41.Fractures of the Midfoot and Forefoot

CHAPTER41 Fractures of the Midfoot and Forefoot Roy W. Sanders • Steven Papp THE TARSAL NAVICULAR Anatomy Mechanism of Injury Diagnosis CORTICAL AVULSION FRACTURES NAVICULAR TUBEROSITY FRACTURES FRACTURES OF THE NAVICULAR BODY Mechanism of Injury and Diagnosis Treatment Authors’ Recommended Treatment STRESS FRACTURES OF THE TARSAL NAVICULAR Mechanism of Injury Clinical Evaluation Radiographic Evaluation Treatment and Results Complications CUBOID AND CUNEIFORM BONES Mechanism of Injury CUBOID FRACTURES Clinical Evaluation Radiographic Evaluation Treatment Authors’ Preferred Method of Treatment CUNEIFORM FRACTURES Mechanism of Injury Radiographic Evaluation Treatment Authors’ Preferred Method of Treatment METATARSAL BONES Anatomy Mechanism of Injury METATARSAL BASE FRACTURES (EXCLUDING FIFTH METATARSAL) Authors’ Preferred Method of Treatment METATARSAL SHAFT FRACTURES Clinical Evaluation Radiographic Evaluation Treatment METATARSAL NECK FRACTURES Authors’ Preferred Method of Treatment METATARSAL HEAD FRACTURES Authors’ Preferred Method of Treatment FRACTURES OF THE FIFTH METATARSAL BASE Anatomy Classification Tuberosity Avulsion Fractures Jones Fracture Diaphyseal Stress Fractures Authors’ Preferred Method of Treatment STRESS FRACTURES OF METATARSAL DIAPHYSIS Clinical and Radiographic Evaluation Treatment Authors’ Preferred Method of Treatment PHALANGEAL FRACTURES Mechanism of Injury Clinical Evaluation Radiographic Evaluation 2199 2200 PART X Trauma OPEN FRACTURES Treatment Authors’ Preferred Method of Treatment HALLUCAL FRACTURES Authors’ Preferred Method of Treatment LESSER TOE FRACTURES Authors’ Preferred Method of Treatment SESAMOID BONES Anatomy Mechanism of Injury Clinical Evaluation Radiographic Evaluation Differential Diagnosis Conservative Treatment Surgical Treatment Authors’ Preferred Method of Treatment DISLOCATIONS OF SESAMOID BONES THE TARSAL NAVICULAR Anatomy The tarsal navicular is located in the uppermost portion of the medial longitudinal arch of the foot and acts as the keystone of the arch.80 The body of the tarsal navicular is a six-sided disk that is horseshoe shaped and sits between the talar head and the three cuneiform bones.35,113 It has a concave proximal articular surface that articulates with the head of the talus. Dorsally, laterally, and on the plantar surfaces, numerous short ligaments attach to the tarsal navicular. These include the dorsal and plantar cuneonavicular ligaments distally and the plantar, dorsal, and interosseous cuboideonavicular ligaments laterally.113 In addition, as described by Eichenholtz and Levine,35 a dorsal talonavicular ligament and an anterior division of the deltoid ligament, known as the tibionavicular ligament, exist; both offer strong support on the anteromedial aspect of the joint (Fig 41–1). The medial surface slopes posteriorly to end in the prominent tuberosity, where a portion of the posterior tibial tendon is inserted. Much of the tuberosity accepts the attachment of the plantar calcaneonavicular (spring) ligament arising from the sustentaculum tali. This complex, combined with the anterior process of the calcaneus, makes up the acetabulum pedis as described by Sarrafian115 (Fig. 41–2). This socket allows the foot to swivel around the head of the talus. At heel strike, the subtalar joint is everted. The talonavicular joint and calcaneocuboid joints (transverse tarsal) are parallel or unlocked, allowing for flexibility. At toe-off, the subtalar joint is supinated, and the talonavicular and calcaneocuboid joint are nonparallel or locked, allowing for stability. Foot pronation and supination are dependent on normal talonavicular function. Loss of motion at the talonavicular joint results in significant loss of subtalar motion.4 The distal surface of the navicular is also concave and is divided into three articular facets for articulation with each of the three cuneiform bones, but there is little motion at these joints. Acetabulum pedis 1 Figure 41–1 Schematic of superficial deltoid ligament shows the anterior tibionavicular ligament (1), arising from the anterior colliculus of the medial malleolus and inserting into the dorsomedial aspect of the navicular. (From Pankovich AM, Shivaram MS: Acta Orthop Scand 50:217-223, 1979.) Figure 41–2 Acetabulum pedis, a confluence of structures that articulate with the talar head. (From Sarrafian SK: Anatomy of the Foot and Ankle. Philadelphia, Lippincott, 1983, p 173.) CHAPTER 41 Fractures of the Midfoot and Forefoot 2201 2 1 2 2 1 A B Figure 41–3 Blood supply to navicular. A, In a 4-year-old girl, demonstrating that most of blood supply comes from a single artery (1), with a few penetrating radiate vessels (2). B, Similar findings in a 13-year-old boy. (From Sarrafian SK: Anatomy of the Foot and Ankle. Philadelphia, Lippincott, 1983, p 302.) The blood supply to the navicular is also important for understanding the results of injury to this bone. Because of the extensive articular cartilage surrounding the bone, blood vessels can enter only from the dorsal and plantar surface and from the tuberosity (Fig. 41–3).115 Sarrafian pointed out that the dorsal pedis artery supplies the dorsum of the bone, and the medial plantar branch of the posterior tibial artery supplies the plantar surface. A network of vessels formed from both these branches supplies the tuberosity. Torg et al131 performed microangiographic studies of the navicular and found that although the medial and lateral thirds of the bone had a good blood supply, the central third was largely avascular. Sarrafian115 also noted that the number of vessels supplying the navicular decreased with increasing age, possibly explaining the rise in the rate of avascular necrosis (AVN) and nonunion after fracture of this bone in elderly patients. avulsed along with a varying amount of bone (Fig. 41–5). The third injury, the navicular body fracture, occurs after a high-energy crush and results in articular comminution. It is often associated with shortening of the medial column and dorsal extrusion of part of the navicular (Fig. 41–6). The fourth type of fracture is the tarsal navicular stress fracture, which usually results from overuse and repetitive trauma. Diagnosis A navicular fracture should be suspected after an injury to the foot or when the patient has continued complaints of pain in the midfoot. Radiographs should be Mechanism of Injury Four characteristic types of fractures can occur to the tarsal navicular.35,80,113 The first is a relatively minor twisting injury that results in a cortical avulsion fracture known as a chip fracture; this is best seen on the lateral radiograph (Fig. 41–4). This fracture usually represents a dorsal ligamentous and capsular avulsion fracture. With more force, usually from an everted foot with pull from the posterior tibial tendon, a tuberosity fracture can occur, in which the medial tuberosity is Figure 41–4 Lateral radiograph showing chip fracture of tarsal navicular. McKeever83 suggested that disruption of the synchondrosis between the two bones could result in a painful avulsion of the accessory bone. 41–7). because missed fractures result in displacement of the navicular with secondary collapse of the medial column of the foot. Schiller and Ray118 suggested several criteria to evaluate injuries of the middle part of the foot.57 CORTICAL AVULSION FRACTURES Fractures of the dorsal lip of the navicular are the most common type of navicular fractures encountered. and point tenderness on the dorsal and dorsomedial aspect of the foot in the area of the talonavicular junction. Figure 41–5 Tuberosity avulsion fracture (arrow). The signs and symptoms of dorsal avulsion fractures consist of pain. When in doubt. a bone scan or magnetic resonance (MR) image should be obtained to document the fracture.2202 PART X Trauma Tuberosity fractures are seen with the foot in moderate equinus when oblique and AP views are obtained.124 The mechanism of injury should be sought. Crush fractures to the navicular body are seen in all views. Nevertheless. In addition. Interestingly. . obtained in the anteroposterior (AP). When radiographs are negative and a high index of suspicion exists. especially in the midfoot. and lateral projections so that the fracture can be clearly seen. Giannestras and Sammarco39 emphasize the association of this injury with a lateral sprain of the ankle. This is critical. Dorsal cortical avulsion fractures are best seen on the lateral radiograph.39 They accounted for 47% of fractures of the navicular in the series reported by Eichenholtz and Levine. and associated fractures. swelling. Figure 41–6 Comminuted fracture of the navicular body. On a normal AP radiograph the shadow of the navicular should overlap all three cuneiforms equally. The mechanism of injury is usually an acute plantar flexion inversion injury of the foot in which the talonavicular ligament avulses a portion of the navicular from the proximal dorsal aspect of that bone. oblique. radiographs of the contralateral side may be helpful. where the avulsion of the dorsal navicular appears at the level of the talonavicular joint.35 They are often associated with sprains of the midfoot. Computed tomography (CT) is required to delineate the extent of lateral involvement because plain films do not always show these fracture lines well (Fig. one third of the cases reported by Main and Jowett80 were initially missed. Care should be taken to avoid mistaking an accessory navicular for a fracture. In these instances the cause may be a nondisplaced fracture or a stress fracture. as opposed to the sharp line of a fracture. A careful clinical search for point tenderness helps to distinguish these injuries.39 Usually a smooth line separating the two bones is visible. On the lateral radiograph the cuneiform should overlap and lie in line with the navicular. should be considered. An oblique radiograph should be made for all suspicious cases of injury to the middle part of the foot. no space should be seen between the bases of the first and the second metatarsal. most authors suggested that treatment should be symptomatic. they recommend a below-knee walking cast for 3 to 4 weeks.CHAPTER 41 Fractures of the Midfoot and Forefoot 2203 A Navicular tuberosity Figure 41–7 A. they recommend delayed excision of the fragment. If the fragment is large enough to be a symptomatic bony prominence. Historically. He suggests. Computed tomography scan demonstrates that fracture is in both sagittal and transverse planes. however. however. As a result. surgical treatment is often unnecessary. Ace). then keeping patients non–weight bearing for 6 to 8 weeks will give their major ligamentous injury longer to recover.22 and Garcia and Parkes38 all recommended an elastic dressing with partial weight bearing on crutches for 4 weeks. NAVICULAR TUBEROSITY FRACTURES Fractures of the navicular tuberosity result from acute eversion of the foot. If the .39 With attempted eversion of the foot. that is. leading to increased tension on the medial inserting structures. This increased tension results in an avulsion fracture of the navicular tuberosity.35. excising the fragment if pain persists after immobilization. Watson-Jones134 stated that although results were usually excellent after short-term immobilization. When symptoms of pain are severe and the chip fragment is larger than a flake of bone.39 Coker and Arnold. The patient usually gives a history of having twisted the foot and complains of pain over the navicular tuberosity that is accentuated by weight bearing.39 Because of the other insertions of the posterior tibial tendon in the forefoot. Comminuted fracture of tarsal navicular (arrow). the fracture is usually only minimally displaced. the posterior tibial tendon and the strong attachment of the deltoid ligament to the tuberosity of the navicular. by way of the spring ligament. Giannestras and Sammarco39 recommend the use of an elastic dressing (Elastoplast. Giannestras and Sammarco. Chapman16 recommends a short period of immobilization and states that minimal disability usually results. followed by the use of a molded longitudinal arch support. For patients who had mild pain and who were not very active. If significant soft tissue swelling and ecchymosis are present. he recommended immobilization for 6 weeks. We agree with a short period of immobilization for these fractures. these avulsion injuries could represent part of a midtarsal subluxation. B. open reduction with internal fixation is indicated not only to minimize pain and posttraumatic arthritis but also to decrease the risk of subsequent midtarsal subluxation. B Dorsal avulsion fractures should be treated conservatively. If such a subluxation was present. pain is referred to the involved area secondary to the increased tension applied to the posterior tibial tendon and thus to the fracture site. When the avulsed fragment is a major portion of the articular surface of the navicular. a shearing fracture of the navicular along the lines of the intercuneiform joints occurred. B Figure 41–8 Surgical treatment of navicular tuberosity avulsion fracture.35. If a painful nonunion persisted. they are usually the result of direct axial load secondary to a fall from a height with the patient landing on the feet. a crushing component was added to the injury. a below-knee walking cast with the foot in the neutral position was used. At the same time the navicular bone fragments turned upward and hinged on the dorsal talonavicular ligaments. They stressed that fractures of the navicular body were in continuum with fracture–dislocations.2204 PART X Trauma symptoms were severe. Main and Jowett80 believed that the classification of midtarsal injuries should be based on the direction of the forces acting on the joint. A. We generally agree with these concepts. a nonunion is likely. it was usually asymptomatic and therefore disregarded. In that case we recommend open reduction with anatomic repositioning under direct visualization. however. A 3. These authors stressed that although nonunion could occur. Similarly. Postoperative management includes non–weight bearing for 8 weeks in an off-the-shelf cast boot.0-mm cancellous partially threaded lag screw should be used (Fig. surgical excision of the tubercle was recommended. Lateral radiograph showing fixation. 41–8). Nyska et al94 believed that the forefoot and cuneiforms were compressed by a longitudinal force when the ankle was plantar flexed.113 Eftekhar et al34 and Nadeau and Templeton93 suggested that the mechanism of injury for a vertical fracture of the talar body with dorsal dislocation of a variable portion of the navicular was forcible plantar flexion and abduction of the midtarsal joint. When these fractures do occur. Dorsal radiograph showing fracture (arrow). In this instance the foot swiveled about the axis of the interosseous talocalcaneal ligament. at which time the cast was removed and weight bearing advanced. or it was retracted posteriorly and medially by the posterior tibial tendon and spring ligament. For example. B. After excision the patient was kept in a below-knee cast for 4 weeks.94. but when a diastasis of greater than 5 mm is seen. the avulsion can take a rather large portion of the medial navicular. The raw surfaces of the tendon were sutured back to the remaining navicular under the same tension that existed before excision of the navicular tubercle. secondary to the navicular being trapped between the cuneiforms and . however. This technique is also used when a symptomatic nonunion develops. When longitudinal forces were applied across the foot. A FRACTURES OF THE NAVICULAR BODY Mechanism of Injury and Diagnosis Fractures of the body of the navicular are uncommon because of the strong associated ligamentous attachments to the bone. followed by progressive weight bearing in the boot over the following month. giving the classic radiographic finding of a vertical fracture dislocation with dorsal dislocation of the fracture fragments. The talus then acted as a wedge with the medial tuberosity held in place. When this longitudinal force was applied to the metatarsals in a plantar-flexed foot. This in turn crushed the navicular variably against the talar head.5-mm screw overdrilled to lag the fragment or a 4. followed by internal fixation. a force moving the foot medially on the talus usually resulted in a swivel dislocation of the talonavicular joint in which the calcaneocuboid joint remained intact.80. New York. Type 3 fractures include fractures with central or lateral comminution (Fig. Type 3.31 If severe swelling and fracture blisters are present. and compartment syndrome are indications for urgent management. Marked tenderness over the medial aspect of the navicular is usually present. Motion of the foot. whereas major forces resulted in dorsal displacement of the fragments. In a type 2 fracture. Otherwise. and as an intraoperative fracture reduction aid. Patients who have such injuries should undergo a careful documented neurovascular exam and inspection for open wounds and compartment syndrome. as supplemental fixation in certain cases of limited internal fixation. severe skin tenting or soft tissue swelling. the foot may be displaced in a medial direction such that the talar head appears to be shifted laterally on the AP radiograph. (From Hansen ST Jr. External Fixation External fixation can serve many roles in the treatment of these injuries and therefore is an invaluable technique to know. the displaced fracture fragments can be palpated on the dorsal aspect of the foot. Surgery is planned and performed as dictated by soft tissue swelling and patient factors. or instability. the most common type. p 361. If severe. Sangeorzan et al. DiGiovanni lists four settings: for obtaining preliminary stabilization and alignment in a grossly unstable injury pattern prior to definitive management. as seen clinically or on a Harris axial view (Fig. minor forces resulted in nondisplaced fractures. 41–9B).113 using radiographic evaluation. and the presence of associated injuries. Type 1. classified fractures of the body of the navicular by the degree and direction of displacement. and the medial border of the foot is disrupted at the navicular cuneiform joint.) . Skin tenting. Thus. Type 2. irreducible dislocation. The wrinkle test is used to determine if swelling is acceptable. 1993. Clinically. A B C Figure 41–9 Classification of navicular body fractures according to Sangeorzan et al. 41–9A). Sanders and Hansen111 noted that with an intact medial fragment and a crushed lateral component. the navicular was crushed eccentrically such that the foot followed the deforming force. The major fragment is dorsomedial. produces localized pain. the number of articular fragments. particularly inversion–eversion and abduction–adduction.CHAPTER 41 Fractures of the Midfoot and Forefoot 2205 the talar head. with the hindfoot shifted into varus. neurovascular compromise. with a small. Raven. a closed reduction and preliminary stabilization in a bulky Jones dressing and posterior slab in neutral position to rest the soft tissues is appropriate. often comminuted plantar lateral fragment. The calcaneonavicular joint is not disrupted. Swiontkowski MF: Orthopaedic Trauma Protocols. the fracture line traverses the body of the tarsal navicular dorsolaterally to plantar–medially (Fig. There may be lateral displacement of the foot with some disruption or subluxation of the calcaneocuboid joint. patients usually have pain that is localized to the midtarsal aspect of the foot. open wounds. 41–9C). the alignment of the forefoot.113 A. In a type 1 fracture the primary fracture line is transverse in the coronal plane. it is prudent to wait until the soft tissue has recovered before proceeding with operative intervention. 41–10). with a dorsal fragment that consists of less than 50% of the body (Fig. C. The major fragment is usually the medial one. they can be recognized by gross midfoot deformity. ecchymosis. On the AP radiograph the medial border of the foot does not appear to be disrupted. B. Before the onset of swelling. as a means to observe the soft tissues of a severely traumatized or crushed foot. With the addition of lateral or medially directed forces.39 Treatment Timing of Surgery Navicular dislocation or perinavicular subluxation are not uncommon in association with navicular fractures. Crossan24 advocated the resection of fracture fragments to relieve symptoms in patients in whom open reduction was impossible (Fig. depending on which column of the foot (medial or lateral) needs to be reduced through traction. because the loss of bone in the medial column severely disables the patient as the foot collapses into adduction and cavovarus. especially in a comminuted fracture pattern. Pins can be placed in the metatarsal shaft and calcaneus or talus. LN. Note that hindfoot varus is evident with uncovering of the anterior aspect of the calcaneal posterior facet. Bonvallet9 advocated open reduction and anatomic repositioning using internal fixation. medial navicular.111. B. 41–11). CC joint.113 As early as the 1950s. After vertical (type 2) navicular fracture. C. by using the principle of ligamentaxis. This technique is mentioned only to be condemned. which can be best seen clinically from behind. Cadaveric navicular osteotomy model designed to indicate fracture pathologic process. Internal Fixation Treatment in the past was largely nonsurgical. uncovering the talar head and giving a radiographic appearance of lateral shift of the talar head. calcaneocuboid joint. lateral navicular.45. the posterior tibial tendon will force the foot medially. acted as a sagging cornerstone in a vault . MN.2206 PART X Trauma Talar head Normal side in valgus Injured side in varus A B Ankle MN LN Navicular osteotomy CC joint Posterior facet C Figure 41–10 A. which. He believed that the generally poor results of conservative therapy were caused by nonanatomic positioning of the navicular. after inadequate reduction.80. *Talar head. This results in varus shift of the hindfoot. with manipulative reduction used for displaced fractures. sustaining this fracture to the tarsal navicular. D and E. Arrows indicate gap present from navicular excision.5-mm cannulated lag screw was performed successfully. then referred for further care. A 26-year-old man fell out of a palm tree. wedged in place for a fusion mass. . Defect was filled with structural iliac crest bone graft. This repair failed. and revision using large 6. F.CHAPTER 41 Fractures of the Midfoot and Forefoot 2207 Total navicular excision A B C E 1 year postrevision D F Figure 41–11 A. Patient was seen in a local hospital and treated with complete navicular excision and pinning. and held with staples. B and C. Clinically these patients were still exhibiting pain. Dick30 was advocating primary arthrodesis for all tarsal navicular body fractures with dorsally displaced fragments. closed reduction was of little or no value.45. All displaced.L. Main and Jowett80 also suggested that fusions be limited to the naviculocuneiform joints and that talonavicular fusions be performed only in cases of severe . 41–12). In his perception. Although manual traction can be used. or iliac crest. Kirschner wires must be drilled into the individual fragments to be used as joysticks to control the fragments and assist in reduction. distal tibia. By 1942. This distraction overcomes the deforming force of the anterior and posterior tibial tendons and allows the displaced fragments to fall back into position for subsequent fixation. primarily from the remaining unfused subtalar joints. Nyska et al94 also suggested that talonaviculocuneiform fusions were required when the navicular body was severely comminuted. Arthrodesis For the more comminuted fractures. Day believed that a quadruple arthrodesis (triple arthrodesis plus an arthrodesis of the naviculocuneiform joint) produced results superior to those obtained after fusion of only the involved joints. surgical intervention had become the more accepted treatment for this injury. The approach to the talonavicular joint is made through an anteromedial incision between the anterior and the posterior tibial tendons. Paoli.113 comminution. but they condemned the addition of a triple arthrodesis. which may extend across the nonessential naviculocuneiform joints and into the cuneiforms if needed.81 Cancellous bone grafting to fill central defects in the bone after elevation of depressed fragments may be necessary. Finally and most recently. open reduction with internal fixation with lag screws is necessary to prevent not only avascular necrosis and nonunion of the navicular but also collapse of the medial column. usually within 6 to 12 months after injury. Garcia and Parks38 used the degree of damage to the articular cartilage surfaces as the criterion for immediate arthrodesis of either the talonavicular or naviculocuneiform joint in younger patients. P. resulted in an asymptomatic foot. Hansen45 described “ankylosis” procedures as an alternative to arthrodesis for the treatment of acute fractures. Fracture reduction can be obtained with the use of large or small pointed Weber reduction forceps. Alternatively.26 using amputation specimens. Both Giannestras and Sammarco39 and Garcia and Parkes38 indicated that when the fractured navicular body was displaced. found that localized arthrodesis (i. allograft or synthetic bone void filler products may be used. comminuted fractures and fracture–dislocations are treated surgically. These can be inserted through stab incisions or through the open wound to grip the major fracture fragments perpendicular to the fracture line. traumatic flat feet with degenerative arthritis. Most authors currently limit fusions to the pathologic process found at the time of surgery. Eichenholtz and Levine35 believed that if the fracture was too comminuted for internal fixation. in cases in which complete reduction could be obtained. indirect reduction is more often performed. Penn) or small external fixator.D. If at any time the fracture fragments shift. an arthrodesis of either the talonavicular or the naviculocuneiform joint was required.2208 PART X Trauma construction..91. particularly when there were two major fragments with little or no comminution.94. They noted that occasionally a triple arthrodesis was indicated. using a medially placed small fragment distractor (Synthes. I. Authors’ Recommended Treatment Patients with nondisplaced fractures are treated in a non–weight-bearing cast for 8 to 10 weeks until fracture healing is seen radiographically. They stated that triple arthrodesis never resulted in a rating better than fair according to their criteria. In this situation the cuneiforms are considered anchors for stabilization whereby the fracture fragments are secured with lag screws. Range of motion should not be started until the surgeon is convinced that union has occurred. In these cases. Day.113 A small capsulotomy in the talonavicular joint should be performed to visualize the fracture and the talonavicular articular surfaces. Similarly.e. secondary deformities manifested after resumption of weight bearing and progressed to painful. primary or delayed arthrodesis of the talonavicular or naviculocuneiform must be considered. This bone can be obtained from the calcaneus. In 1933. Nadeau and Templeton93 also recommended open reduction. arthrodesis involving the talonavicular and naviculocuneiform joints) resulted in a loss of nearly all the inversion and eversion of the foot. These screws are often removed after the fracture has healed. Occasionally. Most authors currently agree that for all but the most minimally displaced fractures. but this necessarily resulted in a complete loss of hindfoot motion. Wilson140 found that primary arthrodesis of the talonavicular joint. open reduction with internal fixation is required. internal fixation might not be possible.45. with one pin placed in the talar neck and the other in the medial cuneiform or base of the first metatarsal. but formal joint fusion is not done (Fig. By the 1970s. On this view. C.45 Cannulated screws have neither adequate purchase nor sufficient strength for optimal fixation. Fixation is obtained by using two or more screws in a lag mode and inserted through dorsomedial and dorsolateral stab incisions. a distractor or laminar spreaders are needed. Intraoperative view demonstrates reduction of the navicular using a medial distractor. Adequate fixation may be achieved with 4. but use of 3. may be used to augment the fixation. navicular fixation was lost. Blue Bell.5-mm screws is stronger and minimizes the chance of screw breakage.5 to 3. Lateral radiograph shows navicular fracture.5-mm cortical lag screws without extending the fixation into the distal cuneiforms. A. and grafting was planned for the cuboid. When small articular fragments exist. In most cases they can be stabilized with 3. mini-fragment screws or Biofix bioabsorbable pins (Bionx Implants. and the navicular could no longer be held with screws. D and E. bone grafting and plating were performed to restore the cuboid. When there is minimal comminution and the lateral frag- . Computed tomography scan coronal cuts demonstrate level of navicular comminution.0-mm cancellous screws. B. A screw was placed into the navicular. with a lateral laminar spreader to realign the midfoot. After reduction. Penn). Because of the comminution.CHAPTER 41 Fractures of the Midfoot and Forefoot 2209 Navicular fracture Talus Talus Calc A Cuboid distraction and grafting B E Indirect reduction using small external fixator C D Figure 41–12 Comminuted navicular fracture with cuboid crush (“nutcracker injury”). the joint surfaces are evaluated for articular depression and loose bodies. Therefore an ankylosis procedure was performed. The dorsal and plantar fragments of Sangeorzan type 1 displaced intraarticular navicular fractures are rarely highly comminuted. During the procedure.2 mm. the cuboid appears relatively intact. Similarly. as well as fracture at the level of the tuberosity and calcaneal (Calc) involvement. locking the navicular to cuneiforms using a plate.5-mm cortical screws is more advantageous because the larger core diameter of the 3. Sangeorzan type 2 fractures are more difficult to reduce because the lateral plantar fragment may be comminuted and the dorsomedial fragment may be dislocated at the talonavicular joint. ranging from 1. Nadeau and Templeton93 described a displaced fracture treated with open reduction.2210 PART X Trauma ment is large. and collapse of either the medial or lateral column is possible. If fixation is limited. Kirschner wires placed through the talonavicular joint may be removed after 6 weeks. case that was treated surgically with two screws and early mobilization. Once again. the plate must be removed with a second procedure once the fracture has healed. Three had good results. and in 50% of type 3 fractures. and one had a fair result. Sangeorzan et al113 reported on 21 navicular body fractures. one or more smooth 1. More recently. which were displaced. late partial collapse of the navicular. Using their classification system.or 2. the patient had no limitation of function and no pain. When the naviculocuneiform articulation is highly comminuted. the medial column should be brought out to length with a structural bone graft. In a large series of 67 navicular fractures. They found patients commonly had disability in the long term. Eichenholtz and Levine35 treated 19 body fractures. Eftekhar et al34 reported on one patient treated with open reduction 6 days after injury. Of these 29 fractures of the navicular body. with average American Orthopaedic Foot and Ankle Society (AOFAS) scores of 71. Fifty patients in this study had navicular body fractures. medial-to-lateral lag screws are used to fix the fracture. augmentation with a mini external fixator is an option. with one excellent result. If the injury extends into the calcaneocuboid joint.5 years of follow-up. or if talonavicular subluxation needs to be corrected. The authors concluded that both the type of fracture and the accuracy of surgical reduction directly correlated with the final outcome. Weight bearing and motion may be gradually increased after radiographs show evidence of union. Only one case was managed initially with open reduction followed by casting. The remaining 24 fractures. the dorsomedial fragment should be reduced with screws aimed obliquely into the second or third cuneiform. Main and Jowett80 reported on 15 longitudinal and 14 longitudinal and medial compression injuries. Patients complaining of subtalar pain later in their course of treatment can subsequently be converted to a triple arthrodesis. only four patients thought they had a “normal” foot. all five undisplaced fractures had good or excellent outcomes. Postoperatively the foot is immobilized in a non–weight-bearing short-leg cast for 10 to 12 weeks. Greenberg and Sheehan43 reported one Complications Partial AVN. Complete avascular necrosis occurred in two cases and partial necrosis in four. However. the joint may be debrided of cartilage and fused without sequelae. the patient had full range of motion without pain.6. fixed anatomically. and one was painful.117 Bridge plating offers more stable fixation and the advantage of no pin site problems common in the foot. Nineteen months after treatment the patient reported no pain or limp but had lost approximately 50% of his supination and pronation. Five cases subsequently underwent late surgical treatment: three talonaviculocuneiform fusions and two triple arthrodeses. Patients with isolated injuries to the navicular. Only a 4-month follow-up was provided. in 67% of type 2 fractures. if fixation to a distal segment is not possible. Nyska et al94 reported on four fractures with only 6 months to a year of follow-up. Navicular fractures were not classified in this study. Temporary bridge plating from the talar neck onto the cuneiforms or first metatarsal is another technique that prevents collapse of the medial column. three good results. When the talonavicular joint is damaged. If reconstruction with screws and Biofix pins is not possible secondary to comminution and collapse. Alternatively. Fixation by this method reduces both the navicular fracture and the naviculocuneiform joint disruption. attention to articular reconstruction is of critical importance because of the significance of this articulation. When the lateral fragment is small or comminuted. Although two thirds of the patients had a good functional result with no pain during activities of daily living. with 3. and posttraumatic arthritis are often seen after a navicular . and one fair result. Comminution and subluxation of the plantar lateral fragment should be addressed with ankylosis between the navicular and the cuboid or lateral cuneiform. Sangeorzan type 3 fractures also demonstrate comminution in the plantar lateral fragment and cannot be reduced securely by screw fixation alone. A talonavicular fusion is then performed. this should be fixed separately with additional lag screws. Richter et al108 recently reviewed their experience with 155 patients who had fractures or fracture–dislocations of the midfoot. 14 had a good result. included only one excellent and five good results (25%). Results Results in the literature are primarily based on isolated case reports. a satisfactory reduction was obtained in all type 1 displaced fractures.0-mm pins are inserted from the navicular fragment into the talar head and neck. Thus the vast majority of displaced fractures (18 of 24) had only fair or poor results. the large medial or dorsomedial fragment must be fixed in anatomic position by anchoring screws into the cuneiforms. Anchoring screws may be removed at 6 months to prevent screw breakage from cyclic loading across the joints. Of the 15 patients with a satisfactory reduction. with restoration of the medial and lateral column scored closer to normal. Treatment and Results Towne et al132 presented two cases. an incidence of 0. Khan et al70 stated that a stress fracture of the tarsal navicular was a frequently recognized injury. In the first a vertical fracture of the navicular required open reduction and internal fixation with bone grafting. and on the lateral view a cleft is noted to run from the proximal plantar aspect to the distal dorsal margin and to separate a triangular osseous structure located dorsal to the rest of the navicular body. because of continued symptoms. the area of the navicular are reproduced. Although Brailsford thought this represented idiopathic AVN of the lateral segment. The first reported cases appeared in 1970. Hunter. Using these techniques. The authors also pointed out that conventional radiographs were often negative but that tomograms often revealed a vertical fracture of the tarsal navicular. By 1994. or quadruple arthrodesis. followed by a triple or quadruple arthrodesis. In any case. Healing without sequelae resulted. when Towne et al132 described a stress or fatigue fracture of the tarsal navicular in two patients. particularly track. and oblique views when a navicular stress fracture is suspected. She noted that these patients were usually involved in athletic activities. in many cases it appeared to follow a traumatic event. This is best managed by repositioning the medial column and hindfoot with a structural bone graft. In this syndrome the forefoot is shifted medially. If collapse or painful arthrosis occurs.132 Hunter58 found that when these patients stand on their toes and exert downward pressure on the metatarsal heads.48 Both bone and CT scans can be used to distinguish between a bipartite navicular and a stress fracture. to delineate the fracture and its amount of separation. Partial fractures located in the dorsal cortex involved the proximal articular surface in most cases. Torg et al. one of whom required open reduction and internal fixation. first described by Brailsford10 in 1939. naviculocuneiform. Hunter58 first suggested the use of a bone scan for verification of the stress fracture. development of a late progressive hindfoot varus deformity follows. Devas29 reported two additional cases in 1975. Osteochondritis of the adult tarsal navicular. lateral.CHAPTER 41 Fractures of the Midfoot and Forefoot 2211 fracture.7%. specifically after bone scanning. Goergen et al41 reported two additional cases in runners. reconstructive structural bone block fusions may be indicated. Orva et al95 found only one case in 142 stress fractures.58 Torg et al. In 1981. They also suggested a bone scan if the initial views were negative.58. Radiographic Evaluation Towne et al132 found that although initial radiographs might fail to reveal the fracture. reported 21 cases the following year. painful feet in whom the tarsal navicular Clinical Evaluation Patients usually give a history of the insidious onset of an ill-defined soreness or cramping sensation over the dorsum of the foot or the medial aspect of the longitudinal arch.132 AP radiographs in cases of a bipartite navicular reveal the bone to be comma shaped and bent.33 True stress fractures occur in the sagittal plane. Torg et al131 suggested standing AP. results in late collapse of the lateral side of the navicular. films taken several months later can reveal a vertical radiolucent line in the tarsal navicular. Wiley and Brown137 reported on three patients with stiff.58.131 in a multicenter study. such as a talonavicular.131. They emphasized that the tarsal navicular is often underpenetrated on these radiographs and that a coned-down AP view centered on the navicular may be required. both in older women. the symptoms of pain in .110 The AP radiograph is diagnostic and shows the talar head articulating with the lateral cuneiform.131 A fatigue fracture of the tarsal navicular may be confused with a bipartite navicular. because a failure to recognize this entity and curtail the athletic activity can result in fracture displacement. triple. followed by non–weight bearing for 3 months. usually occurring in track and field athletes.70. talonaviculocuneiform. pulling the hindfoot into varus. and outlined the diagnosis and treatment for this disorder.45 Symptomatic arthrosis and bone collapse can occur in displaced fractures.131. the authors found all fractures to be located in the sagittal plane in the central third of the bone. In the second case a nondisplaced stress fracture of the navicular was treated with crutches and non–weight bearing for 4 months. STRESS FRACTURES OF THE TARSAL NAVICULAR Mechanism of Injury Stress fractures of the tarsal navicular were once thought to be exceedingly rare. Khan et al70 and Kiss et al71 recommend a CT scan of these lesions. Although the earlier reports suggested the use of tomograms to document the fracture. Hunter58 stressed that these injuries were probably more common than recognized.131 and Khan et al70 emphasize the importance of this diagnosis in athletes. even after optimal fixation. Both Wiley and Brown137 and Sanders and Hansen111 thought that a triple arthrodesis was required to correct the pain. Displaced fractures. Wiley and Brown137 noted that a nonunion. compression fractures usually involve the entire body of the cuboid. or a medullary cyst. The fracture line is identified. It was important to fully expose the fracture’s distal limits before the graft was inserted. probably because both the cuboid and the cuneiform bones occupy a protected and buttressed location in the metatarsus. With displacement.83. The authors reported on 19 fractures in 18 patients. They suggested that correction using a structural iliac crest bone block graft and a Dwyer calcaneal osteotomy. Brailsford10 described the deformity that he believed was secondary to osteochondritis or osteonecrosis in the adult. Although these authors termed this entity “listhesis of the tarsal scaphoid. Complications The principal complication of a stress fracture of the tarsal navicular is a delayed union or nonunion. This is followed by a 6-week program of rehabilitation with a graduated return to activity. surgical intervention is required. If left untreated over a long period. 41–13). These authors stressed the importance of non–weight bearing in the healing phase. Of the 15 patients with adequate follow-up.140 Chapman16 stated that these fractures more often occur in conjunction with fractures of the cuneiforms or the bases of the lateral metatarsals.83. If the fracture was detected early and treatment was applied. coupled with a triple or quadruple arthrodesis.” it may well have represented a stress fracture of the navicular that became displaced.7.2212 PART X Trauma separated to such a degree that the head of the talus became approximated to the cuneiforms. 12 had been able to return to a preinjury level of activity within 1 year.140 These fractures are most often caused by a direct crushing force or by a fall on the foot in plantar flexion. The most common are avulsion fractures. Six fractures were complete. and one had a residual medullary cyst. Two of the patients received some relief from conservative therapy. because continued weight bearing or immobilization in a weight-bearing cast can lead to prolonged disability. a nonunion can progress to displacement with deformity. In these patients. orthoses are recommended to correct the abnormal anatomy. presumably from separation of the fragments. debrided and autogenous or allogenic bone graft is inserted.53 Occurring less often. was critical to correct the deformity completely. They recommended that uncomplicated partial stress fractures and nondisplaced stress fractures of the tarsal navicular be treated with immobilization using a plaster cast and non–weight bearing for 6 to 8 weeks. delayed healing.76 More recently. an CUBOID FRACTURES Two types of cuboid fractures are typically seen: avulsion fractures and compression fractures. complete fractures. 12 were incomplete. proceeded to the same deformity. the rate of delayed or nonunion was exceedingly low. and the third required a triple arthrodesis. and nonunions should be treated with internal fixation and bone grafting. an inherent abnormal anatomy may be a significant predisposing factor. however. In patients who remained symptomatic. Hunter58 recommended curtailing athletic activity to prevent the development of a displaced stress fracture. Khan et al70 noted that the treatment of tarsal navicular fractures in athletes should include 6 weeks of strict non–weight-bearing cast immobilization. Screw fixation from the smaller lateral fragment into the larger medial fragment can be used. Fitch et al36 noted that stress fractures of the tarsal navicular do not always heal predictably with conservative treatment. but the latter authors recognized that the deformity included medial shifting of the forefoot with a residual varus hindfoot deformity. similar to that of a comminuted tarsal navicular body fracture. left untreated. . Torg et al131 indicated that the failure to treat these fractures with non–weight bearing contributed to disability because of delayed union. and refracture. When open reduction and internal fixation is indicated. CUBOID AND CUNEIFORM BONES Mechanism of Injury Isolated fractures of the cuboid and cuneiform bones are quite rare.16. with accompanying inversion or eversion. but a more serious injury. Garcia and Parks38 emphasize that cuboid fractures are often associated with tarsometatarsal or midtarsal dislocations or subluxations and that the cuboid may also be involved in calcaneal fractures (Fig. followed by immobilization and non–weight bearing until union occurs. delayed unions. autologous bone graft was inserted after en bloc resection of the fracture surfaces. nonunion. In patients in whom repeated stress fractures of the navicular are noted despite an alteration in training techniques. a similar dorsal approach to navicular body fractures is used. radiographs usually showed wide separation of a complete fracture. In such cases. which occur on the lateral aspect of the foot and are often confused with a routine ankle sprain. extension of an incomplete fracture. 47. with progressive ambulation. Hermel and Gershon-Cohen52 recommend early midtarsal fusion for comminuted fractures associated with subluxation or dislocation of the cuboid. Associated tenderness over the medial aspect of Chopart’s joint suggests associated subluxation. As emphasized by Hermel and Gershon-Cohen. which they named the “nutcracker fracture of the cuboid” because the cuboid. These cases required distraction. 10 of 12 had associated fractures of the midfoot. Case reports have shown a high incidence of missed injuries on plain films and suggest the need for routine CT scan with these injuries. This resulted in an impacted and comminuted fracture often associated with subluxation of Chopart’s joint.39. and the weight of the body was transmitted by the calcaneus through the cuboid and the two lateral metatarsals. Fracture–dislocation of the calcaneocuboid joint (arrows). Radiographic Evaluation Anteroposterior.CHAPTER 41 Fractures of the Midfoot and Forefoot 2213 Cuboid crush Shear fracture Midfoot subluxation Avulsion fracture A B C Figure 41–13 Fractures of the cuboid. lateral. C.39. Giannestras and Sammarco39 and Garcia and Parkes38 recommend a below-knee walking cast for 6 to 8 weeks. Passive abduction and adduction or inversion and eversion of the foot accentuates the pain in the midfoot.114 The patient has pain on the lateral border of the foot. the injury was the result of a swivel mechanism with dislocation of the talonavicular or tarsometatarsal (Lisfranc) with compression on the lateral side. cancellous or corticocancellous grafting. Because most of these fractures are nondisplaced or minimally displaced. As well. Note that all cuboid fractures are associated with other foot injuries. B. and Clinical Evaluation The patient presents with a history of either a direct blow to the lateral aspect of the foot or trauma to the foot following jumping or twisting the foot beneath the body. most authors8. was caught “like a nut in a cracker” between these articulations. believes that the cuboid is an important stabilizer of the lateral column of the foot and that malunion will result in pain and deformity. A. and five of the 12 patients in this study required initial fasciotomy. Sangeorzan and Swiontkowski114 presented four cases. In each patient the toes were fixed. The treatment of displaced fractures is more controversial. An insidious onset of persistent lateral foot pain should also be investigated.135 Treatment The treatment of cuboid fractures is determined by the severity of the injury. followed by an adequate shoe. and oblique radiographs are necessary in evaluating fractures of the cuboid. dislocation.57 The oblique view is essential to identify the fracture and to determine the presence or absence of associated fractures of the calcaneus or metatarsals.52. Cuboid insufficiency fractures are rare but have been reported.69 recommend early treatment with a shortleg cast for 3 to 4 weeks. with point tenderness over the cuboid. Compression fracture resulting in crushing to cuboid. midtarsal subluxation must be considered. of which three had the articular surface driven into the center of the bone. Most had crush injuries of the navicular or metatarsals. The force required to cause this fracture is significant.57. or a fracture along the medial column. Shear fracture to cuboid. Hillegass. Weber and Locher135 reported on 12 patients with displaced compression fractures of the cuboid. In a few cases. He suggests internal fixation with iliac crest grafting to reconstruct the cuboid. which lies protected between the fourth and fifth metatarsals and the anterior process of the calcaneus.73.52 in patients with the nutcracker fracture and an associated avulsion fracture of the navicular tubercle.53 however. Hermel and Gershon-Cohen52 reported five cases of this crush injury.37 . and oblique radiographs are useful in evaluating cuneiform fractures. Penn) is applied laterally to hold the bone out to length. and eight required mini-fragmentary plates.39. inversion and eversion of the forefoot are distinctly painful. When the joint surface is irreparably damaged. an open reduction is performed using a longitudinal incision parallel to the sole of the foot and located over the cuboid. The decision to perform an ankylosis procedure versus an arthrodesis is left to the surgeon’s discretion. Screws can be used to secure the tricortical bone. Paoli. joint fusion is considered in addition to the graft and reduction procedure.52 the oblique radiographs are carefully evaluated.38 Authors’ Preferred Method of Treatment In patients with chip fractures of the cuboid.39 The patient usually complains of pain in the area of the cuneiforms. The bipartite cuneiform is most easily distinguished because of its smooth articular surfaces. particularly those of the nutcracker variety. If the patient needs to be ambulatory. If lamina spreaders do not separate the two articular surfaces easily.6 Treatment Avulsion fractures and nondisplaced fractures are usually treated symptomatically by immobilization in a short-leg weight-bearing cast until the pain subsides. an H plate (Synthes. If a large portion of the calcaneocuboid or cuboid–metatarsal joint is displaced. but if cancellous graft alone is used. long-term complications occur infrequently. accurate reduction and internal fixation will be needed. The results were satisfactory.83 Buchman11 reported osteochondritis dissecans and bipartite cuneiforms. Most patients with symptoms complained of pain from the medial-side injury. residual displacement of the articular surface of the cuboid can result in persistent subluxation of the midtarsal joint. In these injuries.47 displacement of these fractures is unusual. and internal fixation represented the best approach for these injuries. Because of the limited motion in the normal midtarsal joint. Joint reconstruction was possible in all patients and had reasonably good outcomes. Chip fractures are usually nondisplaced because the associated intertarsal ligaments are strong and prevent their displacement. usually at 6 months. . Occasionally a longer plate can be used and an ankylosis procedure performed rather than a fusion. In this situation the plate is extended to the calcaneus or the metatarsal. or if the surgeon is concerned that the cuboid will comminute. with one pin placed in the calcaneus and one in the metatarsal. the plate is removed. Authors’ Preferred Method of Treatment In our experience. which must be distinguished radiographically from fractures. Hillegass53 recommends that if fracture displacement is significant. a small external fixator should be used as a reduction aid. with lateral column collapse and possibly long-term arthritic changes. As with fractures of the cuboid. we prefer weight bearing in an off-the-shelf walker boot for 4 to 6 weeks. the defect should be grafted with cancellous bone if the end plates are strong or with tricortical bone if structural support is needed. isolated fractures of the cuneiforms are rarely displaced. without formal fusion of these Radiographic Evaluation Anteroposterior. If a displaced fracture is present. The mechanism of injury of cuneiform fractures is usually that of direct trauma.2214 PART X Trauma fixation with plates and screws or screws alone. If there is no injury to the ligaments on the medial aspect of the midtarsal joint. lateral. In fractures involving the body of the cuboid. Weber and Locher performed open reduction and internal fixation in 12 patients. Once the bone is distracted. The exact location of tenderness helps to delineate the particular cuneiform involved. Seven patients required bone grafting. Four fixations were accomplished with screws alone.135 joints.53 According to Heck. After fracture has healed. treatment is based on the patient’s requirements for weight bearing. clinical and radiographic evaluation of the medial aspect of the midtarsal joint is essential. and healing with few complications is likely. CUNEIFORM FRACTURES Mechanism of Injury Fractures of the cuneiform bones are quite rare. The fracture should be identified and opened. grafting. or both. the surgeon must be suspicious of an associated “silent” midtarsal joint dislocation. and the authors concluded that distraction. whereas the irregular surfaces of a fracture should be diagnostic. This allows the joints to more normally mold to each other while still allowing some motion. In the stance phase of gait.72. produces a mediolateral torque that often fractures a metatarsal. but motion is begun immediately. usually within 3 months of injury (Fig. particularly at the points of insertion on the tarsal and phalangeal bones. consideration is given to open reduction. however.69. Shereff121 reviewed the pathologic consequences of altered forefoot mechanics. In this situation the head–neck fragment of the metatarsal is displaced beneath the distal metaphysis at the level of the anterior foot arch because the flexor tendons passing near the metatarsophalangeal (MTP) joints and terminating in the phalanges exert a strong proximal and plantar dislocating force on the distal fragment. most notably in the second metatarsal. Displacement of a distal fragment in a plantigrade direction results in increased loading of the metatarsal and can result in an intractable plantar keratosis at that site. and fourth metatarsal bases rarely need treatment other than a wooden-soled shoe or. has been shown to result in stress fractures. lumbricals. we prefer treatment with an off-the-shelf walking boot for 4 to 6 weeks. while the first metatarsal carries twice the load of each METATARSAL BASE FRACTURES (EXCLUDING FIFTH METATARSAL) Metatarsal base fractures can occur alone or in combination with disruption of Lisfranc’s joint as a fracture–dislocation. such as a twisting injury in which the forepart of the foot is fixed as the patient turns. generally with small-fragment or minifragment plates and screws.47 An indirect force. until the fracture heals. consideration must be given to open reduction and fixation. Anatomy Lindholm79 emphasized that because of the rigid ligamentous anchoring of the metatarsal bones to each other. Dorsal displacement of the distal fragment decreases the load applied to that metatarsal and transfers greater pressure to the adjacent metatarsal heads. Distal fractures near the neck of the metatarsal are the exception. Each fracture type has a different prognosis. often with manipulation under anesthesia and radiographic control. of the lateral four metatarsals. particularly the fifth. because in these fractures the metatarsal heads are usually dislocated. With displaced fractures. each of the lesser metatarsals supports an equal load. Mechanism of Injury Metatarsal fractures result from direct or indirect forces. Also. and contact between the fracture surfaces is totally lost. such as a crushing blow to the dorsum of the foot. metatarsal shaft fractures are not likely to become displaced unless extensive damage occurs to the interossei. if painful.110 Repetitive stress. and this section discusses the separate treatment options and their ramifications. metatarsal fractures were the most common. particularly if an associated subluxation or dislocation of the midtarsal joint can be stabilized by restoring cuneiform anatomy. Postoperative care for these patients requires at least 2 months of non–weight bearing in an off-the-shelf walking boot until there is radiographic evidence of healing. Displacement of a metatarsal fracture can therefore lead to a nonplantigrade foot. most fractures of the proximal shaft and base must be evaluated for ligamentous disruption. displacement of simple fractures of the metatarsals is usually minimal. usually at 3 months.63 Three broad types of injuries can cause these fractures: direct crushing injuries to the foot. Weight bearing is delayed until the fracture has healed. Fracture of the first metatarsal base is more difficult to treat. METATARSAL BONES Metatarsal fractures are relatively common and are often the cause of prolonged disability because the fracture is either initially overlooked or unsuccessfully treated.89 Among motorcyclists with foot injuries. and distal ligamentous attachments to the adjacent metatarsals. This is followed by 1 month with full weight bearing in the boot and range of motion exercises out of the boot. Pure fractures of the second. Therefore. treatment is based on the patient’s requirement for ambulation. not only in soldiers but also in athletes and ballet dancers.CHAPTER 41 Fractures of the Midfoot and Forefoot 2215 With a nondisplaced fracture. Finally. Weight bearing is advanced as tolerated. If the fracture is comminuted or intraarticular. and overuse injuries. third. inversion–avulsion injuries. . third. If the patient’s work requires prolonged weight bearing. a cast. medial displacement of the distal fragment of a first metatarsal fracture and lateral displacement of the distal fragment of a fifth metatarsal fracture can lead to a bony prominence that can produce difficulties with footwear in the toe box. 41–14). and fourth metatarsals usually result from a direct force. Combined fractures of the second. Persistent mediolateral displacement of the fracture fragment to an adjacent metatarsal can lead to mechanical impingement and formation of interdigital neuroma. Exposure for these films is usually set to provide penetration of the large tarsal bones. and fourth Radiographic Evaluation Metatarsal shaft fractures are visualized on routine AP. the fractures may be open. particularly of the first or fifth metatarsal. Treatment Open Fractures In injuries resulting from direct or crushing blows. The AP and oblique radiographs are more useful because the shafts of the metatarsals are superimposed on the lateral view. Postoperative management is the same as for metatarsal shaft fractures (see the following discussion). assuming they are not associated with a Lisfranc fracture–dislocation. three. is an essential prerequisite. and four are treated in a wooden-soled shoe. External fixation. In the case of the second.2216 PART X Trauma Metatarsal base fractures Anderson2 emphasizes that these fractures are often overlooked because they occur in motor vehicle accidents in which severe trauma to major bones or visceral organs is more apparent. because of the proximity of adjacent metatarsals. and fourth metatarsals. base fractures of metatarsals two. Figure 41–14 metatarsals. All displaced fractures of the first metatarsal base. are internally fixed with small-fragment or mini-fragment plates and screws or with bioabsorbable pins. When ligamentous instability is not present. Because these fractures are usually associated with massive swelling. and lateral radiographs of the foot (Fig. the foot is swollen. Axial Kirschner wire fixation is performed more routinely in open fractures of the metatarsal shafts to provide soft tissue stability for healing. exact localization of an individual bone may be difficult. Anderson2 emphasized that radiographs of the forefoot are often of poor quality and do not demonstrate the osseous structure of the forefoot adequately. a wellpadded splint may be needed for 7 to 10 days until swelling subsides. If the injury is seen early. When we believe a dislocation may be present but are unsure on radiographic views. In METATARSAL SHAFT FRACTURES Clinical Evaluation In many cases. and this results in overexposure of the smaller metatarsal and phalangeal bones. especially those with intraarticular comminution. and pain at the fracture site. potentially crepitus. usually after the first 12 hours. With avulsions and crushing or twisting injuries. Patients usually complain of pain over the midfoot with an inability to bear weight. however. Authors’ Preferred Method of Treatment Most metatarsal base fractures can be treated conservatively. however. point tenderness may be present over the fracture site. 41–15). we perform fluoroscopic evaluation under anesthesia. third. a high degree of clinical suspicion is needed to diagnose a metatarsal shaft fracture. initial irrigation and debridement with appropriate antibiotic coverage are indicated.38 Adequate radiographic exposure of the metatarsals. oblique.112 All wounds are left open for delayed primary closure or skin grafting.72 With gross displacement. Garcia and Parkes38 suggest that grasping the distal fragment with the thumb and forefinger and flexing and extending the fragment will produce motion. particularly on the dorsal aspect. relatively little false motion can be demonstrated.48 In such instances. just as for other open longbone fractures. palpation of the fracture site may be possible. Ecchymosis over the fracture area is present. In fractures of the first and fifth metatarsals. . Assessment of the neurovascular status of the foot is mandatory. third. Fractures of bases of second. may be required for severe degloving and crush injuries. however. 49. In 1959. C. closed reduction may be attempted.39 Johnson. B. In either case the protection is kept on until the metatarsal is clinically healed. open reduction and internal fixation using crossed Kirschner wires was indicated. the limb is placed in a short-leg non–weight-bearing cast for 6 weeks or until fracture union is evident on radiographs.16. If the reduction is acceptable. Because of its important weight-bearing and biomechanical function in gait. but it usually occurs within 2 to 3 months. A. Displaced fractures. very little misalignment can be accepted. open reduction using plates and screws is recommended. and weight bearing is delayed for 1 to 2 weeks. Often. well-padded work shoe and allowed to ambulate healed more quickly and had a significantly faster return to work compared with patients treated with plaster immobilization and progressive ambulation. For displaced fractures of the first metatarsal shaft. Displaced Fractures Displaced fractures may require more aggressive treatment. cases with proximal injury.49. a plaster splint may be the best and only form of stabilization.50. not all fractures can be held reduced once traction has been released. Open crush injury with associated first metatarsal fracture and dislocation (arrow). DePalma28 noted that if reduction by manipulation and traction was unsuccessful. Shereff121 also emphasizes the importance of adequate fixation to hasten bony union and allow adequate treatment of the soft tissue injuries in open fractures. More Closed Fractures Nondisplaced and minimally displaced metatarsal shaft and neck fractures may be treated with a belowknee walking cast worn for 2 to 4 weeks.39. This means no pain with ambulation and usually precedes . however. in evaluating forefoot injuries in workrelated accidents. the foot is usually placed in an offthe-shelf walker boot. most authors have suggested that displaced metatarsal fractures can be manipulated under anesthesia with Chinese finger traps and the position then held by cast immobilization. If closed reduction is unsuccessful. treatment of the bone injury is identical to that for closed fractures. when the injury is more distal. Chapman16 prefers percutaneous Kirschner wire fixation after closed manipulation to maintain the reduction.91 Once the fracture is stabilized in this manner. a small external fixator or Ilizarov frame may be applied.50.104 The first metatarsal is infrequently fractured because of its size and cortical strength.CHAPTER 41 Fractures of the Midfoot and Forefoot 2217 A B C Figure 41–15 Fractures of metatarsal shafts. In the past. found that patients treated with an oversized. Nondisplaced fractures. AUTHORS’ PREFERRED METHOD OF TREATMENT Nondisplaced fractures are best treated with early weight bearing to tolerance in a wooden-soled shoe.47. If the fracture is extremely painful or if the patient is morbidly obese.38.64 Unfortunately. complete radiographic healing. Once the soft tissue management is controlled. Weight bearing is not permitted until healing is complete. mobilization of adjacent joints may begin immediately.64 however. In this case. When displaced.116 The fifth metatarsal shaft tends to be less important than the first and more important than the second. open reduction and pinning has been advocated in the more modern literature. and fourth metatarsals in the frontal plane (medial to lateral) does not usually result in complications. Therefore we favor open reduction and internal fixation of these fractures. It is much easier to correct deformity acutely than to deal with short malunions and contracted soft tissue later. AUTHORS’ PREFERRED METHOD OF TREATMENT For displaced fractures of the first metatarsal. axial shortening can be accepted rather than subjecting the foot to any form of fixed traction.2218 PART X Trauma specifically. which results in more disability than the metatarsal fracture itself. Fractures will heal despite significant separation of the fragments. two adjacent metatarsal necks or shafts can be exposed adequately through one incision placed midway between and parallel to the metatarsal shafts. any significant dorsal prominence can result in a painful corn. Thus it is more likely that distal fractures will need open reduction. Redisplacement of a closed reduction in a cast. third.16. Berlin. but shortening is not.2. Sagittal angulation is a concern. lengthening using either distraction and subsequent grafting or distraction osteogenesis using the Ilizarov technique can be performed with acceptable results.96. Pinning is best performed according to the method advocated by Heim and Pfeiffer. . we do not hesitate to perform open reduction and pinning of these fractures using the antegrade– retrograde method. in terms of weight bearing and residual bone prominences. the more significant the dorsal angulation of the fracture. three. and these should be treated as nondisplaced fractures. Severely comminuted fractures require either plating or cross-pinning to adjacent and more stable metatarsals. p 349.123 Sisk123 noted that the more distal the fracture of a metatarsal. Pfeiffer KM: Internal Fixation of Small Fractures: Techniques Recommended by the AO Group. He believes that such fixedtraction devices lead to stiffness of the forefoot. followed by reduction and retrograde insertion of the pin into the proximal shaft (Fig. usually with small-fragment or mini-fragment plates.50. however. If unacceptable residual shortening becomes problematic. Similarly. a more exact reduction is needed. should be a cause for concern.79 Usually. These deformities can be prevented if an anatomic reduction of the fracture is obtained. but when sagittal plane deformity is present. 41–16).) Nondisplaced fractures do not require surgery and can be treated with a wooden-soled walking shoe. Fractures of metatarsal shafts two. especially in the sagittal plane. 1987. three. which in turn increased the plantar prominence of the metatarsal head. and fourth metatarsals. Heim and Pfeiffer50 suggest plating rather than pinning because of the easy access to the bone and the ability to maintain an anatomic reduction. with a subsequently painful malunion and transfer lesions.50 This is done first in an antegrade manner through the shaft of the distal fragment and out the metatarsal head and plantar surface.49.50. Because closed methods generally fail. and four generally can be treated in a wooden shoe or a walking boot. Sequential pinning technique for metatarsal shaft fractures. we have little tolerance for malalignment. Springer-Verlag. Johnson64 believes that as long as alignment is maintained by open or closed methods.39. A B C D Figure 41–16 A to D. malreduction of the shaft of the second.121 Open reduction of fractures of metatarsals two. Healing of the fracture with significant plantar displacement of the distal shaft increases the prominence of that metatarsal head and can result in pain with weight bearing. Displacement of any metatarsal fracture in the sagittal plane (dorsal to plantar).38. is a very real concern. and four is carried out through one or more longitudinal dorsal incisions. third. (From Heim U. when an unstable fracture results in excessive angulation in either the sagittal or frontal (in this case. at which time the pins are pulled and the patient is transferred to a wooden-soled shoe. The advantage of internal fixation is early motion. open reduction is indicated. persists after attempted closed reduction. the reliable patient is placed in a woodensoled shoe.79 As described earlier. open reduction and antegrade–retrograde pinning is needed to prevent subsequent complications. All joints should be mobilized on a regular basis while the fractures heal. Heckman48. Both are kept non–weight bearing until the fracture heals. third.CHAPTER 41 Fractures of the Midfoot and Forefoot 2219 Fractures of the shafts of the fifth metatarsal generally can be treated closed. Figure 41–17 Fracture of metatarsal necks associated with first metatarsal shaft fracture. 41–18). that maintenance of a reduction of a completely dislocated metatarsal neck fracture without internal fixation is uncertain. Postoperative treatment is identical to that just described. When the head is displaced plantarly. Weight bearing is not permitted. METATARSAL NECK FRACTURES Fractures of the necks of the metatarsals are usually multiple and are often displaced (Fig. 41–17). for 4 to 6 weeks. fractures through the metatarsal heads themselves are seen clinically more often than is reported in the literature (Fig. closed reduction may be attempted. persistent displacement of the metatarsal head and neck into the plantar aspect of the foot can result in plantar callosities or corns. generally at 8 to 10 weeks. If internal fixation is performed with plates. however. whereas the unreliable or morbidly obese patient is placed in an off-the-shelf walker boot. plating is preferred to pinning to secure the reduction. All were minimally displaced. This closed technique involves running a Kirschner wire from an intact fifth metatarsal neck. . METATARSAL HEAD FRACTURES Usually the result of a shearing force or direct trauma. however.49 noted that these fractures were associated with proximal fractures of the medially adjacent metatarsals.2. Sisk123 recommends longitudinal incisions coupled with open reduction and antegrade–retrograde pinning. with a lack of apposition of the fracture surfaces and plantar displacement of the head and neck fragment. the patient is placed in a molded cast because of the plantar pins.39. with ambulation as described earlier. Occasionally.64.32 Authors’ Preferred Method of Treatment We have found that most metatarsal neck fractures can be treated conservatively with a wooden-soled shoe and progressive weight bearing as tolerated over time. Lindholm79 warns. lateral) plane. After open reduction and internal fixation and pinning. If complete displacement. and fourth metatarsals. This might offer an easier technique of obtaining pin fixation with a closed technique. transversely across the fractured and displaced necks of the second. Stable reduction was achieved by gentle manual manipulation and traction and was maintained with percutaneous pinning. usually angulated plantarly and laterally. except on the heel. This fracture results in a distal fragment of the metatarsal head that is entirely intraarticular and devoid of any capsular attachments.2 As previously noted.88 These fractures can occasionally be reduced under anesthesia by using the Chinese finger traps or by digital pressure under the metatarsal head with traction of the toe. If the bone fails to remain in a reduced position after manipulation under anesthesia. An alternative technique described by Donahue and Manoli involves transverse pinning of displaced metatarsal neck fractures. and head. The lateral Lisfranc joint complex is composed of the base of the fifth metatarsal. and the fourth and fifth intermetatarsal articulations.115. neck. These three bones form three articulations: the cuboid–fourth metatarsal.122. with a variable attachment to the bone. the lateral band of the plantar aponeurosis.126 The facets on the cuboid for the fourth and fifth metatarsals can appear as a continuous curve or can be separated by a distinct angle.75 Stability of the lateral Lisfranc complex is provided by capsular ligaments (dorsal and plantar cubometatarsal ligaments). because this fixation allows immediate motion of the MTP joint postoperatively. Although these fractures are often described by the eponym “Jones fracture” (after Sir Robert Jones. and the tuberosity avulsion fracture. the calcaneal fascia.125 The blood Figure 41–18 Isolated fourth metatarsal head fracture. collectively. tuberosity. III IV V Anatomy The fifth metatarsal consists of a base. the cuboid. I prefer to use Biofix pins to secure the fragment.122 The intraosseous blood supply to the fifth metatarsal tuberosity arises from numerous metaphyseal vessels penetrating the nonarticular surfaces of the tuberosity in a random.65 who described the injury in his own foot). The base presents a flair. however. They noted. but when closed reduction is unsuccessful. as well as weight bearing to tolerance in a wooden-soled shoe.126 The origin of the abductor digiti minimi muscle is on the lateral and medial processes of the os calcis. These three source arteries supply branches to the metatarsal and adjacent joints. and the adjacent intermuscular septum. however. radiate pattern. and the fourth metatarsal. Extrinsic circulation is provided by the dorsal metatarsal artery. and the peroneus brevis tendon. and the dorsal interossei and plantar interossei originate on the shaft of this bone. the cuboid–fifth metatarsal. a true Jones fracture is a transverse fracture of the fifth metatarsal shaft. The muscle then continues distally to insert into the lateral side of the base of the proximal phalanx of the fifth toe. the plantar metatarsal arteries. the tuberosity. This fragment may be pinned in place with Kirschner wires.5-metatarsal articulation. 41–19). open reduction with internal fixation is needed. . and the fibular plantar marginal artery. Authors’ Preferred Method of Treatment Metatarsal head fractures are not common and rarely require treatment other than symptomatic measures. The mechanism of injury was a shear force on the metatarsal head at the time of dislocation of the third MTP joint. that protrudes down and laterally beyond the surfaces of the shaft of the metatarsal and the adjacent cuboid. open reduction is required. which are bound together by strong ligaments (Fig. According to the authors. Closed reduction with traction may be performed if the fragment is displaced. the diaphyseal stress fracture. closed reduction of metatarsal head fractures (and even no reduction) produces an acceptable result. shaft.3 The origin of the flexor digiti minimi brevis muscle is on the base of the fifth metatarsal.2220 PART X Trauma FRACTURES OF THE FIFTH METATARSAL BASE Fractures of the proximal part of the fifth metatarsal can be separated into three types: the Jones fracture.115 The first two. about 18 mm (3/4 in) from the base.25 The tuberosity is also termed the styloid process. that if closed reduction is unsuccessful in obtaining reduction of the metatarsal head fragment.115 This muscle passes under and around the base of the fifth metatarsal. Dukowsky and Freeman33 reported a fracture– dislocation of the articular surface of the third metatarsal head. are termed the cubo-4. is usually extraarticular but can extend In 1902.75 The smooth edges of the ossicle usually can be distinguished from the ragged edges of a displaced avulsion fragment. tension band wiring.103 The mechanism of injury for these fractures was thought to be an avulsion of the tuberosity by a violent contracture of the peroneus brevis muscle during a sudden inversion of the hindfoot. implicated the lateral band of the plantar aponeurosis as a more likely structure causing tuberosity avulsion fractures because of its insertion onto the tip of the tuberosity. also known as a tennis fracture. An established symptomatic nonunion is an indication for electrical stimulation55 or surgical intervention.107 Thus the mechanism of injury remains controversial to this day.129 Jones Fracture HISTORY AND MECHANISM OF INJURY Tuberosity Avulsion Fractures HISTORY AND MECHANISM OF INJURY The fifth metatarsal avulsion fracture. The more common os peroneum is located next to the lateral border of the cuboid and found within the peroneus longus tendon.45.25.97. 41–21).CHAPTER 41 Fractures of the Midfoot and Forefoot 2221 into the cubometatarsal joint. Treatment of nondisplaced avulsion fractures consists of symptomatic care in a hard-soled shoe. The arterial supply to the tuberosity joins the supply of the proximal diaphysis in the area just distal to the tuberosity. When the intraarticular fragment is greater than 30% of the articular surface. the os peroneum and the os vesalianum may be confused with a displaced avulsion fracture fragment. or small-fragment screws (Fig. 41–22).103. however. Most fractures heal by bony union within 8 weeks.” Stewart126 defined a Jones fracture as . Similarly. walking cast. however. fractures of the proximal fifth metatarsal have been indiscriminately called “Jones fractures. Imprecise use of the term “Jones fracture” and failure to distinguish the true acute Jones fracture from stress fracture of the proximal diaphysis and from tuberosity avulsion fractures has created confusion in the orthopaedic literature. including his own foot injury. Sir Robert Jones65 reported a series of four cases of fifth metatarsal fractures.128 A nondisplaced tuberosity fracture in a child may be confused with the apophysis (Fig.75.50 Treatment of these fractures must be individualized based on the needs and desires of the patient.98 A more recent cadaveric study.103. whereas the rare os vesalianum is adjacent to the peroneus brevis insertion. 41–20).105 Frequently reported methods of internal fixation include Kirschner wires. or compression wrap with protected weight bearing.86.3. Figure 41–19 Lateral Lisfranc’s joint complex. The apophysis is first seen in girls between ages 9 and 11 years and in boys between ages 11 and 14 years. The apophysis is distinguished by a smooth.2. A small displaced fragment might require excision.75 Obliteration of the radiolucent line occurs 2 to 3 years after its appearance (see Chapter 10). or when there is an articular step-off greater than 2 mm. open reduction and internal fixation or closed reduction and pinning should be considered to minimize risks of degenerative arthritis at the cuboid–fifth metatarsal articulation. Subsequently. This fracture scheme should also provide better communication among treating surgeons and in published descriptions of this injury. Classification Dameron25 and more recently Quill103 have proposed a classification of fifth metatarsal fractures that is practical and aids in the management of these fractures (Fig. radiolucent line running parallel to the shaft. TREATMENT AND RESULTS supply to the proximal diaphysis is derived primarily from the nutrient artery. which gives rise to longitudinal intramedullary branches. typically 1.103 careful reading of the published literature on this fracture reveals that one third of these injuries went on to . tuberosity avulsion fracture. Arrows indicate various types of fifth metatarsal base fractures.5 cm (3/4 inch) from the base. but motion in the transverse (adduction–abduction) plane is limited. radiographic healing occurs in a medial-tolateral direction and lags behind clinical healing by weeks to months. Rosenberg and Sferra summarized the findings of several papers and found that most fractures heal with nonoperative treatment.126 The fourth and fifth metatarsals move freely in the sagittal (dorsiflexion–plantar flexion) plane.5intermetatarsal) joint. 1995. 3.77.92 Lack of clinical healing after 8 to 10 weeks of non–weight-bearing immobilization is not unusual. but non–weight bearing compliance is necessary. Continued protection. cast immobilization.67. (A after Dameron TB: J Am Acad Orthop Surg 3:110-114.126 The mechanism of injury is thought to be a large adduction force applied to the forefoot while the ankle is plantar flexed. unless the patient is a high-performance athlete or an informed patient who refuses conservative treatment. D. B. C.75. surgical management may be undertaken.65. Displaced metaphyseal–diaphyseal junction fracture: zone 2. Although medial comminution can occur. Diaphyseal shaft stress fracture: zone 3. Displaced tuberosity avulsion fracture: zone 1.25 TREATMENT AND RESULTS Treatment of an acute nondisplaced Jones fracture consists of non–weight bearing immobilization for 6 to 8 weeks.129 When treating these fractures with nonsurgical methods. this location corresponds to the area between the insertion of the peroneus brevis and tertius tendons.) a transverse fracture at the junction of the diaphysis and the metaphysis. there is no extension distal to the intermetatarsal (4. Fracture zones of the base of the fifth metatarsal:1.75 The indiscriminate use of the term “Jones fracture” has left interpretation of the literature confusing.103 In these instances.109 According to Quill.2222 PART X Trauma 2 1 3 Shaft A Avulsion Os peroneum B C D Figure 41–20 A. 2 zone of metaphyseal– diaphyseal junction. Forced adduction of the forefoot therefore results in a fracture at the junction of the shaft and the base. Anatomically. or surgical intervention may be undertaken at that time. shaft stress fracture zone. such as when the patient missteps on the lateral border of the foot. B to D. open reduction with internal fixation is necessary and can be performed. Therefore he believes that an argument for early surgical management with either medullary screw fixation or bone grafting could be made.0-mm screws in fixing Jones fractures. Surgical techniques employed include tension The diaphyseal stress fracture is a pathologic fracture of the proximal 1. B.5-mm screws were torsionally stronger than 5.77. because 50% of fractures treated closed either do not heal primarily or refracture once initial healing has been documented. a lag screw that engaged the medial cortex was stronger than an intramedullary screw.50 Surgical fixation of these fractures does not guarantee fracture union. p 347.51 The proximity of a proximal diaphyseal stress fracture to the nutrient foramen and adjacent extraosseous plexus can result in fracture site Figure 41–22 Various fixation methods for treatment of proximal fifth metatarsal fractures. Berlin.141 Biomechanical constructs continue to be studied. or a lowprofile plate and screws. When the fracture is displaced. can compound the stresses on the lateral forefoot.0 cm of the fifth metatarsal shaft that occurs secondary to a repetitive distraction force. Diaphyseal Stress Fractures HISTORY AND MECHANISM OF INJURY closed refracture if followed up long enough. a narrowing of the medullary canal. C.CHAPTER 41 Fractures of the Midfoot and Forefoot 2223 Growth plate Apophysis Nondisplaced avulsion fracture (adult) A B band wiring. and alternative imaging techniques be used to detect radiologic union. Isolated lag screw. Apophysis in an 11-year-old boy. Springer-Verlag. Because the fifth metatarsal is a border metatarsal. Finally. however. Tension band wiring.90 Use of intraosseous wiring40 and hook plates are also described.56 In another study.15 We continue to use a large-diameter intramedullary screw and have high union rates. Jones fractures are typically nondisplaced. Figure 41–21 A. (A and B from Heim U. angular deformities such as genu varum or ankle varus. B. cortical hypertrophy.5 to 3. cannulated screw fixation. Fractures that fail nonoperative treatment and remain symptomatic may also be considered for surgery. Eighty-three percent of the patients in the failure group were high-level athletes.129 Radiographically. Larson et al74 showed six treatment failures in 15 patients: four refractures and two symptomatic nonunions. and a periosteal reaction are seen. as well as hindfoot varus or forefoot supination. Pfeiffer KM: Internal Fixation of Small Fractures: Techniques Recommended by the AO Group. Horst et al showed that 6. 1987. A.) . Wright et al also reviewed the failure of six high-level athletes and recommended that large screws be used. Nondisplaced avulsion fracture of tuberosity in an adult. Cannulated screw and tension band. functional bracing be considered to protect fixation. I have no experience with this technique. Alternately. Fractures treated with both PEMFs and a non–weight-bearing cast healed in a mean time of 3 months.143 Conflicting results after similar treatment in these reports was caused by the grouping of Jones fractures and proximal diaphyseal stress fractures into a single category.27.122. and the lesion exhibits no or minimal fracture callus.144 The typical patient with this fracture is a young athlete in the middle of preseason training.27. and then a gradual return to full activities. In the recalcitrant fracture. or in type III fractures. delayed (type II). adjunctive inlay bone grafting must be considered. beyond that which can be compressed with a lag screw. Torg et al130 documented healing in 93% of fifth metatarsal stress fractures treated with 7 weeks of non–weight-bearing immobilization. No refractures occurred. medullary curettage with inlay bone. . indicating an established nonunion.77.130 Recently. This is followed by progressive weight bearing over the next 4 weeks. coupled with a cancellous cannulated titanium lag screw. however. Careful consideration of the athlete’s individual needs can therefore indicate electrical stimulation or internal fixation. Authors’ Preferred Method of Treatment Treatment must be tailored to the patient’s individual needs.0-mm cancellous cannulated titanium screw (depending on bone dimensions) with a countersunk head is ideal. or a wooden-soled shoe. and nonunion (type III). Torg et al130 divided them into three categories: acute (type I). based on the patient’s compliance. When significant intermedullary sclerosis is present.1. The competitive athlete.75. Subsequent reports further documented the recalcitrant nature of these fractures. This can be accomplished using crutches or a walker and a below-knee cast.67. Treatment must be tailored to the radiographic findings. with periosteal reaction demonstrating previous attempts to heal an incomplete fracture. Nine delayed unions and nonunions of the proximal fifth STRESS FRACTURES OF METATARSAL DIAPHYSIS Stress fractures are defined as spontaneous fractures of normal bone that result from a summation of stresses. others have confirmed a similar success rate with restricted-weight-bearing immobilization.2224 PART X Trauma avascularity. The author concluded that when compared with reported healing times and morbidity for conventional casting. Therefore. The currently accepted treatment of choice for acute. but generally not before 6 months postoperatively. Type II fractures show a widened fracture line and intramedullary sclerosis. Duration of treatment until complete healing occurs may be as long as 20 weeks. In hypertrophic nonunions or fractures exhibiting widening of the fracture gap that can be closed with compression. TREATMENT AND RESULTS metatarsal treated with PEMF healed in a mean time of 4 months.to 8. Postoperatively the patient should remain non–weight bearing for 6 weeks to ensure healing.103. Type III fractures demonstrate complete intramedullary canal obliteration. Symptomatic nonunions (type III) usually require surgical intervention. This is followed with screw fixation as just described. compared with substantially lower rates of healing when weight-bearing immobilization was employed. A conservative treatment plan of prolonged non–weight-bearing immobilization may be tried in the sedentary patient for type II diaphyseal stress fractures. and nonunion is possible despite prolonged immobilization. Subsequently. Holmes55 has shown good results using pulsed electromagnetic fields (PEMFs) in the treatment of nonunions.5. requires bone-grafting procedures and an intramedullary screw.67. in the competitive athlete. The adjunctive inlay bone graft uses a tricortical iliac crest graft tailored to match the defect. surgical intervention is preferred. PEMFs were an effective alternative. a 6. the canal must be reamed using variously sized drills to stimulate vascularization. an off-the-shelf fracture boot.129. nondisplaced diaphyseal stress fractures is non–weight-bearing immobilization. Type I fractures represent “early” stress fractures. conservative non–weight-bearing immobilization for 7 to 10 weeks should be the initial treatment.125 Both Stewart126 and Dameron25 noted the frequent occurrence of delayed union or nonunion associated with the conservative management of proximal fifth metatarsal fractures. repetitive stresses can compromise the vascular supply to the metatarsal. In the sedentary patient and the recreational athlete with a type I or a type II fracture. A symptomatic screw may be removed after radiographic evidence of complete healing. or closed axial intramedullary screw fixation. prolonged duration of immobilization is often required for healing. delaying union.75 In separating fifth metatarsal diaphyseal stress fractures by their healing potential. Although PEMFs may be an alternative treatment method. When an atrophic fracture gap is evident. despite their diverse healing potentials. The initial treatment of these fractures is non–weight-bearing immobilization. When the distal phalanx is fractured. coupled with cessation of excess activity (e. These patients do not report a history of a specific injury.. the proximal one is fractured most often (Fig. a technetium bone scan should be used to diagnose the stress fracture.1 however. flexor. a limp usually develops.139 As the pain increases in intensity. Training may then be progressively advanced.78 These fractures occur in the normal bones of healthy people involved in everyday activities.78.18-20 Interestingly. the patient may return to activities of daily living.29. however.39 For all other patients.29. Treatment for all patients includes decreased activity and walking in a wooden-soled shoe until the pain subsides. Fractures of the lesser toes usually occur through the proximal phalanx. interosseous.5. followed closely by the third metatarsal. including tenderness. can occur. 41–25). Thereafter.84 Fractures of PHALANGEAL BONES Fractures of the phalanges represent the most common fractures of the forefoot. Clinical And Radiographic Evaluation The most common presenting complaint is pain on a long march or with increased running on hard pavement.78 Congenital shortening of the first metatarsal has been suggested as a predisposing condition in the development of these stress fractures.92 Angulation of middle and . the foot muscles fatigue and the forefoot experiences significantly increased plantar pressures. were unable to show that the length of the first metatarsal in patients with stress fractures differed significantly from that in a randomly selected control group. swelling.139 Direct point tenderness over the location on the metatarsal shaft where the fracture has occurred is diagnostic.16.16 Fractures of the proximal phalanges of the lesser toes are prone to plantar angulation secondary to the combined action of the toe extensor.78 Although no swelling may occur initially.29 Radiographs taken within 2 weeks of the onset of symptoms usually do not demonstrate a metatarsal stress fracture. 41–23).CHAPTER 41 Fractures of the Midfoot and Forefoot 2225 any one of which by itself is harmless.92.127 The hallucal phalanges are larger and functionally much more important than the phalanges of the lesser toes. usually within 4 to 6 weeks. healthy young patients. Displacement of metatarsal stress fractures is distinctly unusual. it is often comminuted or dislocated (Fig. a wooden-soled or other type of stiffsoled shoe.138 Acker and Drez. as runners are near the end of a long session. an avulsion fracture involving the dorsal aspect of the distal phalanx of the hallux.38. The pain is usually described as an aching or soreness in the foot. Authors’ Preferred Method of Treatment Almost all stress fractures can be diagnosed clinically. the longest of the phalanges. after 2 weeks the pain becomes more disabling.29 Although stress fractures have been reported at many different sites. and Meurman noted only a single completely displaced stress fracture in his series. Treatment The type of treatment selected depends on the patient’s pain and disability. and rarely if ever is a bone scan needed.16 Of the hallucal phalanges. metatarsal stress fractures are seen with increasing frequency in normal. With the current enthusiasm for sports. a fine line is noted in the metatarsal shaft secondary to bone resorption along the fracture surface. and lumbrical muscles.5. The middle and distal phalanges are less often fractured (Fig.39 AP and oblique radiographs are the most useful in detecting metatarsal stress fractures. particularly jogging.g.5. and ecchymosis over the shaft of the involved metatarsal. a bone scan may be necessary for documentation.38. In the highperformance athlete. Most authors suggest a walking cast in only the most painful situations. 41–24).16 Also.38. We have never surgically treated this fracture and only occasionally had to resort to casting with non–weight bearing to treat a delayed union. similar to that seen in the hand. During the period when pain is present and radiographic findings are negative. and definite clinical findings begin to appear.136 the second and third metatarsals usually occur in the middle of the shaft or in the neck of the bone.5 Stress fractures must be diagnosed clinically because radiographic findings lag behind the clinical examination. jogging) until the fracture has healed. First metatarsal stress fractures are classically found in the proximal portion of the bone.87 Most authors note that the second metatarsal is most often involved.29. is warranted. the metatarsals are among the best known and have been termed march fractures because of their frequent occurrence in military personnel. Meurman84 reported that stress fractures of the fourth metatarsal occur in the distal part of the diaphysis.5 Stress fractures are often noted in new military recruits who undergo intensive training to which the bones of the foot are not adapted. or in the nonathlete. Highly comminuted fracture affecting the entire phalanx. Transverse fracture of the shaft. D. A. Displaced neck fracture. A B C Figure 41–24 Various fractures of the distal phalanx of the hallux. T-type fracture of head. Highly comminuted fracture of the phalanx with intraarticular involvement.2226 PART X Trauma A B C D E Figure 41–23 Various fractures of the proximal phalanx of the hallux. Displaced shaft fracture. B. B. E. C. Avulsion of the tuft. A. Nondisplaced shaft with articular involvement. C. . D C distal phalangeal fractures depends more on the direction of the trauma that produced the fracture. A. Mechanism of Injury Fractures of the toes are usually caused by direct trauma to the involved toe. A fracture of the proximal phalanx of the lateral four digits is most often produced by an abduction injury. In all three patients the fracture occurred on the medial aspect of the base of the proximal phalanx. such as occurs when the toe strikes a table leg and results in the classic “night walker fracture.88 Jahss62 emphasized unique “stubbing” injuries to the hallux that result in fracture–dislocations that are often missed. C and D. T-type distal articular fracture. most often the middle or distal phalanx. and all patients had significant hallux valgus.39. B.”39.88 The patient might relate a history of dropping a heavy object on the toe that resulted in a crushing injury to the soft tissue and a fracture of a phalanx. Transverse fractures (arrows). This bowstringing effect on the great toe and the medial collateral ligament resulted in strain that produced an avulsion-type stress fracture of the proximal phalanx.38. seen best on lateral radiograph. Salter II fractures of second proximal phalangeal base (arrows). Clinical Evaluation Jahss62 emphasized that the relatively mild discomfort associated with certain fractures of the hallucal phalanges can allow them to be interpreted as simple .92 Yokoe and Mannoji142 reported three cases of stress fracture of the proximal phalanx of the great toe. The authors believe that hallux valgus leads to the extensor hallucis longus and adductor tendons having a bowstringing effect on the hallux.CHAPTER 41 Fractures of the Midfoot and Forefoot 2227 A B Figure 41–25 Various types of proximal phalangeal fractures of lesser toes. 8 Consideration is given to the use of intramedullary Kirschner wire fixation when severe soft tissue damage is present. The stress fractures reported by Yokoe and Manoji142 were treated by a simple decrease in the athletic activity that produced the fracture. The patient wears a stiff-soled shoe when swelling and pain permit.7. and ambulation can be initiated in a stiff-soled shoe. Alternatively. Crush fractures of the terminal phalanx of the great toe should be treated with elevation and ice. unlike fractures of the fingers. the great toe can be bound to the adjacent two toes for stability. Within 12 to 24 hours.92 The toe is swollen and tender to palpation. Antibiotics are given for 48 hours after initial irrigation and debridement. are most often displaced.38. . Although comminution is often present. marked swelling and ecchymosis of the involved digit are present. He believes that it serves as an important splint to the broken phalanx and that its removal exposes a tender area. the indications for internal fixation of the articular surface are the same as in closed fractures. Authors’ Preferred Method of Treatment In patients with open fractures involving the toes.39 Jahss62 reports that displaced fractures of the hallucal phalanges (when treated early) can usually be reduced by closed means with traction under local anesthesia and that the reduction can usually be maintained in a plaster boot. OPEN FRACTURES Treatment If an open fracture of the lesser toes is present.64 Avulsion of the nail to decompress the subungual hematomas is not warranted. the wounds should be irrigated and debrided just as with any other open fracture. Johnson64 stresses the necessity for simple treatment of nondisplaced phalangeal fractures by protective splinting (usually to an adjacent toe).38. The neurovascular status of the toe distal to the open fracture may be in jeopardy because of the fracture and the crushing of the soft tissues that occurs with the fracture.39.47 Subungual hematomas are usually present and can be relieved by drilling the nail bed. which will prevent the patient from returning to work for weeks.62 Fractures of the hallucal phalanges.92 In simple fractures of the phalanges of the great toe without displacement. With extensive soft tissue damage. He recommends treatment by adhesive strapping for minor angulation or minor Radiographic Evaluation Anteroposterior. There is often a subungual hematoma when the distal phalanx is involved. however. The patient usually relates symptoms of acute pain. debridement of the wound. If a crushing-type fracture of the great toe is severely comminuted and open and involves the majority of the distal phalanx with extensive soft tissue loss. Thus the diagnosis might be overlooked by the physician or the patient might not seek early medical care. symptomatic medication. and crepitus is usually present. Jahss62 emphasized that fractures of the great toe vary from a mildly displaced fracture of the medial or lateral margin of the distal portion of the proximal phalanx to a frank fracture–dislocation. fractures of the lesser toes are often dismissed as sprains. however. HALLUCAL FRACTURES Fractures of the distal phalanx of the great toe are most often secondary to dropping heavy objects on the toe. most of these fractures are not significantly displaced. nail excision. and a terminal Syme amputation may be indicated. as indicated in open fractures of the major bones. Heck47 stresses that in such comminuted fractures. anatomic reduction and Kirschner wire fixation are performed at the time of initial debridement. and lateral radiographs of the toe (not the foot) are necessary to delineate the fracture location and displacement of the fracture. we prefer axial Kirschner wire fixation as a splint to provide stability for soft tissue healing. followed by a cut-out shoe with a stiff sole. Radiographs taken with traction applied to the hallux are often helpful in further evaluating the fracture. no ecchymosis will be present. Any movement of the toe produces pain. Taylor127 stresses the importance of maintaining the nail in treating fractures of the distal phalanx of the hallux. oblique. and difficulty in wearing a shoe or in walking. If such open fractures involve the MTP or interphalangeal (IP) joint of the great toe. This resulted in healing of the stress fracture. Cobey21 recommends treatment with a metatarsal bar. Similarly. swelling. Open fractures of the phalanges usually occur from direct trauma. and immediate ambulation. reduction is not always possible. If the patient is seen very soon after the injury.127 This often results in comminution. If the hallux is involved. but care should be taken to place the toe in a functional position. thorough irrigation and debridement are performed.2228 PART X Trauma sprains. a closed reduction is attempted. being careful not to compromise the circulation.CHAPTER 41 Fractures of the Midfoot and Forefoot 2229 displacement of fractures through the condylar neck. These authors emphasize that with substantial displacement or if dislocation of the adjacent joint is present. one need not be concerned as long as the general alignment of the toe is satisfactory. When such a reduction is obtained. usually within a week to 10 days. . Cobey21 believes that most of the pain associated with a fractured toe results from dorsiflexing the toes with walking. we prefer to wait until the swelling has subsided. closed reduction with or without Kirschner wire fixation may be indicated. and fifth toe phalanges. swelling of the great toe makes soft tissue compromise after surgery commonplace. particularly those associated with dislocations of the adjacent joint. percutaneous pin fixation is performed. we have the patient wear a stiff-soled shoe with a high toe box. residual displacement of these fractures has resulted in arthritic changes and pain with ambulation.50 Authors’ Preferred Method of Treatment We prefer to treat fractures of the middle and distal phalanges of the lateral four toes by adhesive taping to the adjacent toe and using sheet wadding between the toes to prevent maceration. In our experience.64 however. We have found the use of Chinese finger traps applied to the toe with the patient in a supine position and weights draped over the ankle may only occasionally be useful in reducing these fractures. usually by 10 to 12 weeks. Chapman16 and Jahss62 suggest open reduction. Unless open reduction can be done very early. third. timing is critical. Although they recommend attempted reduction. Pins are removed at 6 to 8 weeks based on radiographic evidence of healing. In crushing injuries of the hallucal phalanges with comminution and no involvement of the IP joint. The toes are then strapped together with adhesive tape.16. Authors’ Preferred Method of Treatment In nondisplaced simple fractures of the great toe. particularly when a fracture involves the proximal phalanx of a lesser toe. If open reduction cannot be performed within 24 to 48 hours. The subungual hematoma is drained after sterile preparation. The use of tongue blades also eliminates the need for an expensive metatarsal bar. Cobey found that this method functionally immobilized the toes and the MTP joint without permanently altering the shoe. According to Johnson. open reduction and internal fixation using mini-fragment implants or bioabsorbable pins should be performed. Ambulation is permitted in a stiff-soled shoe with the toe box cut out.62 Isolated medial or lateral condylar fractures or fracture–dislocations typically seen in stubbing injuries are unstable. a practice that may result in longterm complications. most attention is directed to care of the soft tissues. If this is unsuccessful. He therefore recommends the use of a metatarsal bar made from tongue blades and taped to the bottom of the shoe. They treat these injuries by placing a single layer of sheet wadding between the involved toe and two adjacent toes. Long-term sequelae from phalangeal fractures of the lesser toes are rarely reported. This must be balanced with the knowledge that soft tissue contraction will occur from the displacement and may make fracture reduction more difficult. every attempt should be made to correct the displacement.92 Such plantar pressure areas can require later surgical correction. If hallucal phalangeal fractures are displaced and reduction cannot be obtained by manipulation. Johnson64 strongly emphasizes the danger in overtreating and overprotecting patients with fractures of the phalanges. and neither taping adjacent toes together nor a hard leather sole will prevent this dorsiflexion. This is particularly true in fractures involving the IP and MTP joints. Ambulation is begun immediately in a stiff-soled shoe with an adequate toe box. and occasional Sudeck’s atrophy resulting from the more aggressive types of therapy are more significant in regard to long-term disability. Although simple fractures can be pinned. when articular fractures or comminuted shaft fractures of the proximal phalanx of the great toe are seen. After fixation the patient wears a stiff-soled shoe until the fracture is healed. open reduction with internal fixation is recommended. they believe that if an anatomic reduction is not obtained. LESSER TOE FRACTURES In fractures involving the second. The patient then begins early ambulation. fourth. If there is displacement of single fractures of the proximal or distal phalanx of the great toe. swelling. In displaced fractures of the hallux. Giannestras and Sammarco39 and Chapman16 believe that moderate displacement is of no great significance. disability from stiffness. Angulation at the fracture site with malunion can result in a painful plantar pressure area under a toe. If open reduction is required in these injuries. When considering open reduction. They are invested by the deep tendons of the short flexor of the great toe and are joined to each other by a strong. as seen in ballet dancers and athletes.13.92 The hallucal sesamoids are termed by location as either tibial (medial) or fibular (lateral).101.119 Mechanism of Injury The hallucal sesamoids are particularly vulnerable to injury because of their biomechanical function and anatomic location. Incomplete fusion is more common in the tibial sesamoid. and ballet has caused these injuries to become much more common. Moderate displacement of the phalanges of the lateral four toes is usually of no consequence.38.92. longdistance running.60 SESAMOID BONES The anatomist Galen gave the sesamoid bones their name because of their similarity in the size and shape to the flat oval seeds of Sesamum indicum. sesamoids of the MTP joint of the fifth digit are present in only 10% of cases. Although the pain may be reduced or absent at rest. The concave articulating surfaces of the sesamoids contact the plantar aspect of the first metatarsal head and provide a gliding surface for the weight-bearing functions of the first metatarsal.101 Because bipartite sesamoids may be bilateral.22.60. and of the second in 1%.68 The tibial sesamoid is situated directly beneath the medial half of the first metatarsal head. The fibular sesamoid. extends well beyond the lateral margin of the metatarsal head and assumes a relatively protected position in the soft tissues between the first and second metatarsal heads. the presence of a divided sesamoid in the contralateral foot can help in distinguishing it from a fracture. patients should be told that a simple exostectomy will usually relieve symptoms. This injury arises when forced dorsiflexion of the great toe at the MTP joint occurs. as seen in football and soccer players. classically it returns with walking. Only with gross displacement in which closed reduction is not successful should the surgeon consider open reduction.106 A hyperdorsiflexion injury can cause a transverse fracture.39.39 For this reason. of the fourth in 2%.88. They also serve as a fulcrum to increase the mechanical advantage of the flexor hallucis brevis tendons. most of the force is borne by the first metatarsal head.22. where it is often subjected to mechanical trauma. short transverse ligament. against the first metatarsal head and leads to a compression fracture. the surgeon must remember that minimal disability results from these injuries.119 Fractures of the metatarsal sesamoids have always been thought to be quite rare. of the flexor hallucis brevis tendon cover their rough.92 The sesamoids are separated from each other by the flexor hallucis longus tendon as it courses to its insertion into the distal phalanx.23. This compresses the sesamoids. the marked increase in jogging.95. whose mechanism is similar to that of a patellar fracture. Morbidity after malunion of these fractures has not been a significant problem in our practice. particularly the tibial one. an attempt at closed reduction with the patient under local anesthesia can be made by using Chinese finger traps. If complete displacement is present.95.92 However. nonarticular plantar surface. and the tibial sesamoid is more often fractured.22 This occurs .92 However. When a person lands directly on the ball of the foot after a fall. Repetitive trauma can also cause this injury. and thus they are important weightbearing structures.133 The sesamoids elevate the first metatarsal head so that it is level with the adjacent metatarsal heads. a contralateral single sesamoid does not confirm a fracture. however.133 However.106 Anatomy Sesamoids in the hallucal MTP joint are a constant feature of the foot.92. The hallucal sesamoids have a dorsal cartilaginous facet that articulates with the metatarsal head.92 The sesamoids can have one or more ossification centers that may or may not unite.92 The sesamoids are reported to be multipartite in 5% to 30% of normal asymptomatic persons. which can be confused with a fracture. Incomplete coalition of the chondrification centers can result in a bipartite or tripartite sesamoid.106 The pain is located in the region of the sesamoid bones and is associated with any movement of the MTP joint.38. however. however.12. such displacement is extremely unusual. In our experience. Fibers Clinical Evaluation Most patients are able to recall a specific episode of trauma with the sudden onset of sharp pain.2230 PART X Trauma Proximal phalangeal fractures of the lateral four toes are treated in a similar manner. an ancient East Indian plant that was used by the Greeks for purging. Therefore we prefer to treat all these fractures in a closed manner by adhesive strapping and weight bearing.38. it has been postulated that fracture of the fibula sesamoid is quite rare. If it does occur. The toe is then strapped to the adjacent toes with half-inch adhesive tape and plain sheet wadding between the toes. Graves et al42 described four cases of plantar plate injury to the first MTP joint. the distal attachment of the flexor digitorum brevis muscle would be disrupted. Pfeffinger and Mann100 noted that if a sesamoid needed to be removed. More recently. bursitis beneath the tibial sesamoid and flexor hallucis brevis tendinitis also occur in the athlete and may be confused with sesamoid injury. however. and swelling may be present in this region. because both these conditions occur often in the tibial sesamoid. Radiographic Evaluation A fractured sesamoid is usually confirmed by radiographic examination. However. the differential diagnosis of a fractured sesamoid includes fracture of the sesamoid. although two had associated fractures of a sesamoid bone. Therefore they stated emphatically that under no circumstances should both sesamoids be removed. Conservative Treatment The treatment most often recommended after this injury is rest and protection of the first metatarsal head from weight bearing. care must be taken that the digital nerve is identified and protected.38 In addition to the tangential view.CHAPTER 41 Fractures of the Midfoot and Forefoot 2231 specifically at the end of each step. when the MTP joint is in hyperextension and body weight is thrown forward onto the ball of the foot. No history of dislocation occurred in any patient. Using a 0 to 2 bone scintigraphic rating system.101 Graves et al42 noted that the best way to determine a plantar plate disruption was by taking the AP view with both feet on the cassette and centering the beam perpendicular to it. Surgical Treatment As already noted. The sesamoid must be carefully shelled out of the tendon of the flexor hallucis brevis muscle to prevent the later development of a cockup or varus/valgus deformity of the hallux. demonstrates the articular surface of the sesamoids well. with proximal retraction of the sesamoids by the flexor hallucis brevis muscle. prolonged pain despite conservative treatment. osteochondritis.22 hallucis brevis tendon associated with metatarsal neck fractures caused by a crush injury. and a tangential or axial view of the plantar aspect of the first metatarsal head. An axial view of the metatarsal head shows these changes. or casting for 3 to 6 weeks. depending on which sesamoid is involved.119 Although Van Hal et al133 approached the fibular sesamoid through a plantar incision between the first and second metatarsal heads. and displaced fractures. a bipartite or multipartite sesamoid. it could be done with relative impunity. Irwin et al61 described a case of traumatic dislocation of the lateral sesamoid of the flexor . which might not be visible on standard AP projections.39 Most authors recommend non–weight bearing in a stiff shoe. Richardson106 notes that in addition to sesamoiditis. which includes an AP view of the forefoot.16 A fractured sesamoid must be distinguished from osteochondritis dissecans of the first metatarsal sesamoid. caution should be used in interpreting increased scintigraphic activity.59 The x-ray findings of the latter condition are those of fragmentation and irregularity of the sesamoid. The tangential or axial view. the use of a metatarsal bar. These same authors all suggest resection of the sesamoid if pain is not relieved after 6 weeks of enforced rest. They strongly believed that if both sesamoids were removed.38. taking care not to damage the plantar medial cutaneous nerve.22. Pfeffinger and Mann100 suggest that the tibial (medial) sesamoid be approached slightly below the midline on the medial side of the first MTP joint. a dorsal web-splitting incision between the first and second metatarsal heads Differential Diagnosis Other injuries to the sesamoids must be differentiated from fracture. The indications typically given for sesamoid excision include painful nonunion. a lateral view. and osteochondritis dissecans of the sesamoid. Maurice et al82 recommended bone scanning as a reliable way of detecting sesamoid injury and suggested that it be used as a screening test. 25 of 86 (29%) asymptomatic infantry recruits and 7 of 27 (26%) asymptomatic sedentary adults were found to have grade 1 or grade 2 activity. Several authors have emphasized the importance of placing the surgical incision so as to avoid painful scar formation. if only one was removed.133 Van Hal et al133 report the use of a medial longitudinal plantar incision to remove the tibial (medial) sesamoid.100. Chisin et al17 evaluated the specificity of bone scans in this setting. Finally. The authors concluded that when using scintigraphy to evaluate hallucal sesamoid disease. most authors recommend excision of the involved sesamoid. partite sesamoids with stress fractures. Colwill23 suggested the use of tomography to help in the diagnosis of these injuries. also known as a sesamoid view. and development of posttraumatic degenerative changes on the sesamoid articular surface. Radiographically.88. in patients with persistent disability after a reasonable period of conservative therapy.101 Point tenderness is found on the plantar aspect of the foot beneath the first metatarsal head on the tibial or fibular side. and a cock-up deformity would result. although two had associated fractures of a sesamoid bone. 2. and an axial view of the sesamoids demonstrated the sesamoid in the lateral intermetatarsal space. 1958. Diffuse pain beneath the first MTP joint and . Graves et al42 presented four cases with plantar plate injury to the first MTP joint. 1997. Foot Ankle 13:547-549. In the rare event that the patient requires resection. it has been extremely unusual for us to remove the tibial sesamoid. Int Abstr Surg 90:295. 1965. and a fracture with displacement. 2005. The axial views are particularly helpful in distinguishing among osteochondritis dissecans. Although sesamoidectomy was an alternative to repair of the intersesamoid ligament.2232 PART X Trauma will avoid a plantar scar and is safer (see Chapter 10). Clin Orthop Relat Res 122:18-27. Drez DJ: Nonoperative treatment of stress fractures of the proximal shaft of the fifth metatarsal (Jones’ fracture). 5. Finally. two of the patients returned to preinjury activities. 1933. using a stiff-soled shoe. they are placed in a formal below-knee non–weight-bearing fiberglass cast for another 4 to 6 weeks. 1977. 1931. Open reduction and repair of the intersesamoid ligament through a plantar longitudinal incision in the first intermetatarsal web space was successful. Otis JC. Deland JT. 8. J Bone Joint Surg Am 79:241246. 1939.119 Authors’ Preferred Method of Treatment A complete set of radiographs is essential in evaluating injuries to these bones. 1950. This is followed by a wooden-soled shoe and therapy if needed. Westover JL: The ankle joints of college athletes. Although it is important to distinguish between an acute fracture and a bipartite sesamoid. the sesamoid is only given 6 weeks and then excised. 12. 7. They are either non–weight bearing or heel-only weight bearing for 4 weeks. Blazina ME. with proximal retraction of the sesamoids by the flexor hallucis brevis muscle. allowing a lateral swing of the sesamoids around the metatarsal head. Foot Ankle 7:152-155. Clin Orthop Relat Res 42:73-80. the authors concluded that in a sporting population. Burman MS. New York. the diagnosis of plantar plate disruption was made. 9. Lapidus PW: The functional disturbances caused by the inconstant bones and sesamoids of the foot. 10. We find it highly surprising that although most surgeons would wait up to 3 months to begin weight bearing on a displaced fracture in the lower extremity. With nonsurgical treatment. J Bone Joint Surg 15:225-232. 3. and a new method of treatment. Shanker J: Symptomatic bipartite medial cuneiform after injury: A case report. Böhler L: The Treatment of Fractures.100 pain with extremes of joint motion were seen in all patients.100. Anderson LD: Injuries of the forefoot. 1986. Capasso et al14 reported a traumatic dislocation of the lateral sesamoid secondary to disruption of the intersesamoid ligament. The authors concluded that incomplete dislocation can be associated with significant damage to the plantar plate and other soft tissues of the foot. Arch Surg 22:936-975. Bonvallet JM: The surgical treatment of recent scaphoid fractures of the foot. If they show no improvement after the first 4 weeks. Acker JH. Three different types of injury were observed: rupture of the capsule proximal to the sesamoids. J Bone Joint Surg 26:743-750. excision of the sesamoid could limit sporting activities. if they feel improvement. As a result. Brailsford JF: Osteochondritis of the adult tarsal navicular. The lateral dislocation of the sesamoid was suggested by the presence of pain and tenderness around the first MTP joint. 6. 11. 1944. J Bone Joint Surg 21:111-120. At that time. Routine radiographs revealed lateral dislocation of the lateral sesamoid. We therefore prefer to wait a minimum of 6 months before we make the decision to excise the sesamoid. Foot Ankle Surg 11:55-58. Astion DJ. By taking the AP view with both feet on the cassette and centering the beam perpendicular to it. DISLOCATIONS OF SESAMOID BONES Prieskorn et al102 tested fresh-frozen cadaver feet with hyperdorsiflexion stress of the first MTP joint. Buchman J: Osteochondritis of the internal cuneiform. Grune & Stratton. and rupture of the capsular structures medially. Arangio G: Transverse proximal diaphysial fracture of the fifth metatarsal: A review of 12 cases. The patient resumed normal activities 2 months later and had no further disability. Initial treatment was conservative. 4. Venkateswaran B. and one patient was permanently disabled from work. a bipartite sesamoid. rupture of the plantar plate distal to the sesamoids. One patient did require a sesamoidectomy for resistant pain. Kenneally S: Motion of the hindfoot after simulated arthrodesis. 1992. we use the technique recommended by Pfeffinger and Mann. These patients are placed in an off-the-shelf walker boot and given crutches. Stone JR: March fracture: A report of three hundred and seven cases. Bismil Q. they are given a wooden-soled shoe for another 4 weeks to prevent dorsiflexion of the MTP joint. Foster PAL. Bernstein A.14 REFERENCES 1. in reality the treatment is the same. No history of dislocation occurred in any patient. The authors suspected a kick to the ground with the great toe as the probable cause of total rupture of the intersesamoid ligament. Berlin. DiGiovanni CW: Fractures of the navicular. 28. 1984. 43. 1996. Philadelphia. Jahss MH: Stubbing injuries to the hallux. Instr Course Lect 38:483-486. J Bone Joint Surg Am 57:788792. Philadelphia.CHAPTER 41 Fractures of the Midfoot and Forefoot 2233 13. Springer-Verlag. Hunter JC. Peyser A. Giannestras N. Philadelphia. Burton EM. Kacso I. Amaker BH: Stress fracture of the great toe sesamoid in a ballerina: MRI appearance. Chapman M: Fractures and fracture dislocations of the ankle and foot. Glisson RR. 1989. Hens J. Heck CV: Fractures of the bones of the foot (except the talus). AJR Am J Roentgenol 166:888. Day AJ: The treatment of injuries to the tarsal navicular. Green D (eds): Fractures. Graves SC. 33. 1929. Arnold JA: Sports injuries to the foot and ankle. Hunter LY: Stress fractures of the tarsal navicular. Hobart MH: Fracture of the sesamoid bones of the foot. Albano L. Lyddon DW. Carpenter B. Philadelphia. Gilmour WN: Operation for non-union of stress fracture of the tarsal navicular. Foot Ankle Clin North Am 9:25-63. et al: Tarsal navicular stress fractures in runners. . 55. Philadelphia. 47. WB Saunders. Holmes GB Jr: Treatment of delayed unions and nonunions of the proximal fifth metatarsal with pulsed electromagnetic fields. Rossmand J. 29. Foot Ankle Int 16:291-294. AJR Am J Roentgenol 136:201203. 45. 1990. Eftekhar NM. Stevens J: An unusual fracture– dislocation of the tarsal navicular. 1975. 2005. 16. Wardlaw D: Traumatic dislocation of the lateral sesamoid of the great toe: Nonoperative management. 1991. 58. Sheehan JJ: Vertical fracture dislocation of the tarsal navicular. 52. Philadelphia. Franco M. WB Saunders. Clin Orthop Relat Res 34:142-157. 15. Freeman BL: Fracture–dislocation of the articular surface of the third metatarsal head. Nicolopoulos C. J Bone Joint Surg Br 52:390. et al: An uncommon cause of foot pain: The cuboid insufficiency stress fracture. St Louis. In Rockwood C. 1953. 1981. Hermel MB. 19. 57. 32. ed 4. Am J Sports Med 8:137-144. Orthopedics 3:254-255. 22. Dick IL: Impacted fracture–dislocation of the tarsal navicular. 1981. J Foot Ankle Surg 42:315-316. J Orthop Trauma 9:180-182. Lippincott. 1974. 37. 27. 1959. 46. Eichenholtz SN. 40. Foot Ankle Int 25:914-919. Gilbert BJ. 1978. 2004. 1942. Radiology 60:850. Foot Ankle 10:337-339. Part two. 42. Green D (eds): Fractures. 1989. Blackwell JB. Arch Surg 21:456-489. 14. 62. Irwin AS. Clin Orthop Relat Res 103:56. 1993. Jeffers RF. New York. Dukowsky J. Heim U. 2004. In Jahss M (ed): Disorders of the Foot. 1969. Milgrom C: Bone scintigraphy in the assessment of the hallucal sesamoids. Trafton P. Sammarco GJ: Fractures and dislocations of the foot. Clancy WG Jr: Runners’ injuries. Jupiter J (eds): Skeletal trauma. Surg Clin North Am 10:14-77. J Bone Joint Surg 29:359-366. 44. Lippincott–Raven. 38. Tam HB. Am J Sports Med 11:349-353. 36. 1980. J Foot Ankle Surg 43:225-230. Levine DB: Fractures of the tarsal navicular bone. Manoli A: Transverse percutaneous pinning of metatarsal neck fractures. 1976. 35. 1994. Am J Sports Med 8:287-289. Clancy WG Jr: Runners’ injuries. Am J Sports Med 21:591-598. 1977. Proc R Soc Med 35:760. Ifeld FW. Philadelphia. DePalma AF: The Management of Fractures and Dislocations. Donahue MP. Giordano AR. Part one. 26. 1996. Inge GL. Foot Ankle 10:43-44. Ferguson AB: Surgery of the sesamoid bones of the great toe. Lea & Febiger. 1973. Gross TS. In Bateman JE (ed): Foot Science. Lippincott. Parkes JC: Fractures of the foot. 1981. 48. Testa V: Rupture of the intersesamoid ligament of a soccer player’s foot. Philadelphia. 61. 1972. In Browner B. Pediatr Radiol 24:3738. Heckman JD: Fractures and dislocations of the foot. 2003. Horst F. 63. 2004. Churchill Livingstone. 18. Colwill M: Disorders of the metatarsal sesamoids. Crossan ET: Fractures of the tarsal scaphoid and of the os calcis. Clin Orthop Relat Res 85:38-41. Philadelphia. In Rockwood C. 41. Devas M: Stress Fractures. 1990. Fitch KD. Bunch RP: A mechanical model of metatarsal stress fracture during distance running. 60. Julian J: Stress fracture of the fifth metatarsal. 2004. 21. Anderson IF: Overuse ballet injury of the base of the second metatarsal: A diagnostic problem. 34. 1964. 53. Clancy WG Jr: Specific rehabilitation for the injured recreational runner. J Bone Joint Surg Br 71:105-110. Garcia A. 1975. 1989. 1980. Foot Ankle 12:117-122. Hansen ST Jr: Foot injuries. 1933. Sangeorzan BJ: A nutcracker fracture: Cuboid fracture with an associated avulsion fracture of the tarsal navicular. Evans JP. Nunley JA: Torque resistance after fixation of Jones fractures with intramedullary screws. Rosen V: Osteochondritis of the first metatarsal sesamoid. 1930. 17. Green D. 2004. et al: Prevalence and patterns of foot injuries following motorcycle trauma. 1973. WB Saunders. Prieskorn D. 1970. 1983. Foot Ankle Int 15:552-556. In Rockwood C. Hillegass RC: Injuries to the midfoot: A major cause of industrial morbidity. Surg Clin North Am 45:103-117. 64. Heckman J Eds: Fractures in Adults. In Bateman JE (ed): Foot Science. J Bone Joint Surg Am 51:577581. 1947. 1965. Goergen TG. Heckman JD: Fractures and dislocations of the foot. 1982. In Giannestras N (ed): Foot Disorders: Medical and Surgical Management. Johnson VS: Treatment of fractures of the forefoot in industry. Greenberg MJ. Capasso G. Venn-Watson EA. 30. 1989. Joint Bone Spine Revue du Rhumatisme 72:76-78. Maffulli N. DeLee JC. Gershon-Cohen J: The nutcracker fracture of the cuboid by indirect violence. J Orthop Trauma 18:87-91. Crichton KJ. WB Saunders. Am J Sports Med 17:669-674. 51. Chisin R. Fallat LM: Strength analysis of intraosseous wire fixation for avulsion fractures of the fifth metatarsal base. In Mann RA (ed): DuVries’ Surgery of the Foot. 1995. Dameron TB: Fractures and anatomic variations of the proximal portion the fifth metatarsal. 39. Arch Orthop Trauma Surg 109:277-279. Coker TP Jr. J Bone Joint Surg 11:298-302. Harrington T. WB Saunders. 31. Evaluation and treatment of specific injuries. Mosby. 25. 1994. 56. 1980. Am J Sports Med 9:217-219. Pfeiffer KM: Internal fixation of Small Fractures: Techniques Recommended by the AO Group. Bucholz R. 24. 23. 1995. Levine A. 50. 59. 49. Foot Ankle 1:327332. 20. Mann RA: Posttraumatic proximal migration of the first metatarsophalangeal joint sesamoids: A report of four cases. Foot Ankle Int 25:438-439. Maffulli N. 1975. 54. Garrett A: Using a hook plate as alternate fixation for fifth metatarsal base fracture. 1987. Martens M: Surgical treatment of Jones fractures. Cobey JC: Treatment of undisplaced toe fractures with a metatarsal bar made from torque blades. J Bone Joint Surg Br 57:89-97. Sangeorzan BJ. J Orthop Trauma 17:513-520. 1965. Schiller MG. 82. 105. Foot Ankle 7:245-252. Sarrafian SK: Anatomy of the Foot and Ankle. 1987. Saxby T. Philadelphia. 84. Jones R: Fracture of the base of the fifth metatarsal bone by indirect violence. 1995. Finestone A. Key JA. Anderson R: Stress fractures of the tarsal navicular. 2003. 1988. Sangeorzan BJ. Orva S. Jakob R. 81. Mast J. Orthop Clin North Am 26:353-361. 1989. 94. Orthop Trans 13:572. Am J Sports Med 16:378-382. Ganz R: Planning and Reduction Technique in Fracture Surgery. Botte MJ: Jones’ fractures and related fractures of the proximal fifth metatarsal. 1989. 1993. Fuller PJ: Stress fractures of the tarsal navicular bone: CT findings in 55 cases. 104. Br J Radiol 54:1-7. Foot Ankle 13:536-539. Rosenthal DI: Avulsion fracture of the fifth metatarsal: Experimental study of pathomechanics. 2000. Allied Deformities of the Forefoot and Metatarsalgia. 106. et al: Integrity of the first metatarsophalangeal joint: A biomechanical analysis. Paley D: The correction of complex foot deformities using Ilizarov’s distraction osteotomies. 111. 1993. Schneider R. Powers JH: Traumatic and developmental abnormalities of the sesamoid bones of the great toe. Rammelt S. Surg Gynecol Obstet 90:735-745. Kelikian H: Hallux Valgus. Pecina M. Ann Surg 35:697-700. Am J Surg 23:315-321. Templeton J: Vertical fracture–dislocation of the tarsal navicular. 117. 99. Allgower M. Miric A. 97. Khan KM. 91. Morrissey EJ: Metatarsal fractures. Lehman RC. 1965. Lippincott. Almekinders LC. AJR Am J Roentgenol 143:889-891. Margulies JY. 75. Myerson MS: Injuries of the forefoot and toes. 1981. Dislocations. J Trauma 16:669-671. 74. Campbell JT. Kiss ZS. 1961. AJR Am J Roentgenol 160:111-115. 69. 92. 1990. DeLee JC: Fractures of the base of the fifth metatarsal distal to the tuberosity: A review. 2003. Instr Course Lect 42:201-205. 100. et al: Fractures of the body of the tarsal navicular bone: Case reports and literature review. 1985.2234 PART X Trauma 65. 1992. In Mann RA (ed): Surgery of the Foot. 115. Jowett RL: Injuries of the midtarsal joint. Molloy S. Foot Ankle Int 23:163-167. Newman JH. Am J Sports Med 18:277-279. Mann RA: Sesamoid and accessory bones. Torg JS. Wilckens J: The surgical treatment of symptomatic nonunions of the proximal (metaphyseal) fifth metatarsal in athletes. Patterson BM: Pathoanatomy of intra-articular fractures of the calcaneus. Pfeffinger LL. Richter M. Pavlov H. Barbarawi M. Mosby. et al: Fractures and fracture dislocations of the midfoot: Occurrence. 66. J Bone Joint Surg Am 71:1504-1510. 2004. St Louis. Kronmal RA: Stress fractures in ballet dancers. St Louis. 1975. Shelbourne KD. J Bone Joint Surg Am 75:778-789. 1934. 1962. Lindholm R: Operative treatment of dislocated simple fracture of the neck of the metatarsal bone. Berlin. 98. Pearson JB: Pearson JB: Fractures of the base of the metatarsal. Zwipp H: Metatarsal fractures. Kolker D. Clin Orthop Relat Res 293:97111. Khan KM. 76. Spiegel P: The management of fractures with soft-tissue disruptions. 79. 68. Sangeorzan BJ: Temporary bridge plating of the medial column in severe midfoot injuries. Nyska M. Garrett WE: Intramedullary screw fixation of Jones fractures: Analysis of failure. 1994. 1990. 90. Müller ME. 83. Krettek C. Dubravcic S: Stress fractures in figure skaters. 1993. 87. Brukner PD. 109. Am J Sports Med 20:445-449. Ann Chir Gynaecol Tenn 50:328-331. Clin Orthop Relat Res 281:189-192. Mosca V. Shlamkovitch N. 116. Springer-Verlag. 95. Willinegger H: Manual of Internal Fixation: Techniques Recommended by the AO Group. Richardson EG: Injuries to the hallucal sesamoids in the athlete. Meurman KO: Less common stress fractures in the foot. Foot Ankle Int 22:392-398. Mosby. J Bone Joint Surg Br 72:376-378. Foot Ankle Int 16:357-362. 1937. 2001. Milgrom C. 113. Taft TN. Nunley JA: Metatarsal lengthening by distraction osteogenesis: A report of two cases. Hansen ST Jr: Progressive talo-navicular dissociation. Am J Surg 38:721-726. 1993. . J Bone Joint Surg 28:594-602. 1987. Wippermann B. Heineck J. 72. Gautier E: Pericuboid fracture–dislocation with cuboid subluxation. J Bone Joint Surg Am 43:513-516. et al: Fifth metatarsal tuberosity fracture fixation: A biomechanical study. Sanders R. Quill GE Jr: Fractures of the proximal fifth metatarsal. 112. 101. and Sprains. 1990. 80. 96. Richli WR. 1993. 114. causes and longterm results. J Bone Joint Surg Br 69:448-452. Maurice HD. 1992. McKeever FM: Fractures of the tarsal and metatarsal bones. 71. Rettig AC. Yen M. AJR Am J Roentgenol 130:679-681. Fitzgerald RH: Clinical and roentgenographic assessment of total hip arthroplasty: A new hip score. Rosenberg GA. Lawrence SJ. Miller WE. Kearney C. Schildhauer TA. Ray RD: Isolated dislocation of the medial cuneiform bone: A rare injury of the tarsus. Klenerman L: The Foot And Its Disorders. 1992. Lee S. J Bone Joint Surg Am 52:1632-1636. 77. Sanders R. Moshirfar A. 1998. Am J Sports Med 30:55-60. Morrison GM: Fractures of the bones of the feet. 1976. Swiontkowski MF: Displaced fractures of the cuboid. 70. Hulkko A: Delayed unions and nonunions of stress fractures in athletes. 67. J Am Acad Orthop Surg 8:332-338. 1995. 1983. 85. 1989. Larson CM. Sports Med 17:65-76. 1987. Marti C. Nork SE. 78. 1984. Injury 35(Suppl 2):B77-B86. Peason JR: Combined fractures of the base of the fifth metatarsal and the lateral malleolus. Berlin. et al: Displaced intraarticular fractures of the tarsal navicular. WB Saunders. 1946. Bojanic I. Prieskorn D. Foot Ankle Int 24:630-633. Nunley J. Swiontkowski M. 1986. WB Saunders. 1976. Sferra JJ: Treatment strategies for acute fractures and nonunions of the proximal fifth metatarsal. 1970. Foot Ankle 7:229-244. Graves S. 86. BMJ 1:1052-1054. 1989. Watt I: Bone scanning of the foot for unexplained pain. 103. 89. Kavanaugh BF. 110. South Med J 58:1229-1237. 1950. 1902. 93. Clin Orthop Relat Res 193:133-140. Conwell HE: The Management of Fractures. 107. Oxford. 102. et al: Tarsal navicular stress fracture in athletes. 73. 1978. Philadelphia. 1992. Foot Ankle Clin North Am 9:85-104. 1946. 108. Blackwell. Levy JM: Stress fractures of the first metatarsal. Sammarco GJ: The Jones fracture. In Jahss MH (ed): Disorders of the Foot. Teitz CC. Philadelphia. Main BJ. 2002. Nadeau P. Foot Ankle 14:358-365. 1991. 1961. Springer-Verlag. Benirschke SK. 2002. 118. et al: Prevention of overuse injuries of the foot by improved shoe shock attenuation: A randomized prospective study. 2004. J Trauma 29:1448-1451. Kadel NJ. Lichtblau PO: The smashed heel. J Bone Joint Surg Am 80:207-212. Am J Sports Med 20:50-54. 88. Shereff MJ: Fractures of the forefoot. 144. Wright RW. Marks RM: Imaging of the navicular. South Med J 26:833. 127. 1992. 125. Eils E. In Edmonson AS. 1990. Resnick D: Fractures of proximal portion of fifth metatarsal bone: Anatomic and imaging evidence of a pathogenesis of avulsion of the plantar aponeurosis and short peroneal muscle tendon. Radiology 226:857-865. Foot Ankle 13:143-152. Wilson DW: Injuries of the tarsometatarsal joints. Botte M. 129.CHAPTER 41 Fractures of the Midfoot and Forefoot 2235 119. 140. J Bone Joint Surg Am 66:209-214. Zelko RR. Smith TS. Cooley LH. 126. Br J Surg 1:724725. 142. Foot Ankle Int 23:1008-1011. Wilson PD: Fractures and dislocations of the tarsal bones. Mannoji T: Stress fracture of the proximal phalanx of the great toe. 1943. Watson-Jones R: Fractures and Joint Injuries. Am J Sports Med 15:304-307. Shereff MJ. St Louis. 1980. Part B. et al: Stress fractures of the tarsal navicular. 1970. 139. Katz FN: Stress fractures: An analysis of 250 consecutive cases. Am J Sports Med 32:1893-1898. Foot Ankle Clin North Am 9:181-209. Sizensky JA. Yokoe K. Foot Ankle 11:350-353. 1960. Kummer FJ. 135. Williams & Wilkins. 1974. Am J Sports Med 7:95-101. Wilson ESJ. Radiology 92:481-486. 124. 138. 130. Taylor GN: Treatment of the fractured great toe. Rosenbaum D: The influence of muscle fatigue on electromyogram and plantar pressure patterns as an explanation for the incidence of metatarsal stress fractures. Sisk TD: Fractures. Shively RA. 128. 2003. 2002. 141. 1979. 137. Clin Orthop Relat Res 151:256-264. Lange TA. J Bone Joint Surg Br 54:677-686. 1972. 120. Weber M. 1991. 1982. 1984. Torg JS. 134. Yang QM. 132. Torg JS. Fischer DA. Am J Sports Med 10:122-128. 131. 2000. Matthews DK: Strain and loading of the second metatarsal during heel-lift. Towne LC. Instr Course Lect 39:133140. Clin Orthop Relat Res 16:190-198. Wiley JJ. Balduini FC. 2004. Theodorou SJ. 1982. 123. 1995. 122. Cozen LN: Fatigue fracture of the tarsal navicular. et al: Refracture of proximal fifth metatarsal (Jones) fracture after intramedullary screw fixation in athletes. 1986. Sharkey NA. et al: Vascular anatomy of the fifth metatarsal. 1987. et al: Stress fractures of the sesamoids. Arnoczky SP. Ferris L. Zogby RG. Smith JW. Hersh A: The intraosseous blood supply of the fifth metatarsal: Implications for proximal fracture healing. Keene JS. 1946. Rachun A: Proximal diaphyseal fractures of the fifth metatarsal: Treatment of the fractures and their complications in athletes. Blazina ME. Mosby. Weist R. Zelko RR. Disorders of the sesamoids. 133. 136. 2004. 1933. Pavlov H. Rutkowski R: Anatomic variations in the first ray. . Orthopedics 13:731-737. Theodorou DJ. Scranton PE Jr. J Bone Joint Surg Am 77:1050-1057. Am J Sports Med 14:240-242. Brown J: Lithesis of the tarsal scaphoid. 143. Van Hal ME. 121. Locher S: Reconstruction of the cuboid in compression fractures: Short to midterm results in 12 patients. J Bone Joint Surg Br 56:586. Stewart IM: Jones fracture: Fracture of the base of the fifth metatarsal. Am J Sports Med 28:732-736. et al: Fractures of the base of the fifth metatarsal distal to the tuberosity: Classification and guidelines for non-surgical and surgical management. 1980. 1969. J Bone Joint Surg Am 52:376-378. J Bone Joint Surg Am 64:700-712. Crenshaw AH (eds): Campbell’s Operative Orthopaedics. Torg JS: Fractures of the base of the fifth metatarsal distal to the tuberosity. Baker BE: A review of nonoperative treatment of Jones’ fracture. Baltimore. Torg JS. Kakitsubata Y. 1990.