41.fractures of the midfoot and forefoot

Fractures of the Midfoot and ForefootRoy W. Sanders • Steven Papp

2199

C H A P T E R

41

THE TARSAL NAVICULARAnatomyMechanism of InjuryDiagnosisCORTICAL AVULSION FRACTURESNAVICULAR TUBEROSITY FRACTURESFRACTURES OF THE NAVICULAR BODYMechanism of Injury and DiagnosisTreatmentAuthors’ Recommended TreatmentSTRESS FRACTURES OF THE TARSALNAVICULARMechanism of InjuryClinical EvaluationRadiographic EvaluationTreatment and ResultsComplicationsCUBOID AND CUNEIFORM BONESMechanism of InjuryCUBOID FRACTURESClinical EvaluationRadiographic EvaluationTreatmentAuthors’ Preferred Method of TreatmentCUNEIFORM FRACTURESMechanism of InjuryRadiographic EvaluationTreatmentAuthors’ Preferred Method of

Treatment

METATARSAL BONESAnatomyMechanism of InjuryMETATARSAL BASE FRACTURES(EXCLUDING FIFTH METATARSAL)Authors’ Preferred Method of TreatmentMETATARSAL SHAFT FRACTURESClinical EvaluationRadiographic EvaluationTreatmentMETATARSAL NECK FRACTURESAuthors’ Preferred Method of TreatmentMETATARSAL HEAD FRACTURESAuthors’ Preferred Method of TreatmentFRACTURES OF THE FIFTH METATARSALBASEAnatomyClassification

Tuberosity Avulsion FracturesJones FractureDiaphyseal Stress Fractures

Authors’ Preferred Method of TreatmentSTRESS FRACTURES OF METATARSALDIAPHYSISClinical and Radiographic EvaluationTreatmentAuthors’ Preferred Method of TreatmentPHALANGEAL FRACTURESMechanism of InjuryClinical EvaluationRadiographic Evaluation

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THE TARSAL NAVICULAR

AnatomyThe tarsal navicular is located in the uppermostportion of the medial longitudinal arch of the foot andacts as the keystone of the arch.80 The body of the tarsalnavicular is a six-sided disk that is horseshoe shapedand sits between the talar head and the threecuneiform bones.35,113 It has a concave proximal artic-ular surface that articulates with the head of the talus.

Dorsally, laterally, and on the plantar surfaces,numerous short ligaments attach to the tarsal navicu-lar. These include the dorsal and plantar cuneonavic-ular ligaments distally and the plantar, dorsal, andinterosseous cuboideonavicular ligaments laterally.113

In addition, as described by Eichenholtz and Levine,35

a dorsal talonavicular ligament and an anterior divi-sion of the deltoid ligament, known as the tibionavic-ular ligament, exist; both offer strong support on theanteromedial aspect of the joint (Fig 41–1).

The medial surface slopes posteriorly to end in theprominent tuberosity, where a portion of the posterior

tibial tendon is inserted. Much of the tuberosityaccepts the attachment of the plantar calcaneonavicu-lar (spring) ligament arising from the sustentaculumtali. This complex, combined with the anterior processof the calcaneus, makes up the acetabulum pedis asdescribed by Sarrafian115 (Fig. 41–2). This socket allowsthe foot to swivel around the head of the talus. At heelstrike, the subtalar joint is everted. The talonavicularjoint and calcaneocuboid joints (transverse tarsal) areparallel or unlocked, allowing for flexibility. At toe-off,the subtalar joint is supinated, and the talonavicularand calcaneocuboid joint are nonparallel or locked,allowing for stability. Foot pronation and supination aredependent on normal talonavicular function. Loss of motionat the talonavicular joint results in significant loss of sub-talar motion.4 The distal surface of the navicular is alsoconcave and is divided into three articular facets forarticulation with each of the three cuneiform bones,but there is little motion at these joints.

OPEN FRACTURESTreatmentAuthors’ Preferred Method of TreatmentHALLUCAL FRACTURESAuthors’ Preferred Method of TreatmentLESSER TOE FRACTURESAuthors’ Preferred Method of TreatmentSESAMOID BONESAnatomy

Mechanism of InjuryClinical EvaluationRadiographic EvaluationDifferential DiagnosisConservative TreatmentSurgical TreatmentAuthors’ Preferred Method of TreatmentDISLOCATIONS OF SESAMOID BONES

1

Figure 41–1 Schematic of superficial deltoid ligament showsthe anterior tibionavicular ligament (1), arising from the ante-rior colliculus of the medial malleolus and inserting into thedorsomedial aspect of the navicular. (From Pankovich AM,Shivaram MS: Acta Orthop Scand 50:217-223, 1979.)

Acetabulum pedis

Figure 41–2 Acetabulum pedis, a confluence of structuresthat articulate with the talar head. (From Sarrafian SK: Anatomyof the Foot and Ankle. Philadelphia, Lippincott, 1983, p 173.)

CHAPTER 41 Fractures of the Midfoot and Forefoot 2201

The blood supply to the navicular is also importantfor understanding the results of injury to this bone.Because of the extensive articular cartilage surround-ing the bone, blood vessels can enter only from thedorsal and plantar surface and from the tuberosity(Fig. 41–3).115 Sarrafian pointed out that the dorsalpedis artery supplies the dorsum of the bone, and themedial plantar branch of the posterior tibial arterysupplies the plantar surface. A network of vesselsformed from both these branches supplies the tuberosity.

Torg et al131 performed microangiographic studies ofthe navicular and found that although the medial andlateral thirds of the bone had a good blood supply, thecentral third was largely avascular. Sarrafian115 alsonoted that the number of vessels supplying the navic-ular decreased with increasing age, possibly explainingthe rise in the rate of avascular necrosis (AVN) andnonunion after fracture of this bone in elderlypatients.

Mechanism of InjuryFour characteristic types of fractures can occur to thetarsal navicular.35,80,113 The first is a relatively minortwisting injury that results in a cortical avulsion frac-ture known as a chip fracture; this is best seen on thelateral radiograph (Fig. 41–4). This fracture usuallyrepresents a dorsal ligamentous and capsular avulsionfracture. With more force, usually from an everted footwith pull from the posterior tibial tendon, a tuberosityfracture can occur, in which the medial tuberosity is

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 articu-lar comminution. It is often associated with shorten-ing of the medial column and dorsal extrusion of partof the navicular (Fig. 41–6). The fourth type of fractureis the tarsal navicular stress fracture, which usuallyresults from overuse and repetitive trauma.

DiagnosisA navicular fracture should be suspected after an injuryto the foot or when the patient has continued com-plaints of pain in the midfoot. Radiographs should be

A B

1 2

2

2

1

Figure 41–3 Blood supply to navicular. A, In a 4-year-old girl, demonstrating that most of blood supply comes from a singleartery (1), with a few penetrating radiate vessels (2). B, Similar findings in a 13-year-old boy. (From Sarrafian SK: Anatomy of theFoot and Ankle. Philadelphia, Lippincott, 1983, p 302.)

Figure 41–4 Lateral radiograph showing chip fracture oftarsal navicular.

2202 PART X Trauma

obtained in the anteroposterior (AP), oblique, andlateral projections so that the fracture can be clearlyseen.

Schiller and Ray118 suggested several criteria to eval-uate injuries of the middle part of the foot. On anormal AP radiograph the shadow of the navicularshould overlap all three cuneiforms equally. In addi-tion, no space should be seen between the bases of thefirst and the second metatarsal. On the lateral radio-graph the cuneiform should overlap and lie in linewith the navicular. An oblique radiograph should bemade for all suspicious cases of injury to the middlepart of the foot. Nevertheless, one third of the casesreported by Main and Jowett80 were initially missed. In these instances the cause may be a nondisplacedfracture or a stress fracture.

When radiographs are negative and a high index ofsuspicion exists, a bone scan or magnetic resonance(MR) image should be obtained to document the frac-ture. This is critical, because missed fractures result indisplacement of the navicular with secondary collapseof the medial column of the foot.

Dorsal cortical avulsion fractures are best seen onthe lateral radiograph, where the avulsion of the dorsalnavicular appears at the level of the talonavicular joint.

Tuberosity fractures are seen with the foot in moder-ate equinus when oblique and AP views are obtained.Care should be taken to avoid mistaking an accessorynavicular for a fracture.39 Usually a smooth line sepa-rating the two bones is visible, as opposed to the sharpline of a fracture. When in doubt, radiographs of the contralateral side may be helpful. Interestingly,McKeever83 suggested that disruption of the synchon-drosis between the two bones could result in a painfulavulsion of the accessory bone.

Crush fractures to the navicular body are seen in allviews. Computed tomography (CT) is required todelineate the extent of lateral involvement becauseplain films do not always show these fracture lines well(Fig. 41–7).124 The mechanism of injury should besought, and associated fractures, especially in themidfoot, should be considered.57

CORTICAL AVULSION FRACTURES

Fractures of the dorsal lip of the navicular are the mostcommon type of navicular fractures encountered.39

They accounted for 47% of fractures of the navicularin the series reported by Eichenholtz and Levine.35

They are often associated with sprains of the midfoot.The mechanism of injury is usually an acute plantarflexion inversion injury of the foot in which the talo-navicular ligament avulses a portion of the navicularfrom the proximal dorsal aspect of that bone.

The signs and symptoms of dorsal avulsion fracturesconsist of pain, swelling, and point tenderness on thedorsal and dorsomedial aspect of the foot in the areaof the talonavicular junction. Giannestras and Sammarco39 emphasize the association of this injurywith a lateral sprain of the ankle. A careful clinicalsearch for point tenderness helps to distinguish theseinjuries.

Figure 41–5 Tuberosity avulsion fracture (arrow).

Figure 41–6 Comminuted fracture of the navicular body.


Dorsal avulsion fractures should be treated conser-vatively. Chapman16 recommends a short period ofimmobilization and states that minimal disabilityusually results. He suggests, however, excising the frag-ment if pain persists after immobilization. Giannestrasand Sammarco39 recommend the use of an elasticdressing (Elastoplast; Ace). When symptoms of painare severe and the chip fragment is larger than a flakeof bone, they recommend a below-knee walking castfor 3 to 4 weeks. If the fragment is large enough to bea symptomatic bony prominence, they recommenddelayed excision of the fragment. Watson-Jones134

stated that although results were usually excellent aftershort-term immobilization, these avulsion injuriescould represent part of a midtarsal subluxation. If sucha subluxation was present, he recommended immobi-lization for 6 weeks, followed by the use of a moldedlongitudinal arch support.

We agree with a short period of immobilization forthese fractures. If significant soft tissue swelling andecchymosis are present, then keeping patientsnon–weight bearing for 6 to 8 weeks will give theirmajor ligamentous injury longer to recover. When theavulsed fragment is a major portion of the articularsurface of the navicular, however, open reduction withinternal fixation is indicated not only to minimizepain and posttraumatic arthritis but also to decreasethe risk of subsequent midtarsal subluxation.

NAVICULAR TUBEROSITYFRACTURES

Fractures of the navicular tuberosity result from acuteeversion of the foot, leading to increased tension onthe medial inserting structures, that is, the posteriortibial tendon and the strong attachment of the deltoidligament to the tuberosity of the navicular, by way ofthe spring ligament. This increased tension results inan avulsion fracture of the navicular tuberosity.35,39

Because of the other insertions of the posterior tibialtendon in the forefoot, the fracture is usually onlyminimally displaced. As a result, surgical treatment isoften unnecessary.

The patient usually gives a history of having twistedthe foot and complains of pain over the naviculartuberosity that is accentuated by weight bearing.39

With attempted eversion of the foot, pain is referredto the involved area secondary to the increased tensionapplied to the posterior tibial tendon and thus to thefracture site.

Historically, most authors suggested that treatmentshould be symptomatic. For patients who had mildpain and who were not very active, Giannestras andSammarco,39 Coker and Arnold,22 and Garcia andParkes38 all recommended an elastic dressing withpartial weight bearing on crutches for 4 weeks. If the

A

B

NavicularNaviculartuberositytuberosityNaviculartuberosity

Figure 41–7 A, Comminuted fracture of tarsal navicular(arrow). B, Computed tomography scan demonstrates thatfracture is in both sagittal and transverse planes.

2204 PART X Trauma

symptoms were severe, however, a below-knee walkingcast with the foot in the neutral position was used.These authors stressed that although nonunion couldoccur, it was usually asymptomatic and therefore dis-regarded. If a painful nonunion persisted, surgicalexcision of the tubercle was recommended. The rawsurfaces of the tendon were sutured back to theremaining navicular under the same tension thatexisted before excision of the navicular tubercle. Afterexcision the patient was kept in a below-knee cast for4 weeks, at which time the cast was removed andweight bearing advanced.

We generally agree with these concepts, but when adiastasis of greater than 5 mm is seen, a nonunion islikely. Similarly, the avulsion can take a rather largeportion of the medial navicular. In that case we rec-ommend open reduction with anatomic repositioningunder direct visualization, followed by internal fixa-tion. A 3.5-mm screw overdrilled to lag the fragmentor a 4.0-mm cancellous partially threaded lag screwshould be used (Fig. 41–8). This technique is also usedwhen a symptomatic nonunion develops. Postopera-tive management includes non–weight bearing for 8weeks in an off-the-shelf cast boot, followed by pro-gressive weight bearing in the boot over the followingmonth.

FRACTURES OF THE NAVICULAR BODY

Mechanism of Injury and DiagnosisFractures of the body of the navicular are uncommonbecause of the strong associated ligamentous attach-ments to the bone. When these fractures do occur, theyare usually the result of direct axial load secondary toa fall from a height with the patient landing on thefeet.35,80,94,113 Eftekhar et al34 and Nadeau and Temple-ton93 suggested that the mechanism of injury for a ver-tical fracture of the talar body with dorsal dislocationof a variable portion of the navicular was forcibleplantar flexion and abduction of the midtarsal joint.Nyska et al94 believed that the forefoot and cuneiformswere compressed by a longitudinal force when theankle was plantar flexed. This in turn crushed the nav-icular variably against the talar head. The talus thenacted as a wedge with the medial tuberosity held inplace, or it was retracted posteriorly and medially bythe posterior tibial tendon and spring ligament. At thesame time the navicular bone fragments turnedupward and hinged on the dorsal talonavicular liga-ments, giving the classic radiographic finding of a ver-tical fracture dislocation with dorsal dislocation of thefracture fragments.

A

BFigure 41–8 Surgical treatment of navicular tuberosity avul-sion fracture. A, Dorsal radiograph showing fracture (arrow).B, Lateral radiograph showing fixation.

Main and Jowett80 believed that the classification ofmidtarsal injuries should be based on the direction ofthe forces acting on the joint. They stressed that frac-tures of the navicular body were in continuum withfracture–dislocations. For example, a force moving thefoot medially on the talus usually resulted in a swiveldislocation of the talonavicular joint in which the cal-caneocuboid joint remained intact. In this instance thefoot swiveled about the axis of the interosseous talo-calcaneal ligament. When longitudinal forces wereapplied across the foot, however, a crushing compo-nent was added to the injury. When this longitudinalforce was applied to the metatarsals in a plantar-flexedfoot, a shearing fracture of the navicular along the linesof the intercuneiform joints occurred, secondary to thenavicular being trapped between the cuneiforms and


the talar head. Thus, minor forces resulted in non-displaced fractures, whereas major forces resulted in dorsal displacement of the fragments. With theaddition of lateral or medially directed forces, the navicular was crushed eccentrically such that the footfollowed the deforming force.

Sangeorzan et al,113 using radiographic evaluation,classified fractures of the body of the navicular by thedegree and direction of displacement, the number ofarticular fragments, the alignment of the forefoot, andthe presence of associated injuries.

In a type 1 fracture the primary fracture line is trans-verse in the coronal plane, with a dorsal fragment thatconsists of less than 50% of the body (Fig. 41–9A). Onthe AP radiograph the medial border of the foot doesnot appear to be disrupted.

In a type 2 fracture, the most common type, the fracture line traverses the body of the tarsal naviculardorsolaterally to plantar–medially (Fig. 41–9B). Themajor fragment is dorsomedial, with a small, oftencomminuted plantar lateral fragment. The calcaneo-navicular joint is not disrupted.

Type 3 fractures include fractures with central orlateral comminution (Fig. 41–9C). The major frag-ment is usually the medial one, and the medial borderof the foot is disrupted at the navicular cuneiformjoint. There may be lateral displacement of the footwith some disruption or subluxation of the cal-caneocuboid joint.

Sanders and Hansen111 noted that with an intactmedial fragment and a crushed lateral component, thefoot may be displaced in a medial direction such thatthe talar head appears to be shifted laterally on the APradiograph, with the hindfoot shifted into varus, asseen clinically or on a Harris axial view (Fig. 41–10).

Clinically, patients usually have pain that is localized to the midtarsal aspect of the foot. Markedtenderness over the medial aspect of the navicular is usually present. Before the onset of swelling, the

displaced fracture fragments can be palpated on thedorsal aspect of the foot. Motion of the foot, particu-larly inversion–eversion and abduction–adduction,produces localized pain.39

TreatmentTiming of SurgeryNavicular dislocation or perinavicular subluxation arenot uncommon in association with navicular fractures.If severe, they can be recognized by gross midfootdeformity, severe skin tenting or soft tissue swelling,ecchymosis, or instability. Patients who have suchinjuries should undergo a careful documented neu-rovascular exam and inspection for open wounds andcompartment syndrome. Skin tenting, irreducible dis-location, open wounds, neurovascular compromise,and compartment syndrome are indications for urgentmanagement. Otherwise, a closed reduction and pre-liminary stabilization in a bulky Jones dressing andposterior slab in neutral position to rest the soft tissuesis appropriate. Surgery is planned and performed asdictated by soft tissue swelling and patient factors.31 Ifsevere swelling and fracture blisters are present, it isprudent to wait until the soft tissue has recoveredbefore proceeding with operative intervention. Thewrinkle test is used to determine if swelling is acceptable.

External FixationExternal fixation can serve many roles in the treatmentof these injuries and therefore is an invaluable technique to know. DiGiovanni lists four settings: forobtaining preliminary stabilization and alignment ina grossly unstable injury pattern prior to definitivemanagement; as a means to observe the soft tissues ofa severely traumatized or crushed foot; as supplemen-tal fixation in certain cases of limited internal fixation;and as an intraoperative fracture reduction aid,

A B CFigure 41–9 Classification of navicular body fractures according to Sangeorzan et al.113 A, Type 1, B, Type 2. C, Type 3. (From Hansen ST Jr, Swiontkowski MF: Orthopaedic Trauma Protocols. New York, Raven, 1993, p 361.)

2206 PART X Trauma

especially in a comminuted fracture pattern, by usingthe principle of ligamentaxis. Pins can be placed in themetatarsal shaft and calcaneus or talus, depending onwhich column of the foot (medial or lateral) needs tobe reduced through traction.

Internal FixationTreatment in the past was largely nonsurgical, withmanipulative reduction used for displaced fractures.Crossan24 advocated the resection of fracture frag-ments to relieve symptoms in patients in whom open

reduction was impossible (Fig. 41–11). This techniqueis mentioned only to be condemned, because the lossof bone in the medial column severely disables the patient as the foot collapses into adduction andcavovarus.45,80,111,113

As early as the 1950s, Bonvallet9 advocated openreduction and anatomic repositioning using internalfixation. He believed that the generally poor results of conservative therapy were caused by nonanatomicpositioning of the navicular, which, after inadequatereduction, acted as a sagging cornerstone in a vault

Talarhead

A B

NormalNormalsidesideinin

valgusvalgus

InjuredInjuredsidesideinin

varusvarus

Normalsidein

valgus

Injuredsidein

varus

C

AnkleAnkle

PosteriorPosteriorfacetfacet

CC jointCC joint

NavicularNavicularosteotomyosteotomy

LNLN

MNMN

Ankle

Posteriorfacet

CC joint

Navicularosteotomy

LN

MN

Figure 41–10 A, After vertical (type 2) navicular fracture, the posterior tibial tendon will force the foot medially, uncovering thetalar head and giving a radiographic appearance of lateral shift of the talar head. B, This results in varus shift of the hindfoot,which can be best seen clinically from behind. C, Cadaveric navicular osteotomy model designed to indicate fracture pathologicprocess. Note that hindfoot varus is evident with uncovering of the anterior aspect of the calcaneal posterior facet. *Talar head;CC joint, calcaneocuboid joint; LN, lateral navicular; MN, medial navicular.


1 year postrevision1 year postrevision1 year postrevision

Totalnavicularexcision

A B C

E

FDFigure 41–11 A, A 26-year-old man fell out of a palm tree, sustaining this fracture to the tarsal navicular. B and C, Patient was seen in a local hospital and treated with complete navicular excision and pinning, then referred for further care. Arrowsindicate gap present from navicular excision. D and E, Defect was filled with structural iliac crest bone graft, wedged in placefor a fusion mass, and held with staples. F, This repair failed, and revision using large 6.5-mm cannulated lag screw was performed successfully.

2208 PART X Trauma

construction. In his perception, secondary deformitiesmanifested after resumption of weight bearing andprogressed to painful, traumatic flat feet with degen-erative arthritis, usually within 6 to 12 months afterinjury.

By the 1970s, surgical intervention had become themore accepted treatment for this injury. Both Giannes-tras and Sammarco39 and Garcia and Parkes38 indi-cated that when the fractured navicular body wasdisplaced, closed reduction was of little or no value.Nadeau and Templeton93 also recommended openreduction, particularly when there were two majorfragments with little or no comminution. Mostauthors currently agree that for all but the most min-imally displaced fractures, open reduction with inter-nal fixation with lag screws is necessary to prevent notonly avascular necrosis and nonunion of the navicularbut also collapse of the medial column.45,94,113

ArthrodesisFor the more comminuted fractures, internal fixationmight not be possible. In these cases, primary ordelayed arthrodesis of the talonavicular or naviculo-cuneiform must be considered. In 1933, P.D. Wilson140

found that primary arthrodesis of the talonavicularjoint, in cases in which complete reduction could beobtained, resulted in an asymptomatic foot. By 1942,I.L. Dick30 was advocating primary arthrodesis for alltarsal navicular body fractures with dorsally displacedfragments. Day,26 using amputation specimens, foundthat localized arthrodesis (i.e., arthrodesis involvingthe talonavicular and naviculocuneiform joints)resulted in a loss of nearly all the inversion and ever-sion of the foot. Clinically these patients were stillexhibiting pain, primarily from the remaining unfusedsubtalar joints. Day believed that a quadruplearthrodesis (triple arthrodesis plus an arthrodesis ofthe naviculocuneiform joint) produced results supe-rior to those obtained after fusion of only the involvedjoints.

Most authors currently limit fusions to the patho-logic process found at the time of surgery. Eichenholtzand Levine35 believed that if the fracture was too com-minuted for internal fixation, an arthrodesis of eitherthe talonavicular or the naviculocuneiform joint wasrequired. They noted that occasionally a triplearthrodesis was indicated, but this necessarily resultedin a complete loss of hindfoot motion. Similarly,Garcia and Parks38 used the degree of damage to thearticular cartilage surfaces as the criterion for immediate arthrodesis of either the talonavicular ornaviculocuneiform joint in younger patients.

Main and Jowett80 also suggested that fusions belimited to the naviculocuneiform joints and that talo-navicular fusions be performed only in cases of severe

comminution. They stated that triple arthrodesis neverresulted in a rating better than fair according to theircriteria. Nyska et al94 also suggested that talonaviculo-cuneiform fusions were required when the navicularbody was severely comminuted, but they condemnedthe addition of a triple arthrodesis.

Finally and most recently, Hansen45 described“ankylosis” procedures as an alternative to arthrodesisfor the treatment of acute fractures. In this situationthe cuneiforms are considered anchors for stabiliza-tion whereby the fracture fragments are secured withlag screws, which may extend across the nonessentialnaviculocuneiform joints and into the cuneiforms ifneeded, but formal joint fusion is not done (Fig.41–12). These screws are often removed after the fracture has healed.

Authors’ Recommended TreatmentPatients with nondisplaced fractures are treated in anon–weight-bearing cast for 8 to 10 weeks until frac-ture healing is seen radiographically. Range of motionshould not be started until the surgeon is convincedthat union has occurred. If at any time the fracture frag-ments shift, open reduction with internal fixation isrequired.

All displaced, comminuted fractures and frac-ture–dislocations are treated surgically. The approachto the talonavicular joint is made through an antero-medial incision between the anterior and the posteriortibial tendons.45,91,113 A small capsulotomy in the talo-navicular joint should be performed to visualize thefracture and the talonavicular articular surfaces. Frac-ture reduction can be obtained with the use of large orsmall pointed Weber reduction forceps. These can beinserted through stab incisions or through the openwound to grip the major fracture fragments perpen-dicular to the fracture line. Occasionally, Kirschnerwires must be drilled into the individual fragments tobe used as joysticks to control the fragments and assistin reduction.

Although manual traction can be used, indirectreduction is more often performed, using a mediallyplaced small fragment distractor (Synthes, Paoli,Penn) or small external fixator, with one pin placed inthe talar neck and the other in the medial cuneiformor base of the first metatarsal. This distraction over-comes the deforming force of the anterior and poste-rior tibial tendons and allows the displaced fragmentsto fall back into position for subsequent fixation.81

Cancellous bone grafting to fill central defects in thebone after elevation of depressed fragments may benecessary. This bone can be obtained from the calca-neus, distal tibia, or iliac crest. Alternatively, allograftor synthetic bone void filler products may be used.


Fixation is obtained by using two or more screws ina lag mode and inserted through dorsomedial and dor-solateral stab incisions. Adequate fixation may beachieved with 4.0-mm cancellous screws, but use of3.5-mm cortical screws is more advantageous becausethe larger core diameter of the 3.5-mm screws isstronger and minimizes the chance of screw break-age.45 Cannulated screws have neither adequate pur-chase nor sufficient strength for optimal fixation.When small articular fragments exist, mini-fragmentscrews or Biofix bioabsorbable pins (Bionx Implants,Blue Bell, Penn), ranging from 1.5 to 3.2 mm, may beused to augment the fixation.

The dorsal and plantar fragments of Sangeorzantype 1 displaced intraarticular navicular fractures arerarely highly comminuted. In most cases they can bestabilized with 3.5-mm cortical lag screws withoutextending the fixation into the distal cuneiforms.

Sangeorzan type 2 fractures are more difficult toreduce because the lateral plantar fragment may becomminuted and the dorsomedial fragment may bedislocated at the talonavicular joint. Because of thecomminution, a distractor or laminar spreaders areneeded. After reduction, the joint surfaces are evalu-ated for articular depression and loose bodies. Whenthere is minimal comminution and the lateral frag-

A B

C D

E

Cuboid distraction and grafting

Indirect reduction usingsmall external fixator

Navicular fracture

TalusTalus

TalusTalus

CalcCalc

Talus

Talus

Calc

Figure 41–12 Comminuted navicular fracture with cuboid crush (“nutcracker injury”). A, Lateral radiograph shows navicularfracture. On this view, the cuboid appears relatively intact. B, Computed tomography scan coronal cuts demonstrate level ofnavicular comminution, as well as fracture at the level of the tuberosity and calcaneal (Calc) involvement. C, Intraoperative viewdemonstrates reduction of the navicular using a medial distractor, with a lateral laminar spreader to realign the midfoot. A screwwas placed into the navicular, and grafting was planned for the cuboid. D and E, During the procedure, navicular fixation waslost, and the navicular could no longer be held with screws. Therefore an ankylosis procedure was performed, locking the nav-icular to cuneiforms using a plate. Similarly, bone grafting and plating were performed to restore the cuboid.

2210 PART X Trauma

ment is large, medial-to-lateral lag screws are used tofix the fracture. When the lateral fragment is small orcomminuted, the dorsomedial fragment should bereduced with screws aimed obliquely into the secondor third cuneiform.

Comminution and subluxation of the plantar lateralfragment should be addressed with ankylosis betweenthe navicular and the cuboid or lateral cuneiform.Alternatively, if fixation to a distal segment is not possible, or if talonavicular subluxation needs to becorrected, one or more smooth 1.6- or 2.0-mm pinsare inserted from the navicular fragment into the talarhead and neck. If fixation is limited, and collapse ofeither the medial or lateral column is possible, aug-mentation with a mini external fixator is an option.Temporary bridge plating from the talar neck onto thecuneiforms or first metatarsal is another technique thatprevents collapse of the medial column.117 Bridgeplating offers more stable fixation and the advantageof no pin site problems common in the foot. However,the plate must be removed with a second procedureonce the fracture has healed.

Sangeorzan type 3 fractures also demonstrate com-minution in the plantar lateral fragment and cannotbe reduced securely by screw fixation alone. Onceagain, the large medial or dorsomedial fragment mustbe fixed in anatomic position by anchoring screws intothe cuneiforms. Fixation by this method reduces boththe navicular fracture and the naviculocuneiform jointdisruption. If the injury extends into the calca-neocuboid joint, this should be fixed separately withadditional lag screws.

When the naviculocuneiform articulation is highlycomminuted, the joint may be debrided of cartilageand fused without sequelae. When the talonavicularjoint is damaged, attention to articular reconstructionis of critical importance because of the significance ofthis articulation. If reconstruction with screws andBiofix pins is not possible secondary to comminutionand collapse, the medial column should be broughtout to length with a structural bone graft. A talonavic-ular fusion is then performed. Patients complaining of subtalar pain later in their course of treatment cansubsequently be converted to a triple arthrodesis.

Postoperatively the foot is immobilized in anon–weight-bearing short-leg cast for 10 to 12 weeks.Kirschner wires placed through the talonavicular jointmay be removed after 6 weeks. Weight bearing andmotion may be gradually increased after radiographsshow evidence of union. Anchoring screws may beremoved at 6 months to prevent screw breakage fromcyclic loading across the joints.

ResultsResults in the literature are primarily based on isolatedcase reports. Greenberg and Sheehan43 reported one

case that was treated surgically with two screws andearly mobilization. Only a 4-month follow-up wasprovided; the patient had full range of motion withoutpain. Nadeau and Templeton93 described a displacedfracture treated with open reduction, with 3.5 years offollow-up; the patient had no limitation of functionand no pain. Eftekhar et al34 reported on one patienttreated with open reduction 6 days after injury. Nine-teen months after treatment the patient reported nopain or limp but had lost approximately 50% of hissupination and pronation.

Main and Jowett80 reported on 15 longitudinal and14 longitudinal and medial compression injuries. Of these 29 fractures of the navicular body, all fiveundisplaced fractures had good or excellent outcomes.The remaining 24 fractures, which were displaced,included only one excellent and five good results(25%). Thus the vast majority of displaced fractures(18 of 24) had only fair or poor results.

Nyska et al94 reported on four fractures with only 6months to a year of follow-up. Three had good results,and one was painful. In a large series of 67 navicularfractures, Eichenholtz and Levine35 treated 19 body frac-tures. Only one case was managed initially with openreduction followed by casting. Five cases subsequentlyunderwent late surgical treatment: three talonaviculo-cuneiform fusions and two triple arthrodeses, with oneexcellent result, three good results, and one fair result.

More recently, Sangeorzan et al113 reported on 21navicular body fractures. Using their classificationsystem, a satisfactory reduction was obtained in alltype 1 displaced fractures, in 67% of type 2 fractures,and in 50% of type 3 fractures. Complete avascularnecrosis occurred in two cases and partial necrosis infour. Of the 15 patients with a satisfactory reduction,14 had a good result, and one had a fair result.Although two thirds of the patients had a good func-tional result with no pain during activities of dailyliving, only four patients thought they had a “normal”foot. The authors concluded that both the type of fracture and the accuracy of surgical reduction directlycorrelated with the final outcome.

Richter et al108 recently reviewed their experiencewith 155 patients who had fractures or fracture–dislo-cations of the midfoot. Fifty patients in this study hadnavicular body fractures. They found patients com-monly had disability in the long term, with averageAmerican Orthopaedic Foot and Ankle Society(AOFAS) scores of 71. Patients with isolated injuries tothe navicular, fixed anatomically, with restoration ofthe medial and lateral column scored closer to normal.Navicular fractures were not classified in this study.

ComplicationsPartial AVN, late partial collapse of the navicular, andposttraumatic arthritis are often seen after a navicular


fracture, even after optimal fixation.45 Symptomaticarthrosis and bone collapse can occur in displacedfractures. If collapse or painful arthrosis occurs, recon-structive structural bone block fusions may be indi-cated, such as a talonavicular, naviculocuneiform,talonaviculocuneiform, triple, or quadruple arthrodesis.

Osteochondritis of the adult tarsal navicular, firstdescribed by Brailsford10 in 1939, results in late col-lapse of the lateral side of the navicular. AlthoughBrailsford thought this represented idiopathic AVN ofthe lateral segment, in many cases it appeared tofollow a traumatic event. In any case, development ofa late progressive hindfoot varus deformity follows. Inthis syndrome the forefoot is shifted medially, pullingthe hindfoot into varus.110 The AP radiograph is diag-nostic and shows the talar head articulating with thelateral cuneiform. This is best managed by re-positioning the medial column and hindfoot with astructural bone graft, followed by a triple or quadru-ple arthrodesis.

STRESS FRACTURES OF THE TARSAL NAVICULAR

Mechanism of InjuryStress fractures of the tarsal navicular were oncethought to be exceedingly rare. The first reported casesappeared in 1970, when Towne et al132 described astress or fatigue fracture of the tarsal navicular in twopatients. Devas29 reported two additional cases in1975, both in older women. Orva et al95 found onlyone case in 142 stress fractures, an incidence of 0.7%.Goergen et al41 reported two additional cases inrunners, one of whom required open reduction andinternal fixation.

In 1981, Hunter58 stressed that these injuries wereprobably more common than recognized. She notedthat these patients were usually involved in athleticactivities, particularly track. Torg et al,131 in a multi-center study, reported 21 cases the following year. By 1994, Khan et al70 stated that a stress fracture of the tarsal navicular was a frequently recognized injury, usually occurring in track and field athletes, and outlined the diagnosis and treatment for this disorder.

Clinical EvaluationPatients usually give a history of the insidious onset ofan ill-defined soreness or cramping sensation over thedorsum of the foot or the medial aspect of the longi-tudinal arch.58,70,131,132 Hunter58 found that when thesepatients stand on their toes and exert downward pres-sure on the metatarsal heads, the symptoms of pain in

the area of the navicular are reproduced. Hunter,58 Torget al,131 and Khan et al70 emphasize the importance ofthis diagnosis in athletes, because a failure to recog-nize this entity and curtail the athletic activity canresult in fracture displacement.

Radiographic EvaluationTowne et al132 found that although initial radiographsmight fail to reveal the fracture, because of continuedsymptoms, films taken several months later can reveala vertical radiolucent line in the tarsal navicular. Theauthors also pointed out that conventional radio-graphs were often negative but that tomograms oftenrevealed a vertical fracture of the tarsal navicular.Hunter58 first suggested the use of a bone scan for verification of the stress fracture.

Torg et al131 suggested standing AP, lateral, andoblique views when a navicular stress fracture is sus-pected. They emphasized that the tarsal navicular isoften underpenetrated on these radiographs and thata coned-down AP view centered on the navicular maybe required. They also suggested a bone scan if theinitial views were negative.

Although the earlier reports suggested the use oftomograms to document the fracture, Khan et al70 andKiss et al71 recommend a CT scan of these lesions,specifically after bone scanning, to delineate the frac-ture and its amount of separation. Using these tech-niques, the authors found all fractures to be located inthe sagittal plane in the central third of the bone.Partial fractures located in the dorsal cortex involvedthe proximal articular surface in most cases.131

A fatigue fracture of the tarsal navicular may be con-fused with a bipartite navicular.58,131,132 AP radiographsin cases of a bipartite navicular reveal the bone to becomma shaped and bent, and on the lateral view a cleftis noted to run from the proximal plantar aspect to thedistal dorsal margin and to separate a triangularosseous structure located dorsal to the rest of the nav-icular body.33 True stress fractures occur in the sagittalplane.48 Both bone and CT scans can be used to distinguish between a bipartite navicular and a stressfracture.

Treatment and ResultsTowne et al132 presented two cases. In the first a verti-cal fracture of the navicular required open reductionand internal fixation with bone grafting, followed bynon–weight bearing for 3 months. In the second casea nondisplaced stress fracture of the navicular wastreated with crutches and non–weight bearing for 4months. Healing without sequelae resulted.

Wiley and Brown137 reported on three patients with stiff, painful feet in whom the tarsal navicular

2212 PART X Trauma

separated to such a degree that the head of the talusbecame approximated to the cuneiforms. Althoughthese authors termed this entity “listhesis of the tarsalscaphoid,” it may well have represented a stress fracture of the navicular that became displaced. Two ofthe patients received some relief from conservativetherapy, and the third required a triple arthrodesis.

Hunter58 recommended curtailing athletic activity toprevent the development of a displaced stress fracture.In patients in whom repeated stress fractures of thenavicular are noted despite an alteration in trainingtechniques, an inherent abnormal anatomy may be asignificant predisposing factor. In such cases, orthosesare recommended to correct the abnormal anatomy.With displacement, however, surgical intervention isrequired.

Torg et al131 indicated that the failure to treat thesefractures with non–weight bearing contributed to dis-ability because of delayed union, nonunion, andrefracture. They recommended that uncomplicatedpartial stress fractures and nondisplaced stress frac-tures of the tarsal navicular be treated with immobi-lization using a plaster cast and non–weight bearingfor 6 to 8 weeks. Displaced fractures, complete frac-tures, delayed unions, and nonunions should betreated with internal fixation and bone grafting, fol-lowed by immobilization and non–weight bearinguntil union occurs. These authors stressed the impor-tance of non–weight bearing in the healing phase,because continued weight bearing or immobilizationin a weight-bearing cast can lead to prolonged dis-ability. When open reduction and internal fixation isindicated, a similar dorsal approach to navicular bodyfractures is used. The fracture line is identified,debrided and autogenous or allogenic bone graft isinserted. Screw fixation from the smaller lateral frag-ment into the larger medial fragment can be used.76

More recently, Khan et al70 noted that the treatmentof tarsal navicular fractures in athletes should include6 weeks of strict non–weight-bearing cast immobiliza-tion. This is followed by a 6-week program of rehabil-itation with a graduated return to activity. If thefracture was detected early and treatment was applied,the rate of delayed or nonunion was exceedingly low.

ComplicationsThe principal complication of a stress fracture of thetarsal navicular is a delayed union or nonunion. Fitchet al36 noted that stress fractures of the tarsal naviculardo not always heal predictably with conservative treat-ment. In patients who remained symptomatic, radio-graphs usually showed wide separation of a completefracture, extension of an incomplete fracture, delayedhealing, or a medullary cyst. In these patients, an

autologous bone graft was inserted after en bloc resec-tion of the fracture surfaces. It was important to fullyexpose the fracture’s distal limits before the graft wasinserted. The authors reported on 19 fractures in 18patients. Six fractures were complete, 12 were incom-plete, and one had a residual medullary cyst. Of the 15patients with adequate follow-up, 12 had been able toreturn to a preinjury level of activity within 1 year.

If left untreated over a long period, a nonunion canprogress to displacement with deformity, similar tothat of a comminuted tarsal navicular body fracture.Brailsford10 described the deformity that he believedwas secondary to osteochondritis or osteonecrosis inthe adult. Wiley and Brown137 noted that a nonunion,left untreated, proceeded to the same deformity, pre-sumably from separation of the fragments. Both Wileyand Brown137 and Sanders and Hansen111 thought thata triple arthrodesis was required to correct the pain,but the latter authors recognized that the deformityincluded medial shifting of the forefoot with a resid-ual varus hindfoot deformity. They suggested that cor-rection using a structural iliac crest bone block graftand a Dwyer calcaneal osteotomy, coupled with atriple or quadruple arthrodesis, was critical to correctthe deformity completely.

CUBOID AND CUNEIFORM BONES

Mechanism of InjuryIsolated fractures of the cuboid and cuneiform bonesare quite rare, probably because both the cuboid andthe cuneiform bones occupy a protected and but-tressed location in the metatarsus.16,83,140 These frac-tures are most often caused by a direct crushing forceor by a fall on the foot in plantar flexion, with accom-panying inversion or eversion.83,140 Chapman16 statedthat these fractures more often occur in conjunctionwith fractures of the cuneiforms or the bases of thelateral metatarsals. Garcia and Parks38 emphasize thatcuboid fractures are often associated with tar-sometatarsal or midtarsal dislocations or subluxationsand that the cuboid may also be involved in calcanealfractures (Fig. 41–13).

CUBOID FRACTURES

Two types of cuboid fractures are typically seen: avul-sion fractures and compression fractures. The mostcommon are avulsion fractures, which occur on thelateral aspect of the foot and are often confused with a routine ankle sprain.7,53 Occurring less often,but a more serious injury, compression fractures usuallyinvolve the entire body of the cuboid.


Hermel and Gershon-Cohen52 reported five cases ofthis crush injury, which they named the “nutcrackerfracture of the cuboid” because the cuboid, which liesprotected between the fourth and fifth metatarsals andthe anterior process of the calcaneus, was caught “likea nut in a cracker” between these articulations. In eachpatient the toes were fixed, and the weight of the bodywas transmitted by the calcaneus through the cuboidand the two lateral metatarsals. This resulted in animpacted and comminuted fracture often associatedwith subluxation of Chopart’s joint.

Weber and Locher135 reported on 12 patients withdisplaced compression fractures of the cuboid. Theforce required to cause this fracture is significant, andfive of the 12 patients in this study required initial fas-ciotomy. As well, 10 of 12 had associated fractures ofthe midfoot. Most had crush injuries of the navicularor metatarsals. In a few cases, the injury was the resultof a swivel mechanism with dislocation of the talo-navicular or tarsometatarsal (Lisfranc) with compres-sion on the lateral side.

Clinical EvaluationThe patient presents with a history of either a directblow to the lateral aspect of the foot or trauma to thefoot following jumping or twisting the foot beneaththe body.39,52,57,114 The patient has pain on the lateralborder of the foot, with point tenderness over thecuboid. Associated tenderness over the medial aspectof Chopart’s joint suggests associated subluxation, dislocation, or a fracture along the medial column.Passive abduction and adduction or inversion andeversion of the foot accentuates the pain in themidfoot. An insidious onset of persistent lateral footpain should also be investigated. Cuboid insufficiencyfractures are rare but have been reported.37

Radiographic EvaluationAnteroposterior, lateral, and oblique radiographs arenecessary in evaluating fractures of the cuboid.39,57 Theoblique view is essential to identify the fracture and todetermine the presence or absence of associated frac-tures of the calcaneus or metatarsals. As emphasizedby Hermel and Gershon-Cohen,52 in patients with thenutcracker fracture and an associated avulsion fractureof the navicular tubercle, midtarsal subluxation mustbe considered. Case reports have shown a high inci-dence of missed injuries on plain films and suggest theneed for routine CT scan with these injuries.73,135

TreatmentThe treatment of cuboid fractures is determined by theseverity of the injury. Because most of these fracturesare nondisplaced or minimally displaced, mostauthors8,47,69 recommend early treatment with a short-leg cast for 3 to 4 weeks, followed by an adequate shoe.Giannestras and Sammarco39 and Garcia and Parkes38

recommend a below-knee walking cast for 6 to 8weeks, with progressive ambulation.

The treatment of displaced fractures is more contro-versial. Hermel and Gershon-Cohen52 recommendearly midtarsal fusion for comminuted fractures asso-ciated with subluxation or dislocation of the cuboid.Hillegass,53 however, believes that the cuboid is animportant stabilizer of the lateral column of the footand that malunion will result in pain and deformity.He suggests internal fixation with iliac crest grafting toreconstruct the cuboid.

Sangeorzan and Swiontkowski114 presented fourcases, of which three had the articular surface driveninto the center of the bone. These cases required dis-traction, cancellous or corticocancellous grafting, and

Cuboid crushCuboid crush

Avulsion fractureAvulsion fracture

Cuboid crush

Avulsion fracture

A B C

Shearfracture

Midfootsubluxation

Figure 41–13 Fractures of the cuboid. A, Compression fracture resulting in crushing to cuboid. B, Shear fracture to cuboid. C, Fracture–dislocation of the calcaneocuboid joint (arrows). Note that all cuboid fractures are associated with other foot injuries.

2214 PART X Trauma

fixation with plates and screws or screws alone. Theresults were satisfactory, and the authors concludedthat distraction, grafting, and internal fixation repre-sented the best approach for these injuries.

Weber and Locher performed open reduction andinternal fixation in 12 patients. Four fixations wereaccomplished with screws alone, and eight requiredmini-fragmentary plates. Seven patients required bonegrafting. Joint reconstruction was possible in allpatients and had reasonably good outcomes. Mostpatients with symptoms complained of pain from themedial-side injury.135

Authors’ Preferred Method of TreatmentIn patients with chip fractures of the cuboid, clinicaland radiographic evaluation of the medial aspect ofthe midtarsal joint is essential. If there is no injury tothe ligaments on the medial aspect of the midtarsaljoint, treatment is based on the patient’s requirementsfor weight bearing. If the patient needs to be ambula-tory, we prefer weight bearing in an off-the-shelfwalker boot for 4 to 6 weeks.

In fractures involving the body of the cuboid, par-ticularly those of the nutcracker variety,52 the obliqueradiographs are carefully evaluated. In these injuries,residual displacement of the articular surface of thecuboid can result in persistent subluxation of the mid-tarsal joint, with lateral column collapse and possiblylong-term arthritic changes.

If a large portion of the calcaneocuboid orcuboid–metatarsal joint is displaced, an open reduc-tion is performed using a longitudinal incision paral-lel to the sole of the foot and located over the cuboid.The fracture should be identified and opened. Iflamina spreaders do not separate the two articular sur-faces easily, or if the surgeon is concerned that thecuboid will comminute, a small external fixator shouldbe used as a reduction aid, with one pin placed in thecalcaneus and one in the metatarsal.

Once the bone is distracted, the defect should begrafted with cancellous bone if the end plates arestrong or with tricortical bone if structural support isneeded. Screws can be used to secure the tricorticalbone, but if cancellous graft alone is used, an H plate(Synthes, Paoli, Penn) is applied laterally to hold thebone out to length.

When the joint surface is irreparably damaged, jointfusion is considered in addition to the graft and reduc-tion procedure.

Occasionally a longer plate can be used and anankylosis procedure performed rather than a fusion. Inthis situation the plate is extended to the calcaneus orthe metatarsal, or both, without formal fusion of these

joints. After fracture has healed, the plate is removed,usually at 6 months. This allows the joints to morenormally mold to each other while still allowing somemotion.

The decision to perform an ankylosis procedureversus an arthrodesis is left to the surgeon’s discretion.

CUNEIFORM FRACTURES

Mechanism of InjuryFractures of the cuneiform bones are quite rare.39,53

According to Heck,47 displacement of these fractures isunusual, and healing with few complications is likely.The mechanism of injury of cuneiform fractures isusually that of direct trauma.39 The patient usuallycomplains of pain in the area of the cuneiforms. Theexact location of tenderness helps to delineate the par-ticular cuneiform involved. As with fractures of thecuboid, inversion and eversion of the forefoot are distinctly painful.38

Radiographic EvaluationAnteroposterior, lateral, and oblique radiographs areuseful in evaluating cuneiform fractures. Chip fracturesare usually nondisplaced because the associated inter-tarsal ligaments are strong and prevent their displace-ment.83 Buchman11 reported osteochondritis dissecansand bipartite cuneiforms, which must be distinguishedradiographically from fractures. The bipartitecuneiform is most easily distinguished because of its smooth articular surfaces, whereas the irregular surfaces of a fracture should be diagnostic.6

TreatmentAvulsion fractures and nondisplaced fractures areusually treated symptomatically by immobilization ina short-leg weight-bearing cast until the pain subsides.Hillegass53 recommends that if fracture displacementis significant, accurate reduction and internal fixationwill be needed. Because of the limited motion in thenormal midtarsal joint, long-term complications occurinfrequently.

Authors’ Preferred Method of TreatmentIn our experience, isolated fractures of the cuneiformsare rarely displaced. If a displaced fracture is present,the surgeon must be suspicious of an associated“silent” midtarsal joint dislocation.


With a nondisplaced fracture, treatment is based onthe patient’s requirement for ambulation. If thepatient’s work requires prolonged weight bearing, weprefer treatment with an off-the-shelf walking boot for 4 to 6 weeks.

With displaced fractures, consideration is given toopen reduction, particularly if an associated sub-luxation or dislocation of the midtarsal joint can bestabilized by restoring cuneiform anatomy.

Postoperative care for these patients requires at least2 months of non–weight bearing in an off-the-shelfwalking boot until there is radiographic evidence ofhealing. This is followed by 1 month with full weightbearing in the boot and range of motion exercises outof the boot.

METATARSAL BONESMetatarsal fractures are relatively common and areoften the cause of prolonged disability because the fracture is either initially overlooked or unsuc-cessfully treated.69,72,89 Among motorcyclists with foot injuries, metatarsal fractures were the mostcommon.63 Three broad types of injuries can causethese fractures: direct crushing injuries to the foot,inversion–avulsion injuries, and overuse injuries. Eachfracture type has a different prognosis, and this sectiondiscusses the separate treatment options and theirramifications.

AnatomyLindholm79 emphasized that because of the rigid liga-mentous anchoring of the metatarsal bones to eachother, particularly at the points of insertion on thetarsal and phalangeal bones, displacement of simplefractures of the metatarsals is usually minimal. Also,metatarsal shaft fractures are not likely to become dis-placed unless extensive damage occurs to the interos-sei, lumbricals, and distal ligamentous attachments tothe adjacent metatarsals. Distal fractures near the neckof the metatarsal are the exception, however, becausein these fractures the metatarsal heads are usually dis-located, and contact between the fracture surfaces istotally lost. In this situation the head–neck fragmentof the metatarsal is displaced beneath the distal me-taphysis at the level of the anterior foot arch becausethe flexor tendons passing near the metatarsopha-langeal (MTP) joints and terminating in the phalangesexert a strong proximal and plantar dislocating forceon the distal fragment.

Shereff121 reviewed the pathologic consequences ofaltered forefoot mechanics. In the stance phase of gait,each of the lesser metatarsals supports an equal load,while the first metatarsal carries twice the load of each

of the lateral four metatarsals. Displacement of ametatarsal fracture can therefore lead to a non-plantigrade foot. Displacement of a distal fragment ina plantigrade direction results in increased loading ofthe metatarsal and can result in an intractable plantarkeratosis at that site. Dorsal displacement of the distalfragment decreases the load applied to that metatarsaland transfers greater pressure to the adjacentmetatarsal heads. Persistent mediolateral displacementof the fracture fragment to an adjacent metatarsal canlead to mechanical impingement and formation ofinterdigital neuroma. Finally, medial displacement of the distal fragment of a first metatarsal fracture and lateral displacement of the distal fragment of afifth metatarsal fracture can lead to a bony prominencethat can produce difficulties with footwear in the toebox.

Mechanism of InjuryMetatarsal fractures result from direct or indirectforces. Combined fractures of the second, third, andfourth metatarsals usually result from a direct force,such as a crushing blow to the dorsum of the foot.47

An indirect force, such as a twisting injury in which theforepart of the foot is fixed as the patient turns, pro-duces a mediolateral torque that often fractures ametatarsal, particularly the fifth.110 Repetitive stress, notonly in soldiers but also in athletes and ballet dancers,has been shown to result in stress fractures, mostnotably in the second metatarsal.

METATARSAL BASE FRACTURES(EXCLUDING FIFTH METATARSAL)

Metatarsal base fractures can occur alone or in combi-nation with disruption of Lisfranc’s joint as a frac-ture–dislocation. Therefore, most fractures of theproximal shaft and base must be evaluated for liga-mentous disruption, often with manipulation underanesthesia and radiographic control.

Pure fractures of the second, third, and fourthmetatarsal bases rarely need treatment other than a wooden-soled shoe or, if painful, a cast, until thefracture heals, usually within 3 months of injury (Fig. 41–14). Weight bearing is advanced as tolerated.

Fracture of the first metatarsal base is more difficultto treat. If the fracture is comminuted or intraarticular,consideration must be given to open reduction and fixation, generally with small-fragment or mini-fragment plates and screws. Weight bearing is delayeduntil the fracture has healed, usually at 3 months, but motion is begun immediately.

2216 PART X Trauma

Authors’ Preferred Method of TreatmentMost metatarsal base fractures can be treated con-servatively, assuming they are not associated with a Lisfranc fracture–dislocation. When we believe a dislocation may be present but are unsure on radio-graphic views, we perform fluoroscopic evaluationunder anesthesia.

When ligamentous instability is not present, basefractures of metatarsals two, three, and four are treatedin a wooden-soled shoe. Because these fractures areusually associated with massive swelling, a well-padded splint may be needed for 7 to 10 days untilswelling subsides.

All displaced fractures of the first metatarsal base,especially those with intraarticular comminution, areinternally fixed with small-fragment or mini-fragmentplates and screws or with bioabsorbable pins. Post-operative management is the same as for metatarsalshaft fractures (see the following discussion).

METATARSAL SHAFT FRACTURES

Clinical EvaluationIn many cases, a high degree of clinical suspicion is needed to diagnose a metatarsal shaft fracture.

Anderson2 emphasizes that these fractures are oftenoverlooked because they occur in motor vehicle accidents in which severe trauma to major bones orvisceral organs is more apparent.

Patients usually complain of pain over the midfootwith an inability to bear weight. With avulsions andcrushing or twisting injuries, the foot is swollen, particularly on the dorsal aspect. Ecchymosis over thefracture area is present, usually after the first 12 hours.If the injury is seen early, point tenderness may bepresent over the fracture site; however, because of theproximity of adjacent metatarsals, exact localization ofan individual bone may be difficult.72

With gross displacement, particularly of the first orfifth metatarsal, palpation of the fracture site may bepossible. In fractures of the first and fifth metatarsals,Garcia and Parkes38 suggest that grasping the distalfragment with the thumb and forefinger and flexingand extending the fragment will produce motion,potentially crepitus, and pain at the fracture site. In the case of the second, third, and fourth metatarsals,relatively little false motion can be demonstrated.Assessment of the neurovascular status of the foot ismandatory.

Radiographic EvaluationMetatarsal shaft fractures are visualized on routine AP,oblique, and lateral radiographs of the foot (Fig.41–15). The AP and oblique radiographs are moreuseful because the shafts of the metatarsals are super-imposed on the lateral view.38 Adequate radiographicexposure of the metatarsals, however, is an essentialprerequisite.

Anderson2 emphasized that radiographs of the fore-foot are often of poor quality and do not demonstratethe osseous structure of the forefoot adequately. Expo-sure for these films is usually set to provide penetra-tion of the large tarsal bones, and this results inoverexposure of the smaller metatarsal and phalangealbones.

TreatmentOpen FracturesIn injuries resulting from direct or crushing blows, thefractures may be open.48 In such instances, initial irri-gation and debridement with appropriate antibioticcoverage are indicated, just as for other open long-bone fractures.112 All wounds are left open for delayedprimary closure or skin grafting. Axial Kirschner wirefixation is performed more routinely in open fracturesof the metatarsal shafts to provide soft tissue stabilityfor healing. External fixation, however, may berequired for severe degloving and crush injuries. In

Metatarsalbase fractures

Figure 41–14 Fractures of bases of second, third, and fourthmetatarsals.


cases with proximal injury, a small external fixator orIlizarov frame may be applied.

Shereff121 also emphasizes the importance of ade-quate fixation to hasten bony union and allow ade-quate treatment of the soft tissue injuries in openfractures. Often, however, when the injury is moredistal, a plaster splint may be the best and only formof stabilization. Once the soft tissue management iscontrolled, treatment of the bone injury is identical tothat for closed fractures.

Closed FracturesNondisplaced and minimally displaced metatarsalshaft and neck fractures may be treated with a below-knee walking cast worn for 2 to 4 weeks.39 Johnson,64

however, in evaluating forefoot injuries in work-related accidents, found that patients treated with anoversized, well-padded work shoe and allowed toambulate healed more quickly and had a significantlyfaster return to work compared with patients treatedwith plaster immobilization and progressive ambulation.

AUTHORS’ PREFERRED METHOD OF TREATMENT

Nondisplaced fractures are best treated with earlyweight bearing to tolerance in a wooden-soled shoe. Ifthe fracture is extremely painful or if the patient ismorbidly obese, the foot is usually placed in an off-the-shelf walker boot, and weight bearing is delayedfor 1 to 2 weeks. In either case the protection is kepton until the metatarsal is clinically healed. This meansno pain with ambulation and usually precedes

complete radiographic healing, but it usually occurswithin 2 to 3 months.

Displaced FracturesDisplaced fractures may require more aggressive treat-ment.16,49,50,104 The first metatarsal is infrequently frac-tured because of its size and cortical strength. Becauseof its important weight-bearing and biomechanicalfunction in gait, very little misalignment can beaccepted.

For displaced fractures of the first metatarsal shaft,closed reduction may be attempted. If the reduction isacceptable, the limb is placed in a short-legnon–weight-bearing cast for 6 weeks or until fractureunion is evident on radiographs. Weight bearing is notpermitted until healing is complete.

Chapman16 prefers percutaneous Kirschner wire fixation after closed manipulation to maintain thereduction. If closed reduction is unsuccessful, openreduction using plates and screws is recom-mended.49,50,91 Once the fracture is stabilized in thismanner, mobilization of adjacent joints may beginimmediately.

In the past, most authors have suggested that dis-placed metatarsal fractures can be manipulated underanesthesia with Chinese finger traps and the positionthen held by cast immobilization.38,39,47,64 Unfortu-nately, not all fractures can be held reduced once trac-tion has been released. In 1959, DePalma28 noted thatif reduction by manipulation and traction was unsuc-cessful, open reduction and internal fixation usingcrossed Kirschner wires was indicated. More

A B CFigure 41–15 Fractures of metatarsal shafts. A, Nondisplaced fractures. B, Displaced fractures. C, Open crush injury with asso-ciated first metatarsal fracture and dislocation (arrow).

2218 PART X Trauma

specifically, malreduction of the shaft of the second,third, and fourth metatarsals in the frontal plane(medial to lateral) does not usually result in compli-cations. Fractures will heal despite significant separa-tion of the fragments, and these should be treated asnondisplaced fractures.

Displacement of any metatarsal fracture in the sagit-tal plane (dorsal to plantar), however, should be acause for concern. Healing of the fracture with signif-icant plantar displacement of the distal shaft increasesthe prominence of that metatarsal head and can resultin pain with weight bearing.38,123 Sisk123 noted that themore distal the fracture of a metatarsal, the more sig-nificant the dorsal angulation of the fracture, which inturn increased the plantar prominence of themetatarsal head. Thus it is more likely that distal fractures will need open reduction.

Similarly, any significant dorsal prominence canresult in a painful corn. These deformities can be pre-vented if an anatomic reduction of the fracture isobtained.

Because closed methods generally fail, especially in the sagittal plane, open reduction and pinning has been advocated in the more modern litera-ture.16,39,49,50,121 Open reduction of fractures ofmetatarsals two, three, and four is carried out throughone or more longitudinal dorsal incisions.2,50,79

Usually, two adjacent metatarsal necks or shafts can beexposed adequately through one incision placedmidway between and parallel to the metatarsal shafts.Pinning is best performed according to the methodadvocated by Heim and Pfeiffer.50 This is done first inan antegrade manner through the shaft of the distalfragment and out the metatarsal head and plantarsurface, followed by reduction and retrograde insertionof the pin into the proximal shaft (Fig. 41–16).Severely comminuted fractures require either platingor cross-pinning to adjacent and more stablemetatarsals.

Sagittal angulation is a concern, but shortening isnot. Johnson64 believes that as long as alignment ismaintained by open or closed methods, axial shorten-ing can be accepted rather than subjecting the foot toany form of fixed traction. He believes that such fixed-traction devices lead to stiffness of the forefoot, whichresults in more disability than the metatarsal fractureitself. If unacceptable residual shortening becomesproblematic, lengthening using either distraction andsubsequent grafting or distraction osteogenesis usingthe Ilizarov technique can be performed with accept-able results.96,116

The fifth metatarsal shaft tends to be less im-portant than the first and more important than thesecond, third, and fourth metatarsals, in terms ofweight bearing and residual bone prominences.

Nondisplaced fractures do not require surgery and canbe treated with a wooden-soled walking shoe. Whendisplaced, a more exact reduction is needed. In thiscase, Heim and Pfeiffer50 suggest plating rather thanpinning because of the easy access to the bone and theability to maintain an anatomic reduction.

AUTHORS’ PREFERRED METHOD OF TREATMENT

For displaced fractures of the first metatarsal, we havelittle tolerance for malalignment. Redisplacement of aclosed reduction in a cast, with a subsequently painfulmalunion and transfer lesions, is a very real concern.Therefore we favor open reduction and internal fixa-tion of these fractures, usually with small-fragment ormini-fragment plates.

Fractures of metatarsal shafts two, three, and fourgenerally can be treated in a wooden shoe or a walkingboot, but when sagittal plane deformity is present, wedo not hesitate to perform open reduction andpinning of these fractures using the antegrade–retrograde method. It is much easier to correct deformity acutely than to deal with short malunionsand contracted soft tissue later.

A

B

C

DFigure 41–16 A to D, Sequential pinning technique formetatarsal shaft fractures. (From Heim U, Pfeiffer KM: InternalFixation of Small Fractures: Techniques Recommended by theAO Group. Berlin, Springer-Verlag, 1987, p 349.)


Fractures of the shafts of the fifth metatarsal gener-ally can be treated closed, with ambulation asdescribed earlier. Occasionally, when an unstable fracture results in excessive angulation in either thesagittal or frontal (in this case, lateral) plane, platingis preferred to pinning to secure the reduction.

After open reduction and internal fixation andpinning, the patient is placed in a molded cast becauseof the plantar pins. Weight bearing is not permitted,except on the heel, for 4 to 6 weeks, at which time thepins are pulled and the patient is transferred to awooden-soled shoe. If internal fixation is performedwith plates, the reliable patient is placed in a wooden-soled shoe, whereas the unreliable or morbidly obesepatient is placed in an off-the-shelf walker boot. Bothare kept non–weight bearing until the fracture heals,generally at 8 to 10 weeks.

The advantage of internal fixation is early motion.All joints should be mobilized on a regular basis whilethe fractures heal.

METATARSAL NECK FRACTURES

Fractures of the necks of the metatarsals are usuallymultiple and are often displaced (Fig. 41–17).2 As

previously noted, persistent displacement of themetatarsal head and neck into the plantar aspect of thefoot can result in plantar callosities or corns.2,39,88

These fractures can occasionally be reduced underanesthesia by using the Chinese finger traps or bydigital pressure under the metatarsal head with trac-tion of the toe. Lindholm79 warns, however, that main-tenance of a reduction of a completely dislocatedmetatarsal neck fracture without internal fixation isuncertain.

If complete displacement, with a lack of appositionof the fracture surfaces and plantar displacement of thehead and neck fragment, persists after attemptedclosed reduction, open reduction is indicated.64,79 Asdescribed earlier, Sisk123 recommends longitudinalincisions coupled with open reduction and ante-grade–retrograde pinning.

An alternative technique described by Donahue andManoli involves transverse pinning of displacedmetatarsal neck fractures. This closed techniqueinvolves running a Kirschner wire from an intact fifthmetatarsal neck, transversely across the fractured anddisplaced necks of the second, third, and fourthmetatarsals. This might offer an easier technique ofobtaining pin fixation with a closed technique.32

Authors’ Preferred Method of TreatmentWe have found that most metatarsal neck fractures canbe treated conservatively with a wooden-soled shoeand progressive weight bearing as tolerated over time.When the head is displaced plantarly, closed reductionmay be attempted. If the bone fails to remain in areduced position after manipulation under anesthesia,however, open reduction and antegrade–retrogradepinning is needed to prevent subsequent complica-tions. Postoperative treatment is identical to that justdescribed.

METATARSAL HEAD FRACTURES

Usually the result of a shearing force or direct trauma,fractures through the metatarsal heads themselves areseen clinically more often than is reported in the lit-erature (Fig. 41–18). This fracture results in a distalfragment of the metatarsal head that is entirely intraar-ticular and devoid of any capsular attachments.Heckman48,49 noted that these fractures were associatedwith proximal fractures of the medially adjacentmetatarsals. All were minimally displaced, usuallyangulated plantarly and laterally. Stable reduction wasachieved by gentle manual manipulation and tractionand was maintained with percutaneous pinning.

Figure 41–17 Fracture of metatarsal necks associated withfirst metatarsal shaft fracture.

2220 PART X Trauma

Dukowsky and Freeman33 reported a fracture–dislocation of the articular surface of the thirdmetatarsal head. The mechanism of injury was a shearforce on the metatarsal head at the time of dislocationof the third MTP joint. According to the authors, closedreduction of metatarsal head fractures (and even noreduction) produces an acceptable result. They noted,however, that if closed reduction is unsuccessful inobtaining reduction of the metatarsal head fragment,open reduction with internal fixation is needed.

Authors’ Preferred Method of TreatmentMetatarsal head fractures are not common and rarelyrequire treatment other than symptomatic measures.Closed reduction with traction may be performed ifthe fragment is displaced, but when closed reductionis unsuccessful, open reduction is required. This frag-ment may be pinned in place with Kirschner wires. I prefer to use Biofix pins to secure the fragment,however, because this fixation allows immediatemotion of the MTP joint postoperatively, as well asweight bearing to tolerance in a wooden-soled shoe.

FRACTURES OF THE FIFTHMETATARSAL BASE

Fractures of the proximal part of the fifth metatarsalcan be separated into three types: the Jones fracture,the diaphyseal stress fracture, and the tuberosity avulsion fracture. Although these fractures are oftendescribed by the eponym “Jones fracture” (after SirRobert Jones,65 who described the injury in his ownfoot), a true Jones fracture is a transverse fracture ofthe fifth metatarsal shaft, about 18 mm (3/4 in) fromthe base.

AnatomyThe fifth metatarsal consists of a base, tuberosity, shaft,neck, and head. The base presents a flair, the tuberos-ity, that protrudes down and laterally beyond the sur-faces of the shaft of the metatarsal and the adjacentcuboid.25 The tuberosity is also termed the styloidprocess. The lateral Lisfranc joint complex is composedof the base of the fifth metatarsal, the cuboid, and thefourth metatarsal, which are bound together by strongligaments (Fig. 41–19). These three bones form three articulations: the cuboid–fourth metatarsal, thecuboid–fifth metatarsal, and the fourth and fifth inter-metatarsal articulations.115 The first two, collectively,are termed the cubo-4,5-metatarsal articulation.75

Stability of the lateral Lisfranc complex is providedby capsular ligaments (dorsal and plantarcubometatarsal ligaments), the lateral band of theplantar aponeurosis, and the peroneus brevistendon.115,122,126 The facets on the cuboid for the fourthand fifth metatarsals can appear as a continuous curveor can be separated by a distinct angle.126

The origin of the abductor digiti minimi muscle ison the lateral and medial processes of the os calcis, thecalcaneal fascia, and the adjacent intermuscularseptum.115 This muscle passes under and around thebase of the fifth metatarsal, with a variable attachmentto the bone. The muscle then continues distally toinsert into the lateral side of the base of the proximalphalanx of the fifth toe.3 The origin of the flexor digitiminimi brevis muscle is on the base of the fifthmetatarsal, and the dorsal interossei and plantarinterossei originate on the shaft of this bone.

Extrinsic circulation is provided by the dorsalmetatarsal artery, the plantar metatarsal arteries, andthe fibular plantar marginal artery. These three sourcearteries supply branches to the metatarsal and adjacentjoints.122 The intraosseous blood supply to the fifthmetatarsal tuberosity arises from numerous metaphy-seal vessels penetrating the nonarticular surfaces of thetuberosity in a random, radiate pattern.125 The blood

VV

IVIV

IIIIII

V

IV

III

Figure 41–18 Isolated fourth metatarsal head fracture.


supply to the proximal diaphysis is derived primarilyfrom the nutrient artery, which gives rise to longitudi-nal intramedullary branches. The arterial supply to thetuberosity joins the supply of the proximal diaphysisin the area just distal to the tuberosity.

ClassificationDameron25 and more recently Quill103 have proposeda classification of fifth metatarsal fractures that is prac-tical and aids in the management of these fractures(Fig. 41–20). This fracture scheme should also providebetter communication among treating surgeons and inpublished descriptions of this injury. Imprecise use ofthe term “Jones fracture” and failure to distinguish thetrue acute Jones fracture from stress fracture of the proximal diaphysis and from tuberosity avulsionfractures has created confusion in the orthopaedic literature.

Tuberosity Avulsion FracturesHISTORY AND MECHANISM OF INJURY

The fifth metatarsal avulsion fracture, also known as atennis fracture, is usually extraarticular but can extend

into the cubometatarsal joint.97,103 The mechanism ofinjury for these fractures was thought to be an avul-sion of the tuberosity by a violent contracture of theperoneus brevis muscle during a sudden inversion ofthe hindfoot.2,25,86,98 A more recent cadaveric study,however, implicated the lateral band of the plantaraponeurosis as a more likely structure causing tuberos-ity avulsion fractures because of its insertion onto thetip of the tuberosity.107 Thus the mechanism of injuryremains controversial to this day.103,128

A nondisplaced tuberosity fracture in a child may beconfused with the apophysis (Fig. 41–21). The apoph-ysis is distinguished by a smooth, radiolucent linerunning parallel to the shaft. The apophysis is first seenin girls between ages 9 and 11 years and in boysbetween ages 11 and 14 years.75 Obliteration of theradiolucent line occurs 2 to 3 years after its appearance(see Chapter 10).

Similarly, the os peroneum and the os vesalianummay be confused with a displaced avulsion fracturefragment. The more common os peroneum is locatednext to the lateral border of the cuboid and foundwithin the peroneus longus tendon, whereas the rareos vesalianum is adjacent to the peroneus brevis inser-tion.75 The smooth edges of the ossicle usually can bedistinguished from the ragged edges of a displacedavulsion fragment.

TREATMENT AND RESULTS

Treatment of nondisplaced avulsion fractures consistsof symptomatic care in a hard-soled shoe, walking cast,or compression wrap with protected weight bearing.Most fractures heal by bony union within 8 weeks. Asmall displaced fragment might require excision.When the intraarticular fragment is greater than 30%of the articular surface, however, or when there is anarticular step-off greater than 2 mm, open reductionand internal fixation or closed reduction and pinningshould be considered to minimize risks of degenera-tive arthritis at the cuboid–fifth metatarsal articula-tion.45,105 Frequently reported methods of internalfixation include Kirschner wires, tension band wiring,or small-fragment screws (Fig. 41–22).50 Treatment ofthese fractures must be individualized based on theneeds and desires of the patient. An established symptomatic nonunion is an indication for electricalstimulation55 or surgical intervention.3,75,103,129

Jones FractureHISTORY AND MECHANISM OF INJURY

In 1902, Sir Robert Jones65 reported a series of fourcases of fifth metatarsal fractures, including his ownfoot injury. Subsequently, fractures of the proximalfifth metatarsal have been indiscriminately called“Jones fractures.” Stewart126 defined a Jones fracture as

Figure 41–19 Lateral Lisfranc’s joint complex.

2222 PART X Trauma

to 8 weeks, unless the patient is a high-performanceathlete or an informed patient who refuses conserva-tive treatment.75,103 In these instances, surgical man-agement may be undertaken.77,129

When treating these fractures with nonsurgicalmethods, radiographic healing occurs in a medial-to-lateral direction and lags behind clinical healing byweeks to months.92 Lack of clinical healing after 8 to10 weeks of non–weight-bearing immobilization isnot unusual. Continued protection, cast immobiliza-tion, or surgical intervention may be undertaken atthat time.75

The indiscriminate use of the term “Jones fracture”has left interpretation of the literature confusing.Rosenberg and Sferra summarized the findings ofseveral papers and found that most fractures heal withnonoperative treatment, but non–weight bearing com-pliance is necessary.109 According to Quill,103 carefulreading of the published literature on this fracturereveals that one third of these injuries went on to

1

2 3 Shaft

A

AvulsionAvulsionAvulsion

Os peroneum

B C DFigure 41–20 A, Fracture zones of the base of the fifth metatarsal:1, tuberosity avulsion fracture; 2 zone of metaphyseal–diaphyseal junction; 3, shaft stress fracture zone. B to D, Arrows indicate various types of fifth metatarsal base fractures. B, Displaced tuberosity avulsion fracture: zone 1. C, Displaced metaphyseal–diaphyseal junction fracture: zone 2. D, Diaphysealshaft stress fracture: zone 3. (A after Dameron TB: J Am Acad Orthop Surg 3:110-114, 1995.)

a transverse fracture at the junction of the diaphysisand the metaphysis, typically 1.5 cm (3/4 inch) fromthe base. Although medial comminution can occur,there is no extension distal to the intermetatarsal (4,5-intermetatarsal) joint.126

The mechanism of injury is thought to be a largeadduction force applied to the forefoot while the ankleis plantar flexed, such as when the patient missteps onthe lateral border of the foot.65,67,126 The fourth andfifth metatarsals move freely in the sagittal (dorsiflex-ion–plantar flexion) plane, but motion in the trans-verse (adduction–abduction) plane is limited. Forcedadduction of the forefoot therefore results in a fractureat the junction of the shaft and the base. Anatomically,this location corresponds to the area between theinsertion of the peroneus brevis and tertius tendons.25


Treatment of an acute nondisplaced Jones fractureconsists of non–weight bearing immobilization for 6


closed refracture if followed up long enough. There-fore he believes that an argument for early surgicalmanagement with either medullary screw fixation orbone grafting could be made, because 50% of fracturestreated closed either do not heal primarily or refrac-ture once initial healing has been documented.

Finally, Jones fractures are typically nondisplaced.When the fracture is displaced, however, open reduc-tion with internal fixation is necessary and can be performed. Fractures that fail nonoperative treatmentand remain symptomatic may also be considered forsurgery. Surgical techniques employed include tension

band wiring, cannulated screw fixation, or a low-profile plate and screws.50

Surgical fixation of these fractures does not guaran-tee fracture union. Larson et al74 showed six treatmentfailures in 15 patients: four refractures and two symp-tomatic nonunions. Eighty-three percent of thepatients in the failure group were high-level athletes.Wright et al also reviewed the failure of six high-levelathletes and recommended that large screws be used,functional bracing be considered to protect fixation,and alternative imaging techniques be used to detectradiologic union.141

Biomechanical constructs continue to be studied.Horst et al showed that 6.5-mm screws were torsion-ally stronger than 5.0-mm screws in fixing Jones frac-tures.56 In another study, a lag screw that engaged themedial cortex was stronger than an intramedullaryscrew.90 Use of intraosseous wiring40 and hook plates arealso described.15 We continue to use a large-diameterintramedullary screw and have high union rates.

Diaphyseal Stress FracturesHISTORY AND MECHANISM OF INJURY

The diaphyseal stress fracture is a pathologic fractureof the proximal 1.5 to 3.0 cm of the fifth metatarsalshaft that occurs secondary to a repetitive distractionforce.77,129

Radiographically, cortical hypertrophy, a narrowingof the medullary canal, and a periosteal reaction are seen. Because the fifth metatarsal is a bordermetatarsal, angular deformities such as genu varum orankle varus, as well as hindfoot varus or forefootsupination, can compound the stresses on the lateralforefoot.51 The proximity of a proximal diaphysealstress fracture to the nutrient foramen and adja-cent extraosseous plexus can result in fracture site

Nondisplacedavulsionfracture(adult)Growth plate

Apophysis

A BFigure 41–21 A, Apophysis in an 11-year-old boy. B, Nondisplaced avulsion fracture of tuberosity in an adult.

Figure 41–22 Various fixation methods for treatment of proximal fifth metatarsal fractures. A, Isolated lag screw. B, Tensionband wiring. C, Cannulated screw and tension band. (A and B from Heim U, Pfeiffer KM: Internal Fixation of Small Fractures:Techniques Recommended by the AO Group. Berlin, Springer-Verlag, 1987, p 347.)

2224 PART X Trauma

avascularity. Therefore, prolonged duration of immo-bilization is often required for healing. Alternately,repetitive stresses can compromise the vascular supplyto the metatarsal, delaying union.122,125

Both Stewart126 and Dameron25 noted the frequentoccurrence of delayed union or nonunion associatedwith the conservative management of proximal fifthmetatarsal fractures. Subsequent reports further documented the recalcitrant nature of these fractures.27,67,77,129,143 Conflicting results after similartreatment in these reports was caused by the groupingof Jones fractures and proximal diaphyseal stress frac-tures into a single category, despite their diversehealing potentials.75

In separating fifth metatarsal diaphyseal stress frac-tures by their healing potential, Torg et al130 dividedthem into three categories: acute (type I), delayed(type II), and nonunion (type III). Type I fractures rep-resent “early” stress fractures, with periosteal reactiondemonstrating previous attempts to heal an incom-plete fracture. Type II fractures show a widened fractureline and intramedullary sclerosis. Type III fracturesdemonstrate complete intramedullary canal oblitera-tion, indicating an established nonunion.


The currently accepted treatment of choice for acute, nondisplaced diaphyseal stress fractures isnon–weight-bearing immobilization. Torg et al130 doc-umented healing in 93% of fifth metatarsal stress frac-tures treated with 7 weeks of non–weight-bearingimmobilization, compared with substantially lowerrates of healing when weight-bearing immobilizationwas employed. Subsequently, others have confirmed asimilar success rate with restricted-weight-bearingimmobilization.1,144

The typical patient with this fracture is a youngathlete in the middle of preseason training. The initialtreatment of these fractures is non–weight-bearingimmobilization. Duration of treatment until completehealing occurs may be as long as 20 weeks, andnonunion is possible despite prolonged immobiliza-tion. Careful consideration of the athlete’s individualneeds can therefore indicate electrical stimulation or internal fixation. A conservative treatment plan ofprolonged non–weight-bearing immobilization maybe tried in the sedentary patient for type II diaphysealstress fractures. The competitive athlete, however,requires bone-grafting procedures and an intra-medullary screw.

Symptomatic nonunions (type III) usually requiresurgical intervention.27,67,75,103,130 Recently, Holmes55

has shown good results using pulsed electromagneticfields (PEMFs) in the treatment of nonunions. Ninedelayed unions and nonunions of the proximal fifth

metatarsal treated with PEMF healed in a mean timeof 4 months. Fractures treated with both PEMFs and anon–weight-bearing cast healed in a mean time of 3 months. No refractures occurred. The author concluded that when compared with reported healingtimes and morbidity for conventional casting,medullary curettage with inlay bone, or closed axialintramedullary screw fixation, PEMFs were an effectivealternative.

Authors’ Preferred Method of TreatmentTreatment must be tailored to the patient’s individualneeds. In the sedentary patient and the recreationalathlete with a type I or a type II fracture, conservativenon–weight-bearing immobilization for 7 to 10 weeksshould be the initial treatment. This can be accom-plished using crutches or a walker and a below-kneecast, an off-the-shelf fracture boot, or a wooden-soledshoe, based on the patient’s compliance.

In the recalcitrant fracture, in the competitiveathlete, or in type III fractures, surgical intervention ispreferred. Treatment must be tailored to the radio-graphic findings. In hypertrophic nonunions or frac-tures exhibiting widening of the fracture gap that canbe closed with compression, a 6.5- to 8.0-mm cancel-lous cannulated titanium screw (depending on bonedimensions) with a countersunk head is ideal.

When an atrophic fracture gap is evident, beyondthat which can be compressed with a lag screw, andthe lesion exhibits no or minimal fracture callus,adjunctive inlay bone grafting must be considered. Theadjunctive inlay bone graft uses a tricortical iliac crestgraft tailored to match the defect, coupled with a can-cellous cannulated titanium lag screw.

When significant intermedullary sclerosis is present,the canal must be reamed using variously sized drillsto stimulate vascularization. This is followed withscrew fixation as just described.

Postoperatively the patient should remainnon–weight bearing for 6 weeks to ensure healing.This is followed by progressive weight bearing over thenext 4 weeks, and then a gradual return to full activi-ties. A symptomatic screw may be removed after radio-graphic evidence of complete healing, but generallynot before 6 months postoperatively.

Although PEMFs may be an alternative treatmentmethod, I have no experience with this technique.

STRESS FRACTURES OFMETATARSAL DIAPHYSISStress fractures are defined as spontaneous fractures ofnormal bone that result from a summation of stresses,


any one of which by itself is harmless.78 These fracturesoccur in the normal bones of healthy people involvedin everyday activities. These patients do not report ahistory of a specific injury.29

Although stress fractures have been reported atmany different sites, the metatarsals are among thebest known and have been termed march fracturesbecause of their frequent occurrence in military per-sonnel.5 Stress fractures are often noted in new mili-tary recruits who undergo intensive training to whichthe bones of the foot are not adapted.29,87 Most authorsnote that the second metatarsal is most often involved,followed closely by the third metatarsal.5,78

Congenital shortening of the first metatarsal hasbeen suggested as a predisposing condition in thedevelopment of these stress fractures.138 Acker andDrez,1 however, were unable to show that the lengthof the first metatarsal in patients with stress fracturesdiffered significantly from that in a randomly selectedcontrol group.

With the current enthusiasm for sports, particularlyjogging, metatarsal stress fractures are seen with increas-ing frequency in normal, healthy young patients.18-20

Interestingly, as runners are near the end of a longsession, the foot muscles fatigue and the forefoot expe-riences significantly increased plantar pressures.136

Clinical And Radiographic EvaluationThe most common presenting complaint is pain on along march or with increased running on hard pave-ment. The pain is usually described as an aching orsoreness in the foot.78,139 As the pain increases in inten-sity, a limp usually develops.5,29,78 Although noswelling may occur initially, after 2 weeks the painbecomes more disabling, and definite clinical findingsbegin to appear, including tenderness, swelling, andecchymosis over the shaft of the involved metatarsal.139

Direct point tenderness over the location on themetatarsal shaft where the fracture has occurred isdiagnostic.5

Stress fractures must be diagnosed clinically becauseradiographic findings lag behind the clinical examina-tion.29 Radiographs taken within 2 weeks of the onsetof symptoms usually do not demonstrate a metatarsalstress fracture. Thereafter, however, a fine line is notedin the metatarsal shaft secondary to bone resorptionalong the fracture surface.38,39 AP and oblique radio-graphs are the most useful in detecting metatarsalstress fractures. During the period when pain is presentand radiographic findings are negative, a technetiumbone scan should be used to diagnose the stress fracture.

First metatarsal stress fractures are classically foundin the proximal portion of the bone.29,84 Fractures of

the second and third metatarsals usually occur in themiddle of the shaft or in the neck of the bone.Meurman84 reported that stress fractures of the fourthmetatarsal occur in the distal part of the diaphysis. Dis-placement of metatarsal stress fractures is distinctlyunusual, and Meurman noted only a single completelydisplaced stress fracture in his series.

TreatmentThe type of treatment selected depends on the patient’spain and disability. Most authors suggest a walkingcast in only the most painful situations.5,38,39 For allother patients, a wooden-soled or other type of stiff-soled shoe, coupled with cessation of excess activity(e.g., jogging) until the fracture has healed, is warranted.

Authors’ Preferred Method of TreatmentAlmost all stress fractures can be diagnosed clinically,and rarely if ever is a bone scan needed. In the high-performance athlete, a bone scan may be necessary fordocumentation. Treatment for all patients includesdecreased activity and walking in a wooden-soled shoeuntil the pain subsides, usually within 4 to 6 weeks.Training may then be progressively advanced, or in thenonathlete, the patient may return to activities of dailyliving.

We have never surgically treated this fracture andonly occasionally had to resort to casting withnon–weight bearing to treat a delayed union.

PHALANGEAL BONESFractures of the phalanges represent the most commonfractures of the forefoot.16,38,92,127 The hallucal pha-langes are larger and functionally much more impor-tant than the phalanges of the lesser toes.16 Of thehallucal phalanges, the proximal one is fractured mostoften (Fig. 41–23). When the distal phalanx is frac-tured, it is often comminuted or dislocated (Fig.41–24).16 Also, an avulsion fracture involving thedorsal aspect of the distal phalanx of the hallux,similar to that seen in the hand, can occur.

Fractures of the lesser toes usually occur through theproximal phalanx, the longest of the phalanges. Themiddle and distal phalanges are less often fractured(Fig. 41–25).16

Fractures of the proximal phalanges of the lesser toesare prone to plantar angulation secondary to the com-bined action of the toe extensor, flexor, interosseous,and lumbrical muscles.92 Angulation of middle and

2226 PART X Trauma

A B C D EFigure 41–23 Various fractures of the proximal phalanx of the hallux. A, Nondisplaced shaft with articular involvement. B, T-type fracture of head. C, Displaced neck fracture. D, Displaced shaft fracture. E, Highly comminuted fracture affecting theentire phalanx.

A B CFigure 41–24 Various fractures of the distal phalanx of the hallux. A, Avulsion of the tuft. B, Transverse fracture of the shaft.C, Highly comminuted fracture of the phalanx with intraarticular involvement.


distal phalangeal fractures depends more on the direc-tion of the trauma that produced the fracture.

Mechanism of InjuryFractures of the toes are usually caused by directtrauma to the involved toe.88 The patient might relatea history of dropping a heavy object on the toe thatresulted in a crushing injury to the soft tissue and afracture of a phalanx, most often the middle or distalphalanx.38,39,88 Jahss62 emphasized unique “stubbing”injuries to the hallux that result in fracture–disloca-tions that are often missed. A fracture of the proximalphalanx of the lateral four digits is most often pro-duced by an abduction injury, such as occurs when thetoe strikes a table leg and results in the classic “nightwalker fracture.”39,92

Yokoe and Mannoji142 reported three cases of stressfracture of the proximal phalanx of the great toe. In allthree patients the fracture occurred on the medialaspect of the base of the proximal phalanx, and allpatients had significant hallux valgus. The authorsbelieve that hallux valgus leads to the extensor hallu-cis longus and adductor tendons having a bowstring-ing effect on the hallux. This bowstringing effect on thegreat toe and the medial collateral ligament resultedin strain that produced an avulsion-type stress fractureof the proximal phalanx.

Clinical EvaluationJahss62 emphasized that the relatively mild discomfortassociated with certain fractures of the hallucal pha-langes can allow them to be interpreted as simple

A B

C

DFigure 41–25 Various types ofproximal phalangeal fractures oflesser toes. A, Transverse fractures(arrows). B, T-type distal articularfracture. C and D, Salter II fracturesof second proximal phalangealbase (arrows), seen best on lateralradiograph.

2228 PART X Trauma

sprains. Thus the diagnosis might be overlooked by thephysician or the patient might not seek early medicalcare. Similarly, fractures of the lesser toes are oftendismissed as sprains.

The patient usually relates symptoms of acute pain,swelling, and difficulty in wearing a shoe or inwalking.38,39,92 The toe is swollen and tender to palpa-tion, and crepitus is usually present. There is often asubungual hematoma when the distal phalanx isinvolved. Any movement of the toe produces pain. Ifthe patient is seen very soon after the injury, no ecchy-mosis will be present. Within 12 to 24 hours, however,marked swelling and ecchymosis of the involved digitare present.

Open fractures of the phalanges usually occur fromdirect trauma. The neurovascular status of the toedistal to the open fracture may be in jeopardy becauseof the fracture and the crushing of the soft tissues thatoccurs with the fracture.

Radiographic EvaluationAnteroposterior, oblique, and lateral radiographs ofthe toe (not the foot) are necessary to delineate thefracture location and displacement of the fracture.Although comminution is often present, unlike fractures of the fingers, most of these fractures are notsignificantly displaced.38,62 Fractures of the hallucalphalanges, however, are most often displaced. Jahss62

emphasized that fractures of the great toe vary from amildly displaced fracture of the medial or lateralmargin of the distal portion of the proximal phalanxto a frank fracture–dislocation. Radiographs takenwith traction applied to the hallux are often helpful infurther evaluating the fracture.

OPEN FRACTURES

TreatmentIf an open fracture of the lesser toes is present, thewounds should be irrigated and debrided just as withany other open fracture.7,8 Consideration is given tothe use of intramedullary Kirschner wire fixation whensevere soft tissue damage is present. Antibiotics aregiven for 48 hours after initial irrigation and debride-ment. If the hallux is involved, the indications forinternal fixation of the articular surface are the sameas in closed fractures.

Authors’ Preferred Method of TreatmentIn patients with open fractures involving the toes, thorough irrigation and debridement are performed,

as indicated in open fractures of the major bones. Withextensive soft tissue damage, we prefer axial Kirschnerwire fixation as a splint to provide stability for softtissue healing. If such open fractures involve the MTPor interphalangeal (IP) joint of the great toe, anatomicreduction and Kirschner wire fixation are performed atthe time of initial debridement. The patient wears astiff-soled shoe when swelling and pain permit.

HALLUCAL FRACTURES

Fractures of the distal phalanx of the great toe are mostoften secondary to dropping heavy objects on thetoe.127 This often results in comminution.47 Subungualhematomas are usually present and can be relieved by drilling the nail bed.64 Avulsion of the nail todecompress the subungual hematomas is not warranted.92

In simple fractures of the phalanges of the great toewithout displacement, Cobey21 recommends treatmentwith a metatarsal bar. Alternatively, the great toe canbe bound to the adjacent two toes for stability, andambulation can be initiated in a stiff-soled shoe.Johnson64 stresses the necessity for simple treatment ofnondisplaced phalangeal fractures by protective splint-ing (usually to an adjacent toe), symptomatic medica-tion, and immediate ambulation. The stress fracturesreported by Yokoe and Manoji142 were treated by asimple decrease in the athletic activity that producedthe fracture. This resulted in healing of the stress fracture.

Taylor127 stresses the importance of maintaining thenail in treating fractures of the distal phalanx of thehallux. He believes that it serves as an important splintto the broken phalanx and that its removal exposes a tender area, which will prevent the patient fromreturning to work for weeks.

Crush fractures of the terminal phalanx of the greattoe should be treated with elevation and ice, followedby a cut-out shoe with a stiff sole. Heck47 stresses thatin such comminuted fractures, reduction is not alwayspossible, but care should be taken to place the toe ina functional position. If a crushing-type fracture of thegreat toe is severely comminuted and open andinvolves the majority of the distal phalanx with exten-sive soft tissue loss, debridement of the wound, nailexcision, and a terminal Syme amputation may beindicated.39

Jahss62 reports that displaced fractures of the hallu-cal phalanges (when treated early) can usually bereduced by closed means with traction under localanesthesia and that the reduction can usually be main-tained in a plaster boot. He recommends treatment by adhesive strapping for minor angulation or minor


displacement of fractures through the condylar neck. If there is displacement of single fractures of the proximal or distal phalanx of the great toe, every attempt should be made to correct the displacement.16,62

Isolated medial or lateral condylar fractures or frac-ture–dislocations typically seen in stubbing injuriesare unstable. If hallucal phalangeal fractures are dis-placed and reduction cannot be obtained by manipu-lation, particularly those associated with dislocationsof the adjacent joint, Chapman16 and Jahss62 suggestopen reduction.

Authors’ Preferred Method of TreatmentIn nondisplaced simple fractures of the great toe, wehave the patient wear a stiff-soled shoe with a high toebox. In crushing injuries of the hallucal phalanges withcomminution and no involvement of the IP joint,most attention is directed to care of the soft tissues.The subungual hematoma is drained after sterilepreparation.

In displaced fractures of the hallux, a closed reduc-tion is attempted. If this is unsuccessful, open reduc-tion with internal fixation is recommended. This isparticularly true in fractures involving the IP and MTPjoints. In our experience, residual displacement ofthese fractures has resulted in arthritic changes andpain with ambulation. We have found the use ofChinese finger traps applied to the toe with the patientin a supine position and weights draped over the anklemay only occasionally be useful in reducing these frac-tures. When such a reduction is obtained, percuta-neous pin fixation is performed. After fixation thepatient wears a stiff-soled shoe until the fracture ishealed, usually by 10 to 12 weeks. Pins are removed at6 to 8 weeks based on radiographic evidence ofhealing.

If open reduction is required in these injuries,timing is critical. Unless open reduction can be donevery early, swelling of the great toe makes soft tissuecompromise after surgery commonplace. If openreduction cannot be performed within 24 to 48 hours,we prefer to wait until the swelling has subsided,usually within a week to 10 days. This must be bal-anced with the knowledge that soft tissue contractionwill occur from the displacement and may make frac-ture reduction more difficult. Although simple frac-tures can be pinned, when articular fractures orcomminuted shaft fractures of the proximal phalanxof the great toe are seen, open reduction and internalfixation using mini-fragment implants or bioab-sorbable pins should be performed.50

LESSER TOE FRACTURES

In fractures involving the second, third, fourth, andfifth toe phalanges, Giannestras and Sammarco39 andChapman16 believe that moderate displacement is ofno great significance. Although they recommendattempted reduction, they believe that if an anatomicreduction is not obtained, one need not be concernedas long as the general alignment of the toe is satisfac-tory. They treat these injuries by placing a single layerof sheet wadding between the involved toe and twoadjacent toes. The toes are then strapped together withadhesive tape, being careful not to compromise the cir-culation. Ambulation is permitted in a stiff-soled shoewith the toe box cut out. These authors emphasize thatwith substantial displacement or if dislocation of theadjacent joint is present, closed reduction with orwithout Kirschner wire fixation may be indicated.

Cobey21 believes that most of the pain associatedwith a fractured toe results from dorsiflexing the toeswith walking, and neither taping adjacent toestogether nor a hard leather sole will prevent this dorsiflexion. He therefore recommends the use of ametatarsal bar made from tongue blades and taped tothe bottom of the shoe. The patient then begins earlyambulation. Cobey found that this method function-ally immobilized the toes and the MTP joint withoutpermanently altering the shoe. The use of tongueblades also eliminates the need for an expensivemetatarsal bar.

Johnson64 strongly emphasizes the danger inovertreating and overprotecting patients with fracturesof the phalanges, a practice that may result in long-term complications. Long-term sequelae from pha-langeal fractures of the lesser toes are rarely reported.Angulation at the fracture site with malunion canresult in a painful plantar pressure area under a toe,particularly when a fracture involves the proximalphalanx of a lesser toe.92 Such plantar pressure areascan require later surgical correction. According toJohnson,64 however, disability from stiffness, swelling,and occasional Sudeck’s atrophy resulting from themore aggressive types of therapy are more significantin regard to long-term disability.

Authors’ Preferred Method of TreatmentWe prefer to treat fractures of the middle and distalphalanges of the lateral four toes by adhesive taping tothe adjacent toe and using sheet wadding between thetoes to prevent maceration. Ambulation is begunimmediately in a stiff-soled shoe with an adequate toebox.

2230 PART X Trauma

Proximal phalangeal fractures of the lateral four toesare treated in a similar manner. Moderate displace-ment of the phalanges of the lateral four toes is usuallyof no consequence. If complete displacement ispresent, an attempt at closed reduction with thepatient under local anesthesia can be made by usingChinese finger traps. The toe is then strapped to theadjacent toes with half-inch adhesive tape and plainsheet wadding between the toes.

Only with gross displacement in which closedreduction is not successful should the surgeon con-sider open reduction. In our experience, however, such displacement is extremely unusual. When con-sidering open reduction, the surgeon must rememberthat minimal disability results from these injuries.Therefore we prefer to treat all these fractures in aclosed manner by adhesive strapping and weightbearing.

Morbidity after malunion of these fractures has notbeen a significant problem in our practice. If it doesoccur, however, patients should be told that a simpleexostectomy will usually relieve symptoms.

SESAMOID BONESThe anatomist Galen gave the sesamoid bones theirname because of their similarity in the size and shapeto the flat oval seeds of Sesamum indicum, an ancientEast Indian plant that was used by the Greeks forpurging.60,119 Fractures of the metatarsal sesamoidshave always been thought to be quite rare.23,101,133

However, the marked increase in jogging, long-distance running, and ballet has caused these injuriesto become much more common.92,119

AnatomySesamoids in the hallucal MTP joint are a constantfeature of the foot.92 However, sesamoids of the MTPjoint of the fifth digit are present in only 10% of cases,of the fourth in 2%, and of the second in 1%.92 Thehallucal sesamoids are termed by location as eithertibial (medial) or fibular (lateral), and the tibialsesamoid is more often fractured.38,68 The tibialsesamoid is situated directly beneath the medial halfof the first metatarsal head, where it is often subjectedto mechanical trauma. The fibular sesamoid, however,extends well beyond the lateral margin of themetatarsal head and assumes a relatively protectedposition in the soft tissues between the first and secondmetatarsal heads.38,39 For this reason, it has been pos-tulated that fracture of the fibula sesamoid is quiterare.

The hallucal sesamoids have a dorsal cartilaginousfacet that articulates with the metatarsal head. Fibers

of the flexor hallucis brevis tendon cover their rough,nonarticular plantar surface.92 The sesamoids are sep-arated from each other by the flexor hallucis longustendon as it courses to its insertion into the distalphalanx. They are invested by the deep tendons of theshort flexor of the great toe and are joined to eachother by a strong, short transverse ligament. Theconcave articulating surfaces of the sesamoids contactthe plantar aspect of the first metatarsal head andprovide a gliding surface for the weight-bearing functions of the first metatarsal.92

The sesamoids can have one or more ossificationcenters that may or may not unite. Incomplete coali-tion of the chondrification centers can result in abipartite or tripartite sesamoid, which can be confusedwith a fracture.88,92 The sesamoids are reported to bemultipartite in 5% to 30% of normal asymptomaticpersons. Incomplete fusion is more common in thetibial sesamoid.12,101 Because bipartite sesamoids maybe bilateral, the presence of a divided sesamoid in thecontralateral foot can help in distinguishing it from afracture.92 However, a contralateral single sesamoiddoes not confirm a fracture.60

Mechanism of InjuryThe hallucal sesamoids are particularly vulnerable toinjury because of their biomechanical function andanatomic location.133 The sesamoids elevate the firstmetatarsal head so that it is level with the adjacentmetatarsal heads, and thus they are important weight-bearing structures. They also serve as a fulcrum toincrease the mechanical advantage of the flexor hallucis brevis tendons.

When a person lands directly on the ball of the footafter a fall, most of the force is borne by the firstmetatarsal head. This compresses the sesamoids, par-ticularly the tibial one, against the first metatarsal headand leads to a compression fracture. Repetitive traumacan also cause this injury, as seen in ballet dancers andathletes.13,92,95,106

A hyperdorsiflexion injury can cause a transversefracture, whose mechanism is similar to that of a patel-lar fracture. This injury arises when forced dorsiflexionof the great toe at the MTP joint occurs, as seen in foot-ball and soccer players.22,95,106

Clinical EvaluationMost patients are able to recall a specific episode oftrauma with the sudden onset of sharp pain.22,38,39,106

The pain is located in the region of the sesamoid bonesand is associated with any movement of the MTP joint.Although the pain may be reduced or absent at rest, classically it returns with walking.22 This occurs


specifically at the end of each step, when the MTP jointis in hyperextension and body weight is thrownforward onto the ball of the foot.101 Point tendernessis found on the plantar aspect of the foot beneath thefirst metatarsal head on the tibial or fibular side,depending on which sesamoid is involved, andswelling may be present in this region.22

Radiographic EvaluationA fractured sesamoid is usually confirmed by radio-graphic examination, which includes an AP view of the forefoot, a lateral view, and a tangential or axialview of the plantar aspect of the first metatarsal head.101

Graves et al42 noted that the best way to determine aplantar plate disruption was by taking the AP viewwith both feet on the cassette and centering the beamperpendicular to it. The tangential or axial view, alsoknown as a sesamoid view, demonstrates the articularsurface of the sesamoids well.38 In addition to the tan-gential view, Colwill23 suggested the use of tomogra-phy to help in the diagnosis of these injuries.

Maurice et al82 recommended bone scanning as areliable way of detecting sesamoid injury and sug-gested that it be used as a screening test. More recently,however, Chisin et al17 evaluated the specificity of bonescans in this setting. Using a 0 to 2 bone scintigraphicrating system, 25 of 86 (29%) asymptomatic infantryrecruits and 7 of 27 (26%) asymptomatic sedentaryadults were found to have grade 1 or grade 2 activity.The authors concluded that when using scintigraphyto evaluate hallucal sesamoid disease, caution shouldbe used in interpreting increased scintigraphic activity.

Radiographically, the differential diagnosis of a frac-tured sesamoid includes fracture of the sesamoid, abipartite or multipartite sesamoid, and osteochondri-tis dissecans of the sesamoid.16 A fractured sesamoidmust be distinguished from osteochondritis dissecansof the first metatarsal sesamoid, because both theseconditions occur often in the tibial sesamoid.59 The x-ray findings of the latter condition are those of fragmentation and irregularity of the sesamoid. Anaxial view of the metatarsal head shows these changes,which might not be visible on standard AP projections.

Differential DiagnosisOther injuries to the sesamoids must be differentiatedfrom fracture. Graves et al42 described four cases ofplantar plate injury to the first MTP joint, with proxi-mal retraction of the sesamoids by the flexor hallucisbrevis muscle. No history of dislocation occurred inany patient, although two had associated fractures ofa sesamoid bone. Irwin et al61 described a case of trau-matic dislocation of the lateral sesamoid of the flexor

hallucis brevis tendon associated with metatarsal neck fractures caused by a crush injury. Finally,Richardson106 notes that in addition to sesamoiditis,osteochondritis, partite sesamoids with stress fractures,and displaced fractures, bursitis beneath the tibialsesamoid and flexor hallucis brevis tendinitis alsooccur in the athlete and may be confused withsesamoid injury.

Conservative TreatmentThe treatment most often recommended after thisinjury is rest and protection of the first metatarsal headfrom weight bearing.22,38,39 Most authors recommendnon–weight bearing in a stiff shoe, the use of ametatarsal bar, or casting for 3 to 6 weeks. These sameauthors all suggest resection of the sesamoid if pain isnot relieved after 6 weeks of enforced rest.

Surgical TreatmentAs already noted, in patients with persistent disabilityafter a reasonable period of conservative therapy, most authors recommend excision of the involvedsesamoid. The indications typically given for sesamoidexcision include painful nonunion, prolonged paindespite conservative treatment, and development ofposttraumatic degenerative changes on the sesamoidarticular surface.

Pfeffinger and Mann100 noted that if a sesamoidneeded to be removed, it could be done with relativeimpunity, if only one was removed. They stronglybelieved that if both sesamoids were removed, thedistal attachment of the flexor digitorum brevis musclewould be disrupted, and a cock-up deformity wouldresult. Therefore they stated emphatically that underno circumstances should both sesamoids be removed.

Several authors have emphasized the importance ofplacing the surgical incision so as to avoid painful scarformation.88,133 Van Hal et al133 report the use of amedial longitudinal plantar incision to remove thetibial (medial) sesamoid. However, care must be takenthat the digital nerve is identified and protected.Pfeffinger and Mann100 suggest that the tibial (medial)sesamoid be approached slightly below the midline onthe medial side of the first MTP joint, taking care notto damage the plantar medial cutaneous nerve. Thesesamoid must be carefully shelled out of the tendonof the flexor hallucis brevis muscle to prevent the laterdevelopment of a cockup or varus/valgus deformity ofthe hallux.100,119

Although Van Hal et al133 approached the fibularsesamoid through a plantar incision between the firstand second metatarsal heads, a dorsal web-splittingincision between the first and second metatarsal heads

2232 PART X Trauma

will avoid a plantar scar and is safer (see Chapter10).100,119

Authors’ Preferred Method of TreatmentA complete set of radiographs is essential in evaluat-ing injuries to these bones. The axial views are particularly helpful in distinguishing among osteo-chondritis dissecans, a bipartite sesamoid, and a frac-ture with displacement. Although it is important todistinguish between an acute fracture and a bipartitesesamoid, in reality the treatment is the same.

These patients are placed in an off-the-shelf walkerboot and given crutches. They are either non–weightbearing or heel-only weight bearing for 4 weeks. Atthat time, if they feel improvement, they are given awooden-soled shoe for another 4 weeks to preventdorsiflexion of the MTP joint. If they show noimprovement after the first 4 weeks, they are placed ina formal below-knee non–weight-bearing fiberglasscast for another 4 to 6 weeks. This is followed by awooden-soled shoe and therapy if needed.

We find it highly surprising that although most sur-geons would wait up to 3 months to begin weightbearing on a displaced fracture in the lower extremity,the sesamoid is only given 6 weeks and then excised.We therefore prefer to wait a minimum of 6 monthsbefore we make the decision to excise the sesamoid.As a result, it has been extremely unusual for us to remove the tibial sesamoid. In the rare event thatthe patient requires resection, we use the techniquerecommended by Pfeffinger and Mann.100

DISLOCATIONS OF SESAMOID BONES

Prieskorn et al102 tested fresh-frozen cadaver feet withhyperdorsiflexion stress of the first MTP joint. Threedifferent types of injury were observed: rupture of thecapsule proximal to the sesamoids, rupture of theplantar plate distal to the sesamoids, and rupture ofthe capsular structures medially, allowing a lateralswing of the sesamoids around the metatarsal head.The authors concluded that incomplete dislocationcan be associated with significant damage to theplantar plate and other soft tissues of the foot.

Graves et al42 presented four cases with plantar plateinjury to the first MTP joint, with proximal retractionof the sesamoids by the flexor hallucis brevis muscle.No history of dislocation occurred in any patient,although two had associated fractures of a sesamoidbone. Diffuse pain beneath the first MTP joint and

pain with extremes of joint motion were seen in allpatients. By taking the AP view with both feet on thecassette and centering the beam perpendicular to it,the diagnosis of plantar plate disruption was made.Initial treatment was conservative, using a stiff-soledshoe. With nonsurgical treatment, two of the patientsreturned to preinjury activities. One patient didrequire a sesamoidectomy for resistant pain, and onepatient was permanently disabled from work.

Finally, Capasso et al14 reported a traumatic dislo-cation of the lateral sesamoid secondary to disruptionof the intersesamoid ligament. The lateral dislocationof the sesamoid was suggested by the presence of painand tenderness around the first MTP joint. Routineradiographs revealed lateral dislocation of the lateralsesamoid, and an axial view of the sesamoids demon-strated the sesamoid in the lateral intermetatarsalspace. The authors suspected a kick to the ground withthe great toe as the probable cause of total rupture of the intersesamoid ligament. Open reduction andrepair of the intersesamoid ligament through a plantarlongitudinal incision in the first intermetatarsal webspace was successful. The patient resumed normalactivities 2 months later and had no further disability.

Although sesamoidectomy was an alternative torepair of the intersesamoid ligament, the authors concluded that in a sporting population, excision ofthe sesamoid could limit sporting activities.14

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41.fractures of the midfoot and forefoot

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