: Even weight distribution

14. Treatment Border Rays First metatarsal Fifth metatarsal Dislocations Multiple metatarsal shafts Intraarticular fractures

15. 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

16. Articular injuries Frequently require ORIF Fixation: Spans TMT Doesn�t span TMT Temporarily Spans TMT First MT Base Fractures

17. 36 year old males/p MVCActive

18. After ORIF

19. 43 year old male injured in a MVCObserve the articular segment impaction of the base of the first.The first MT is shortened and dorsally displaced while the plantar ligaments remain attached.

20. 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.

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

22. Non-displaced Metatarsal Fractures 2-4 Single metatarsal fractures Treatment usually nonoperative Symptomatic: hard shoe vs AFO vs cast vs elastic bandage Multiple metatarsal fractures Usually symptomatic treatment (as above) May require ORIF if other associated injuries

23. 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.

24. 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

25. 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.

27. 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.

28. Medullary K-wires in Lesser MTs Exit wire distally through the proximal phalanx Plantar wire exit may produce a hyperextension deformity of the MTP

29. 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.

30. 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.

31. Following healing and removal of the pins, good alignment of the forefoot is demonstrated on the multiple radiographic views.

32. 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

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

36. Unusual Articular injuries May require ORIF (especially if first MT) Metatarsal Head Fractures

37. Fifth Metatarsal Fractures Mid diaphyseal fractures Stress fractures (proximal diaphysis) Jones fractures (metadiaphyseal jxn) Tuberosity fractures

38. Proximal Fifth Metatarsal FracturesDameron, TB, JAAOS, 1995 Zone 1 cancellous tuberosity insertion of PB & plantar fascia involve metatarsocuboid joint Zone 2 distal to tuberosity extend to 4/5 articulation Zone 3 distal to proximal ligaments usually stress fractures extend to diaphysis for 1.5 cm

39. Proximal Fifth Metatarsal FracturesDameron, TB, JAAOS, 1995 Relative Frequency Zone 1 93% Zone 2 4% Zone 3 3%

40. 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

41. Fifth Metatarsal Blood Supply

42. 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)

43. Zone 1 Fractures: TuberosityWeiner, 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.

44. Zone 2 Fractures: Metadiaphyseal

45. Treatment Controversial Union frequently a concern Early weight bearing associated with increased nonunion (Torg, Ortho, 1990; Zogby, AJSM, 1987) Zone 2 Fractures: Metadiaphyseal

46. Operative Treatment Medullary Screw Stabilization (Delee, 1983; Kavanaugh, 1978; Dameron, 1975) Bone Graft Stabilization (Dameron, 1975; Hens, 1990; Torg, 1984) Zone 2 Fractures: Metadiaphyseal

47. Zone 2 Fractures: Metadiaphyseal Operative Treatment Medullary Screw Stabilization Bone Graft Stabilization

48. Comminuted fracture of the base of the fifth metatarsal

50. MTP Joint Injuries Sprains �Turf Toe�: hyperextension with injury to thee plantar plate Hyperflexion sprains Dislocations

51. First MTP DislocationsJahss, 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)

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

53. Proximal Phalanx Fractures ORIF for transverse & displaced (?) ORIF intraarticular fractures (?) Interphalangeal Joint Fractures Nonoperative treatment usually Distal Phalanx Fractures Taping usually adequate Hard shoe Fractures of the Great Toe

54. Sesamoid Injuries Sesamoiditis Acute fractures Stress fractures in dancers and runners

55. Fractures of the LesserToes Correct alignment & rotation Attempt taping to adjacent toe May require open reduction and pinning if adequate reduction not obtained

56. 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.

57. 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.

58. 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.

59. This patient was referred after temporary stabilization of a comminuted first metatarsal base fracture

60. 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

61. 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

62. 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.

63. 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

64. 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.

65. Thank You