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3rd Metatarsal head Fracture

Discussion in 'Biomechanics, Sports and Foot orthoses' started by harydial, Sep 19, 2008.

  1. harydial

    harydial Member

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    G'day colleagues,

    I was hoping to get some opinion and suggestion to manage this case I came across last week.

    Basically the gentleman presented to the clinic with:

    History of fractured junction of 3rd met head-shaft from trauma/fall right foot
    38 years old
    Occured in feb 2008
    Was in an air walker for 4 weeks after
    Took x-ray after and was told the fractured has healed
    Based on x-ray the fracture resembles a simple fracture
    However residual pain was still present till today Sept 2008
    Pain is felt wb and especially in the dorsum area of 2-3-4 met head area
    Pain pronouced especially in the 3rd met head
    Wearing shoes helps a bit with the pain
    Pain is more severe after a period of rest and when start walking again
    Pain is about level 6-7 not getting better or worst overall

    I've seen his x-ray taken in late March 08 when the air walker was removed. There is still a sclerotic margin present. I've requested the most recent x-ray again for this present time.

    My differential or possible complication would be
    Possible degenerative changes
    Fracture have not healed up well

    I would like to know any opinion for further managing this patient.

    Is it possible for the fracture to not heal after many months? If it is would putting him back in an air walker be appropriate? for 4-6 weeks?

    Or an orthotic to offload the 3rd met and shift the GRF towards the MLA be suitable?

    When surgical intervention be necessary?

    At the moment I am just waiting to review the latest x-ray films before proceeding any further?

    I anticipate and would value any opinion that may guide me through this case management.

    Many thanks.
  2. Think soft tissue injury/post-traumatic scarring since the force required to cause a metatarsal fracture is certainly also of sufficient magnitude to cause a rupture or tear of the plantar plate, flexor tendons, etc. You must also remember that after a fracture, there will be significant bleeding within the tissues surrounding the fractured area to possibly cause painful scar tissue in the area including entrapment of nerves, tendons and other soft tissue structures. If the x-ray shows normal healing, then an MRI scan would be the diagnostic study of choice to rule out soft tissue pathology.

    On the initial visit, you could certainly fabricate an accommodative insole that would probably make your patient's life much happier. Take 3-6 mm felt and adhere it to the insole/sockliner in the areas corresponding to the 1st, 2nd, 4th and 5th metatarsal heads as illustrated below. Then take a small metatarsal pad and place it just proximal to the 3rd metatarsal head. These two simple, in-office modifications will significantly reduce the magnitude of ground reaction force plantar to the 3rd metatarsal head and make ambulation much less painful and much less difficult for your patient.

    Next, tell the patient to avoid any barefoot walking/standing activities and to wear the padded insoles you have fabricated for him in a thick-soled running/walking shoe as much as possible. Have him start icing the dorsal and plantar aspect of the foot 20 minutes, 2-3 times a day to reduce inflammation, have him do dorsiflexion/plantarflexion range of motion exercises of the affected digits 30 minutes a day, and possibly you may also consider starting him on a course of oral non-steroidal anti-inflammatory drugs (NSAIDS).

    I would recommend custom foot orthoses for the patient if the padding seems helpful. I would also consider a series of cortisone injections in the adjoining area of the 3rd metatarsal fracture if there was no MRI or radiographic evidence of a non-union of the fracture. I will generally use a series of cortisone injections consisting of Marcaine mixed with 6 mg of celestone soluspan, spaced 3-4 weeks apart. Therapeutic ultrasound with deep tissue massage works particularly well in the days and weeks after cortisone injections to help increase the compliance and to reduce the bulk of painful post-traumatic scar tissue that may have formed in the area from the post-traumatic bleeding into the soft tissues.

    If the patient is particularly tender, then returning the patient to a boot-brace walker is a possibility, but would not be my first choice at this stage of the injury due to the muscle weakening and gait disturbances that can occur with these braces. However, if there is a fracture still evident, I certainly would consider using the boot-brace walker.

    Hope this helps.
    Last edited: Sep 19, 2008
  3. Peter

    Peter Well-Known Member

    Dr Kirby,

    I have humbly utilised the above padding/deflection on many cases, and am glad to see one of our most esteemed practitioners do the same.

    One thing I am unsure of is, How many pateints do you have with 6 metatarsals?

    Yours Tongue-in-cheek,

  4. Peter:

    Those two little oval shaped objects in the first metatarsal head area are called sesamoids.;)
  5. Peter

    Peter Well-Known Member


    Think i'll crawl into a dark hole ( or a bottle of rum).
  6. harydial

    harydial Member

    Thank You very much Dr Kirby,

    I'll try the padding as described and advice the patient accordingly. I'll make update again with how the patient is going.

    Kind Regards,
  7. Adrian Misseri

    Adrian Misseri Active Member

    G'Day Harydial,

    I've had a similar situation with a female patient, except she had bilateral 3rd met shaft fractures. She fractured teh second one 2 weeks after the first whlst wearing a camm walker. Very frustrating! As a result, camm walker was out of teh question as someone cannot function with two camm walkers. Had soem great success keeping her in runners, and constructing a similar pad to what Kevin has described. To keep bulk down though, I constructed a plantar pad the same as the red area Kevin has drawn, although used 3mm 180EVA, being that it is firm enough not to deform too much under bodyweight, and will still stop the transmission of ground reaction forces up the third metatarsal shart, as teh GRF willbe taken by met heads 1,2,4 and 5. However once the foot has completely healed (8-10 weeks total and at least 2-3 weeks after pain has stopped on palpation), Id be looking at removing the padding so as not to encourage a plantarflexed 3rd metatarsal head.
    Just a thought??
    Good luck!
  8. CraigT

    CraigT Well-Known Member

    Lesser MT stress fractures can also be offloaded with a low dye tape- I find that if you aggressively plantar flex the 1st and 5th mets when you apply it, you can have great relief even without forefoot padding. You also have the option of adding the padding as described.
    Bilateral fractures? Either she is accident prone or she needs a bone density scan...
  9. Adrian Misseri

    Adrian Misseri Active Member

    Bone density was actually good Craig, unfortunately she was a 40 year old mother with anxiety issues who just wouldn't stop and was a bit accident prone. She was actually In tears when she came in beacuse the doctor had had a bone density scan and came back good. She couldn't understand why she got the fractures. She almost went to tears again when I said she need to rest, and keep off her feet. Was a difficult one....
  10. CraigT

    CraigT Well-Known Member

    Ah yes, one of those patients- The general rule with Met stress fractures is you can do activities that do not hurt.. ie if it only hurts running, then you can walk. People like this will then power walk for 2 hours daily and wonder why the problem is not improving.:rolleyes:
    Perhaps bilateral cam walkers would be a good idea.
    Last edited: Sep 22, 2008
  11. Adrian Misseri

    Adrian Misseri Active Member

    I was tempted..... Also suggetsed that her husband and daughter could help out more around the house...
    Perhaps more psychology would be useful in our podiatry degrees? :hammer:
  12. harydial

    harydial Member

    G'day Adrian & CraigT

    Thanks very much for the feedback. Thats just great having more options and input from you both. I'll definately implement these ideas into my treatment plan. Very much appreciated.
  13. Adrian:

    The English teacher part of me that I inherited just couldn't resist making the above corrections. Your postings would be even more impressive than they already are if you would simply read your postings thoroughly before sending them in for all of us to read.

    Remember, to all of those reading along, that we often only know you and judge your intelligence by the content of your postings, accuracy of your grammar and spelling, and clarity of your message. This is a good lesson for all of us to remember in this electronic age we all live in.:drinks
  14. Adrian Misseri

    Adrian Misseri Active Member

    My apologies Kevin, was scrawled between patients, although that is no excuse.
    Me speech England bad :empathy:


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