Forefoot Fractures

Sean E. Nork, MD

Created March 2004; revised March 2006 & 2011

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

Jurkovich et al, JT, 1995

Highest Sickness Impact Profile (SIP) @ 6 & 12 months
Patients with foot trauma (compared to other lower extremity injuries)

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

Forefoot Function
Platform for weight
bearing

Lever for propulsion

Anatomy
First Metatarsal
Shorter & wider
Bears 1/3 body weight
Tendon attachments: (Tibialis

Lesser Metatarsals
More mobile medial to
lateral
Bear 1/6 weight each

Anterior & Peroneus Longus)

Tibialis Anterior: varus, supination,

elevation
Peroneus Longus: valgus,
pronation, depression

Intermetatarsal ligaments
(2-3, 3-4, 4-5)

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

Tibial Sesamoid:

Tibial FHB
Abductor Hallucis

Fibular Sesamoid: Fibular FHB

Adductor Hallucis
Deep Tverse MT ligament

Anatomy: Phalanges
Great toe (2)
Lesser toes (3 each)
FDB attaches @ intermediate
FDL/EDL attaches @ distal

Biomechanics
Metatarsal heads in
contact with floor 6080% of stance phase
Toes in contact with
floor 75% of stance
phase
Cavanagh, PR, F&A, 1987
Hughes, J, JBJS[Br], 1990

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

Mechanisms of Injury: Forefoot

Industrial accidents
MVA (airbags)
Indirect (twisting injuries)
Other

Physical Examination
Gross deformity
Dislocations
Sensation
Capillary refill
Foot Compartments

Radiographs
Foot trauma series
AP/lat/oblique
Dont forget oblique
Sesamoid view
Tangential view (MT heads)
Contralateral foot films (comparison)
CT Scan (occasionally)

Treatment Principles: Foot

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

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

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

ORIF
Plate and screws
Anatomically reduce
May cross first MTP joint (temp)

First MT Base Fractures

Articular injuries
Frequently require ORIF
Fixation:
Spans TMT
Doesnt span TMT
Temporarily Spans TMT

36 year old male

s/p MVC
Active

Note articular
comminution

After
ORIF

Fixation Strategy
Direct ORIF of comminuted
first MT base fractre
Temporary spanning across
first TMT joint

43 year old male injured in a MVC

Observe the articular segment impaction of the base of the first.
The first MT is shortened and dorsally displaced while the plantar
ligaments remain attached.

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.

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

Non-displaced Metatarsal Fractures 2-4

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

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.

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

Treatment Options
Closed Reduction
Intramedullary pinning with k-wire (0.054 or 0.062)
Pinning of distal segment to adjacent metatarsal
ORIF with dorsal plate fixation

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.

Fixation consisted of a dorsal 2.0

mm plate application after
appropriate irrigation of the
open fracture.

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.

Medullary K-wires in Lesser

MTs

Exit wire distally through the

proximal phalanx

Plantar wire exit may produce

a hyperextension deformity
of the MTP

ST Hansen, Skeletal Trauma

Thispatientsustainedmultiplemetatarsalneckfractures(2,3,4)anda
dislocationofthefifthMTPjoint.Notethelateraltranslation,lateral
angulation,andthedisplacementonthelateralradiograph.

Compliments:DaphneBeingessner,MD

Stabilizationconsistedofclosedreductionandpercutaneouspinfixation
ofthemultiplemetatarsalfracturesandclosedreductionofthefifthMTP
dislocation.NotethelocationandtrajectoryoftheKwires.

Compliments:DaphneBeingessner,MD

Followinghealingandremovalofthepins,goodalignmentofthe
forefootisdemonstratedonthemultipleradiographicviews.

Compliments:DaphneBeingessner,MD

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

Metatarsal Neck Fractures

Usually displace plantarly
May require reduction and
fixation:
Closed reduction and pinning
Open reduction and pinning
ORIF (dorsal plate)

This patient sustained

multiple metatarsal neck
fractures after an MVA.
Note additional fractures at
the first and fifth
metatarsals

Medullary wire fixation

of metatarsal neck
fractures 2, 3, 4

Compliments of S.K. Benirschke

Metatarsal Head Fractures

Unusual
Articular injuries
May require ORIF
(especially if first MT)

Circular saw injury to the

articular surface of the first MT head

Fifth Metatarsal Fractures

Mid diaphyseal fractures
Stress fractures (proximal diaphysis)
Jones fractures (metadiaphyseal jxn)
Tuberosity fractures

Proximal Fifth Metatarsal Fractures

Dameron, TB, JAAOS, 1995
Zone 1 cancellous tuberosity
insertion of PB & plantar fascia
involves metatarsocuboid joint

Zone 2 distal to tuberosity

extends to 4/5 articulation

Zone 3 distal to proximal ligaments

usually stress fractures
extends to diaphysis for 1.5 cm

Proximal Fifth Metatarsal Fractures

Dameron, TB, JAAOS, 1995

Relative Frequency
Zone 1 93%
Zone 2 4%
Zone 3 3%

Fifth Metatarsal Blood Supply

Smith, J et al, F&A, 1992

Shereff, M et al, F&A, 1991

Cadaver Arterial Injection Study (n

= 10)

Fresh leg specimens (after BKA)

(n = 15)

Nutrient artery with intramedullary

branches (retrograde flow to
proximal fifth metatarsal)

Extraosseus circulation:

Multiple metaphyseal arteries

Conclusions: Fracture distal to the
tuberosity disrupts the nutrient
arterial supply and creates relative
avascularity

dorsal metatarsal artery

plantar metatarsal artery
fibular plantar marginal artery

Intraosseus circulation:
Nutrient artery
Metaphyseal vessels
Periosteal complex

Fifth Metatarsal Blood Supply

Smith et al, Foot Ankle 1993

Zone 1 Fractures: Tuberosity

Etiology
Avulsion from lateral plantar aponeurosis
(Richli & Rosenthal, AJR, 1984)
Lawrence, SL, Foot Ankle, 1993

Treatment
Symptomatic
Hard shoe
Healing usually uneventful
(Dameron, T, JBJS, 1975)

Zone 1 Fractures: Tuberosity

Weiner, 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.

Zone 1 Fractures: Tuberosity

Egol et al, F & A Int, 2007
50 fractures in 49 patients
Prospective outcomes study of fifth metatarsal base avulsion
fractures
Protocol: hard shoe, weight bearing as tolerated
Average of 22 days lost from work
86% to pre-injury status at 6 months (only 20% at 3 months)
Conclusions: Fifth metatarsal base fractures associated with
loss of work productivity. Return is expected but takes
significant time, with recovery of 6 months or longer in some
patients

Zone 2 Fractures: Metadiaphyseal

Zone 2 Fractures: Metadiaphyseal

Treatment Controversial
Union frequently a concern
Early weight bearing associated with increased nonunion (Torg, Ortho,
1990; Zogby, AJSM, 1987)

Nondisplaced Fractures: Treatment

Cast with non weight bearing
(Shereff, Ortho, 1990; Heckman, 1984; Hens, 1990; Lawrence, 1993)

Cast with weight bearing

(Kavanaugh, 1978; Dameron, 1975)

Zone 2 Fractures: Metadiaphyseal

Operative Treatment
Medullary Screw Stabilization
(Delee, 1983; Kavanaugh, 1978; Dameron, 1975)

Bone Graft Stabilization

(Dameron, 1975; Hens, 1990; Torg, 1984)

Zone 2 Fractures: Metadiaphyseal

Operative
Treatment
Medullary Screw
Stabilization

Bone Graft
Stabilization

Lehman, Foot Ankle 1987

Zone 2 Fractures: Metadiaphyseal

Operative Treatment
Biomechanical Comparison of Screws
(Sides et al, Foot & Ankle Int, 2006)
Compared 6.5 mm cancellous screw and variable pitch, tapered screw
CONCLUSIONS: Headless, tapered, variable pitch compression screws of the
size tested are not entirely comparable to 6.5-mm lag screws in this
application. They are effective in resisting bending but do not offer
equivalent resistance to thread pull-out.

Recent Review:
Zwitser and Breederveld, Injury, 2009

Fracture of the fifth metatarsal: Diagnosis and

Treatment
Tuberosity fractures:
Non-displaced treated non-operatively
If displaced >2mm or with >30% of the cubometatarsal joint,
operative treatment

Shaft fractures:
Non-displaced treated non-operatively
If displaced >3 or 4mm or >10 degrees angulation, consider
operative treatment

Recent Review:
Zwitser and Breederveld, Injury, 2009

Recent Review:
Zwitser and Breederveld, Injury, 2009

Comminuted fracture of the base of

the fifth metatarsal

After ORIF of the fifth

metatarsal

MTP Joint Injuries

Sprains
Turf Toe: hyperextension with injury to
thee plantar plate
Hyperflexion sprains

Dislocations

First MTP Dislocations

Jahss, 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)

Lesser MTP Dislocations

Uncommon
Dorsal vs Lateral
Usually stable post reduction
Rarely require open reduction
If unstable post reduction, consider k-wire fixation

Fractures of the Great

Toe
Proximal Phalanx Fractures
ORIF for transverse & displaced (?)
ORIF intraarticular fractures (?)

Interphalangeal Joint Fractures

Nonoperative treatment usually

Distal Phalanx Fractures

Taping usually adequate
Hard shoe

Sesamoid Injuries
Sesamoiditis
Acute fractures
Stress fractures in dancers and runners
Treatment
Acute:

Chronic:

padding
strap MTP @ neutral or slight flexion
immobilization in cast/shoe
consider bone grafting
sesamoidectomy: not a simple procedure,
assoc with hallux drift and transfer
lesions, requires tendon (FHB) repair.

Fractures of the LesserToes

Correct alignment & rotation
Attempt taping to adjacent toe
May require open reduction and
pinning if adequate reduction
not obtained

ST Hansen, Skeletal Trauma

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.

Anatomic plates
Cuboid specific plates
Navicular specific plates
both may be useful for complex fractures of these
bones

Thispatientsustainedacomplexconstellationofinjuriestothemidfootandthe
metatarsals.Additionally,thereareassociatedfracturesofthecuboid.Thishas
resultedinlateraltranslationoftheforefoot.

Compliments:SteveBenirschke,MD

Stabilizationconsistedoffixationofallcomponentsoftheinjuryincludingthe
cuboidfracture,themultipleLisFrancjointdislocations,andfixationofthethird
metatarsalbasefracture.Becauseofthecomminutionatthebaseofthethird
metatarsal,alockingimplantwasused.

Compliments:SteveBenirschke,MD

Thispatientwasreferredaftertemporarystabilizationofa
comminutedfirstmetatarsalbasefracture

Compliments:SteveBenirschke,MD

Becauseofthesignificantintraarticularinvolvementofthebaseofthefirst,
fixationconsistedofadirectreductionofthearticularsurfacecombinedwith
spanningofthefirstTMTjoint.Alockingplatewasusedtoensuremaintenance
oflengthofthemedialcolumngiventhelimitedfixationpossibilitiesinthe
medialcuneiform

Compliments:SteveBenirschke,MD

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

Thispatientsmultipleandcomplexfracturesofthemidfoot(andcalcaneus;and
pilon)weresequentialllyfixed.Becauseofthesignificantcomminutionofthe
fourthmetatarsal,alockingplatewasused.

Compliments:SteveBenirschke,MD

Recommended Readings
Cavanaugh,PR,etal.PressureDistributionPatternsunderSymptomfree
Feetduringbarefootstanding.FootAnkle,7:262276,1987
Dameron,TB,FracturesoftheProximalFifthMetatarsal:SelectingtheBest
TreatmentOption.JAcadOrthopSurg,3(2):110114,1995.
Holmes,James.AAOSMonographTheTraumatizedFoot,pages5575,
2002.
Lawrence,SJ,andBotte,MJ.FootFellowsReview:JonesFracturesand
RelatedFracturesoftheProximalFifthMetatarsal.Foot&Ankle,14(6),
358365,1987.
Smith,JW,etal.TheIntraosseusBloodSupplyoftheFifthMetatarsal:
ImplicationsforProximalFractureHealing.Foot&Ankle,13(3),143
152,1992

Recommended Readings
Adelaar,RS:Complicationsofforefootandmidfootfractures.ClinOrthop
RelatRes,(391):2632,2001.
Armagan,OE,andShereff,MJ:Injuriestothetoesandmetatarsals.Orthop
ClinNorthAm,32(1):110,2001.
Griffin,NL,andRichmond,BG:Crosssectionalgeometryofthehuman
forefoot.Bone,37(2):25360,2005.
Mittlmeier,T,andHaar,P:Sesamoidandtoefractures.Injury,35Suppl2:
SB8797,2004.
Zenios,M;Kim,WY;Sampath,Jetal.:Functionaltreatmentofacute
metatarsalfractures:aprospectiverandomisedcomparisonofmanagement
inacastversuselasticatedsupportbandage.Injury,36(7):8325,2005.

Recent Literature
1. Blundell, C. M.; Nicholson, P.; and Blackney, M. W.: Percutaneous screw fixation for fractures of
the sesamoid bones of the hallux. J Bone Joint Surg Br, 84(8): 1138-41, 2002.
2. Dalal, R., and Mahajan, R. H.: Single transverse, dorsal incision for lesser metatarsophalangeal
exposure. Foot Ankle Int, 30(3): 226-8, 2009.
3. Den Hartog, B. D.: Fracture of the proximal fifth metatarsal. J Am Acad Orthop Surg, 17(7): 45864, 2009.
4. Egol, K.; Walsh, M.; Rosenblatt, K.; Capla, E.; and Koval, K. J.: Avulsion fractures of the fifth
metatarsal base: a prospective outcome study. Foot Ankle Int, 28(5): 581-3, 2007.
5. Leumann, A.; Pagenstert, G.; Fuhr, P.; Hintermann, B.; and Valderrabano, V.: Intramedullary screw
fixation in proximal fifth-metatarsal fractures in sports: clinical and biomechanical analysis. Arch
Orthop Trauma Surg, 128(12): 1425-30, 2008.
6. Raikin, S. M.; Slenker, N.; and Ratigan, B.: The association of a varus hindfoot and fracture of the
fifth metatarsal metaphyseal-diaphyseal junction: the Jones fracture. Am J Sports Med, 36(7): 136772, 2008.
7. Sides, S. D.; Fetter, N. L.; Glisson, R.; and Nunley, J. A.: Bending stiffness and pull-out strength of
tapered, variable pitch screws, and 6.5-mm cancellous screws in acute Jones fractures. Foot Ankle
Int, 27(10): 821-5, 2006.
8. Zwitser, E. W., and Breederveld, R. S.: Fractures of the fifth metatarsal; diagnosis and treatment.
Injury, 2009.

Sean E. Nork, MD
Harborview Medical Center
University of Washington
HMC Faculty
Barei, Beingessner, Bellabarba, Benirschke, Chapman, Dunbar,
Hanel, Hanson, Henley, Krieg, Routt, Sangeorzan, Smith, Taitsman

Thank You
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