INJURIES TO THE TOES AND METATARSALS

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Studies on force distribution of the forefoot during the stance phase of gait indicate that each of the lesser metatarsals supports an equal load (1/6 of body weight) and that the first metatarsal carries twice the load of each of the lateral 4 metatarsals (1/3 of body weight).28 Athletic, inversion-type injuries are a common cause of fractures of the fifth metatarsal, which is injured the most frequently. Stress fractures, as described in military recruits, runners, and dancers, are the next most common and occur in the second and third metatarsals.24 Fractures of the first metatarsal are less common because of its relative size and mobility. Fractures of the fourth metatarsal are the least commonly injured because of its relatively protected position and the flexibility of the lateral rays.

Fractures of the metatarsals occur from direct or indirect forces. Direct forces can be subdivided further into acute, episodic stimuli or chronic, repetitive stimuli. Acute direct forces occur most commonly as a result of crushing-type injuries, such as a heavy object falling onto the dorsum of the foot, producing transverse or comminuted fracture patterns, often of adjacent metatarsals, with varying degrees of skin injury. In these cases, a compartment syndrome of the foot must be suspected and treated with early fasciotomy if indicated. Chronic direct forces produce stress fractures, most commonly involving the diaphysis of the second and third metatarsals. Pain initially may be activity related but eventually may become continuous. Indirect forces occur when the forefoot is held fixed and the leg or foot is twisted, most commonly seen with athletic injuries, producing oblique metatarsal fracture pattern with soft tissue swelling. These forces may be combined, such as in motor vehicle or motorcycle accidents, in which direct and indirect forces may act to cause diverse fracture patterns with varying degrees of open and closed skin injuries.

The clinical examination of metatarsal fractures may include pain, swelling, ecchymosis, deformity, inability to bear weight, pain to passive motion, and crepitus. Initial radiographic evaluation should include simulated weight bearing anteroposterior and lateral projections and oblique views. Contralateral views and posteroanterior projections may be necessary, especially if a Lisfranc-type injury is suspected clinically. This injury pattern is addressed fully in a separate article. Bone scans may be required in the evaluation of stress fractures. Although historically described for fractures of the fifth metatarsal, fractures can be divided into proximal, middle, and distal injuries, corresponding to the base, shaft, and neck of the metatarsals. Isolated injuries to the intra-articular head of the metatarsals are rare and are addressed in conjunction with fractures of the neck of the metatarsals.

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FRACTURE OF METATARSAL BASE

Injuries to the base of the metatarsal occur primarily through the metaphyseal bone. Most fractures heal rapidly within 6 weeks. Oblique injuries heal more rapidly than transverse or comminuted ones. Lisfranc variant–type injuries must be ruled out, especially when multiple metatarsals are fractured. Treatment of base fractures consists of immobilization with a cast or cam walking boot, with progressively increasing weight bearing as tolerated. There is less risk of displacement of fractures of

FRACTURE OF METATARSAL SHAFT

Injuries to the metatarsal shaft are relatively more common than injuries to the base. Stress fractures are common. Treatment consists of early suspicion, even with nondiagnostic radiographs, and alleviation of aggravating factors, followed sequentially by rigid-soled wooden shoes and limited weight bearing. Subtle radiographic findings may consist of longitudinal cortical hypertrophy, narrowing of the medullary canal, and periosteal lucency. Subtle transverse lines of sclerosis may represent

FRACTURE OF METATARSAL NECK

Fractures of the neck of the metatarsals are treated similarly to fractures of the shaft. Isolated injuries require only symptomatic treatment with a postoperative shoe; multiple fractures may require surgical stabilization to prevent rotational deformities and the development of painful plantar callus from a prominent condyle. Fractures of the metatarsal heads are the result of shearing forces creating an entirely intra-articular fragment devoid of any capsular attachments. The distal fragment

FRACTURE OF FIFTH METATARSAL

Fractures of the fifth metatarsal deserve special attention their prevalence and their because of historical incidence of delayed union. Jones15a in 1902 is credited with the first description of 4 cases of injury to the base of the fifth metatarsal, including his own, sustained while dancing. Jones15a was the first to recognize that these injuries can occur without direct trauma. It is important to understand the anatomy of the lateral border of the foot to appreciate the uniqueness of these

JONES FRACTURE

Jones fractures are defined as a fracture 1.5 to 2.0 cm distal to the tip of the tuberosity at the metaphyseal-diaphyseal junction. Anatomically, this is the region between the insertion of the peroneus tertius and peroneus brevis tendons. The physiologic mobility of the lateral rays occurs in the sagittal plane of dorsiflexion and plantar flexion. The mechanism of injury for Jones fractures is with the foot in plantar flexion and subjected to forceful adduction, which causes sudden

METATARSO PHALANGEAL JOINT INJURIES

The metatarsophalangeal (MTP) articulations are complex structures that are prone to sprains, subluxations, and dislocations. The MTP joint is formed by the oval concave surface of the base of the proximal phalanx articulating with the corresponding convex metatarsal head. The capsule is supported medially and laterally by the collateral ligaments; plantarly, by the thick fibrocartilaginous plate and flexor tendons; and dorsally, by the thin expansion of the extensor tendons. The plantar plate

SUMMARY

Traumatic injuries to the toes and metatarsals are common injuries affecting nearly every individual. Injuries may be precipitated by industrial accidents or simple bumps in the night. They can produce a wide spectrum of consequences ranging from permanent disability to asymptomatic deformities. With appropriate treatment, most individuals should have the capacity to return to their preinjury functional status.

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    Address reprint requests to Osep E. Armagan, MD, Neurology-Orthopaedic Center (MC 699), University of Illinois at Chicago, 1801 West Taylor Street, Room 2A, Chicago, IL 60612

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