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Fracture - base of metatarsals

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Asher, Jul 18, 2008.

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  1. Asher

    Asher Well-Known Member


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    Hi there,

    Advice would be appreciated on 51 year old female, rheumatoid arthritis for 4 years. I saw the patient 2 months ago for medial forefoot pain - between 1st and 2nd met heads. Tight calf and stiff anterior cavus evident so calf stretches given. Occupation: teacher, usually in high heels - advised to reduce heel height differential gradually (but to maintain some heel height for anterior cavus) and gave gastroc and soleus stretches for 8 weeks.

    Phone review (no examination) after 8 weeks: Pain has reduced 60%. There is no pain in the tarsometatarsal region. GP ordered x-rays but no follow-up as he left town, town without GP altogether.

    X-ray report states "There does appear to be some developing osteoporosis but at this stage is fairly minimal, but in a juxta-articular position which may be the earliest feature visible in rheumatoid arthritis. There are no erosive changes and the demineralisation may simply represent some disuse atrophy in this patient ... There are fractures involved in the proximal ends of 2nd, 3rd and 4th metatarsus adjacent to the TMT joint. The fractures probably do involve the articular surfaces of those joints but there does not appear to be any gross displacement of the fragments. Bone healing not yet established."

    I'm assuming these are fractures and not stress fractures. Should the two be treated any differently?

    Is it odd that its not painful? Does the presence or absence of pain change how this should be treated?

    What should I do with this - I will be seeing her in about 2 weeks when she's in town next.

    Thanks, Rebecca
     
  2. ericajones80

    ericajones80 Member

    do whatever your doctor tells you to do
     
  3. Stanley

    Stanley Well-Known Member

    Rebecca,

    Lab tests confirm diagnoses, they do not make diagnoses.
    Clinically there was no pain in the "fracture area" but there was pain distal. From the distal pain there is a good chance that there is no loss of sensation (but you should double check this). If there is normal sensation of the foot, then you can be sure that the radiologist misinterpreted the radiograph. This happens very frequently.
    Just today I had did a hammer toe surgery at the hospital. The radiology report came back as "healed spurs". No mention of the hammer toe. In fact I rarely if ever get a correct radiology report. :craig:
    For the patient I would do what you are doing. I might make some full length soft orthoses, as the metatarsal heads will become more prominent in time, and you will have to off load them.

    Regards,

    Stanley
     
  4. Mark_M

    Mark_M Active Member

    Hi Rebecca,
    Have you checked the Xray film yourself?
    I would ring the radiologist and speak to them (I have always found them happy to help).
     
  5. Asher

    Asher Well-Known Member

    Thanks Stanley. No Mark, I haven't seen the x-rays yet and will keep that in mind.

    What are the indications to use a removeable walking cast / boot as opposed to orthoses / pressure deflection etc? I haven't had much to do with fractures in the past.

    Rebecca
     
  6. Heather J Bassett

    Heather J Bassett Well-Known Member

    Hi, pain between 1st and 2nd met heads? Neuroma? What is the type of pain she gets? When does she get it what exacerbates it.
    Does osteopaenia not come before osteoporosis? I was not aware that X-Rays are going to be definitive.
    Just thinking out loud.
    cheers
     
  7. Asher

    Asher Well-Known Member

    Hi Heather,

    Neuroma is in my DDx. However, no nervy sensation radiate into toes, not that that rules it out. Pain is exaccerbated with increased length of time on feet and moreso with exercise.

    Whether neuroma, stress fracture, or whatever other diagnosis, I would still want to reduce the forefoot dorsiflexion moments (calf stretches, lower heel height differential) as the first intervention.

    Have not dealt with too many fractures hence my post.

    Overall, with fractures, in what circumstances - not necessarily this one - would I suggest crutches? In what circumstances would I give a cam walker? When orthoses? Any advice??

    Rebecca
     
  8. Mark_M

    Mark_M Active Member

    Hi Rebecca,

    I get referrals from orthopods and GP's requesting orthotics for their patients suffering from stress fractures as a conservative treatment or requesting orthotics after they come out of the cam walker. Over time I have found this to be a reasonably standard form of treatment.

    However If you are unsure of treatment, I would refer on. If there is no GP in town, she still must have a rhematologist. Perhaps your local physiotherapist may have some more experience.

    If you are after some better advice , maybe post the thead in a different forum (foot surgery)

    Hope that helps
     
  9. Rebecca:

    The radiologist, like Stanley said, probably misread the x-rays and misinterpreted bony overlap at the metatarsal bases as fractures. If your patient doesn't have pain there, and isn't neuropathic, then the radiologist is probably wrong. Possibly you can post the radiographs here so we can look at them also. I doubt she spontaneously fractured her metatarsal bases.

    I would bet that her pain between the 1st and 2nd metatarsal heads is either an intermetatarsal neuritis, fibular sesamoiditis or medial 2nd mpj plantar plate pathology. Careful manual examination should be able to differentiate between these structures.

    In many of these cases, I tell these older female patients (yikes....I'm 51 y/o also!)to try wearing jogging or lace-up walking shoes to work, and get out of their dress shoes for two weeks (I will often write them a medical excuse to do so if they feel they need it for their employer). Invariably, it is the shoes in these women that are the main source of their foot injury....get them out of the higher heeled slip-on shoes and, magically, their pain eventually goes away.

    As the patient's foot health professional, you must not be afraid to be, what I call, their shoe dictator. I tell many of my female patients that if they want to continue to wear their dress shoes that they will remain in pain. But if they want to be pain-free they will have to start wearing shoes that are less stylish and more shaped like their feet, not some idealized vision of what a shoe designer thinks feet should look like. Many tears are shed in these discussions, but I tell them my job is to make their pain better, not to be their fashion consultant, and they alone need to make the decision between being pain-free and being stylish. Once they have worn their jogging shoes to work for a few weeks and their pain is improved, few of them come back to me complaining about the harsh words I had with them a few weeks earlier about their poor shoe choices.
     
  10. Asher

    Asher Well-Known Member

    Hi Kevin,

    Wow, I didn't expect to hear from you. I appreciate your advice and will certainly post the x-rays, when I see them, if I have any concerns.

    As a 'foot health professional' I feel very inadequate when it comes to fractures and stress fractures. When I see them, I usually reduce forces for a stress fracture (insoles, arch supports, orthotics), and for fractures (and stress fractures which continue to be symptomatic), send them to the physio for Cam walkers or crutches or whatever the physio wants to give them. I'm embarrassed to admit that I don't know what I should do and when. As a 'foot health professional' I think I should know exactly what needs to be done. Can you help me?

    Firstly, is the difference between a fracture and a stress fracture that a stress fracture is only within the periosteum whereas a fracture goes deeper?

    Generally its metatarsal stress/fractures that I've seen. What treatment should I provide for these (in-shoe devices, activity modification, post-op shoes, Cam walkers, crutches, refer on) and when? Does the presence or absence of pain (in non-neuropathic patients), the level of physical activity or any other factors change the treatment given.

    Thanks for any advice.

    Rebecca
     
  11. Rebecca:

    The treatment of fractures is way beyond the scope of the time I have. Some fractures, such as 5th digit fractures, may be treated with buddy taping to the 4th digit. Other fractures require open reduction and internal fixation (ORIF) for proper healing. Barry Scurran, DPM, wrote a book on foot and ankle trauma a few years back which is an excellent reference. Also, McGlamry's textbooks cover fractures also.

    A stress fracture is a fracture of the bone which is not detectable on radiograph since it is non-displaced, in good alignment, but may still be a through and through fracture, not just on the cortical surface or subperiosteal.

    Is there a reason that you can not give out Cam Walkers? I give them out a lot when I treat foot fractures.
     
  12. Asher

    Asher Well-Known Member

    No reason at all, I've just never had any experience with them - I know its below par. I will get one of the books you mentioned. Thankyou.

    Rebecca
     
  13. Rebecca:

    I would not consider you to be "below par" as a practitioner. I have been fortunate to have been exposed to treating many acute and chronic fractures of the foot and ankle since I have been practicing with orthopedic surgeons over the past 23+ years. The third year surgery residents from the Kaiser Sacramento residency program that I train in my office (one half day a week) do more trauma surgery than most podiatrists, usually are surgically repairing 1-2 ankle fractures a week and treat many foot fractures also. They are much better trained than I am in treating acute fractures surgically. I learn a lot from them also.

    Most non-US podiatrists have had little traning in surgical treatment of foot and ankle fractures and many others have also had little training in conservative fracture treatment. You are not alone. However, if you do desire to increase your knowledge specific to fracture care, probably the best book is by Barry Scurran, that I mentioned earlier "Foot and Ankle Trauma" that is quite thorough in its review of concepts and practical guidance in treatment. I believe it is out of print but still available here.

    Happy reading!
     
  14. Heather J Bassett

    Heather J Bassett Well-Known Member

    Hi been away for a couple of days, what a pleasant surprise to have you back Kevin:drinks:welcome: Look forward to meeting you in Melbourne, Have a safe trip over
    cheers
     
  15. Griff

    Griff Moderator

  16. Asher

    Asher Well-Known Member

    Thanks Ian!
     
  17. Heather:

    My wife and I are at the airport now to travel first to Los Angeles, then Brisbane, then Darwin for a week-long campervan tour of the Northen Territory. Then off to Sydney and Melbourne for the lectures. Good to finally be on vacation!

    Be sure to introduce yourself to me in Melbourne. Looking forward to it.
     
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