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A 40yo female client with osteopenia recently stepped backwards whilst attempting to lift a suitcase onto an upper shelf fracturing her 5th metatarsal.

It was recently re-xrayed 3 and a half weeks post break still showing non-union and no sign of healing (2mm gap). GP's etc have chosen to not cast the foot and have given the client no real instructions other than 'dont weight bare'. This is easier said than done for this lady as an accident as an infant has left her with only the medial half of her other foot. Balancing on crutches is very difficult.

What is the possibility this fracture will unite without any other intervention? Should it be cast? Given the previous injury to the other foot it is important that this fracture is dealt with well.

Alison

 

Has she had an surgical/orthopaedic review ? considering her medical history i would be considering a cast and non weightbearing asap if not surgery to ensure union.
Good luck

 

i have recommended surgical review and probable casting. Can anyone tell me how significant a 2mm gap is at three and a half weeks post fracture? At what point would you expect to see signs of bone healing on xray?

 

First, it is simply best to refer out those cases that you do not have expertise in as it does not serve the patient's best interest.

Still to answer your question it would be important to know anatomically where the fracture is in respect to the fifth metatarsal as well as the geometric orientation of the fracture line.

Review the x-ray, and if the fracture is at the neck of the 5th metatarsal than it should go on to heal uneventfully but should still be wrapped and a stiff soled surgical shoe worn. Casting should be reserved for midshaft/base fractures and these fractures will heal faster with screw fixation to bring compression to the fracture site which will stimulate osteogenesis and reduce the chance for a symptomatic delayed or nonunion.

 

Thanks for the info Lab guy. I agree with your first statement. I am not trying to treat this client myself...just trying to get more understanding. Traumatic acute injuries are not something I see often clinically. I have not even seen the xrays and the client was unable to describe the exact position of the fracture. The reason I saw her was to treat her other foot...at which point she obviously told me the saga of the fracture and her concern that not enough was being done.
Thanks, Alison

 

Hi Alison:
You most liekly are not going to see much healing or reduction in GAP after 3 or 4 weeks. In fact, not unusual to have a wider gap at 3 weeks post injury (you know the stages or wound healing)

You cannot call this a non union at three or 4 weeks. If you are concerned, use a bone stimulator, these work very well for 5th Met Fx.

Also, factor in your patients subjective findings.

Steve

 

How much pain is there? My daughter (18) broke hers (5th met shaft) playing soccer 2 years ago and after 6 weeks, radiographically, there was no union. However, she had no pain and the orthopod's response to all this is..."try going back to some running and then if that's OK get back to soccer"...which she did without incident. His comment to the naysayers is "I treat patients, not X rays"

Freeman Churchill

 

However, ....having ostoepenia and being responsible for a small child which she should be at the very least casts/immobilized so she neither incidentally hurts her child or herself by falling.

Having an Occupational Therapist wife who works primarily in neurology has given me an insight into some strange and tragic events which resulted from parents falling onto children.

Freeman