Larry Fallat, DPM provides an in-depth look at metatarsal fractures. Dr Fallat discusses how to recognize a fracture, assess when to operate and determine what type of fixation should be used to stabilize the fracture.
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Larry Fallat, DPM
Director of the Podiatric Surgical Residency
Beaumont - Wayne Hospital
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Male Speaker: This is actually our 6th Resident Summit Meeting. It was a concept that we thought about a number of years ago, identifying the importance of residence and their education. We determined that at that point in time that we wanted to devote a certain amount of education to residents only. It’s your program. Resident director certainly and attendings from your programs are welcome to be at a meeting like this. The intent was to give you good content, a relaxing atmosphere, wonderful accommodations, food, and the ability to walk away with something you can bring back to your programs and use in the future. PRESENT e-Learning has taken the initiative, spent the dollars to enable this to happen. The sponsors that you see out in the exhibit area, critically important to the entire mission. We certainly hope that you take the opportunity to visit the exhibitors, speak with them, learn as much as you can from them as well. Your faculty is here for you. Take advantage. Questions are there to be answered. We’re here. We provide workshops which you’ll find are very interesting opportunity to get hands-on experience. At the end of the day we want you walking away from this meeting feeling like it was the right move to be here. Quite frankly I’ve been in education for 43 years as a resident director or a chief of department. I’ve always felt that the life blood of this profession comes out of our residency programs. The educational level today exceeds my greatest expectations when I was a young resident myself. So please enjoy everything that we have to provide for you. Our first speaker is Dr. Larry Fallat from Detroit, Michigan. Larry is an educator, involved with fellowship and residency training, tremendous amount of information to share with you. We’ve given them only three talks in a row. So please welcome Dr. Larry Fallat.
Dr. Larry Fallat: Right, I’ve worked with this. Good morning, everybody. I want to thank you for getting up so early and being here. This meeting is unique and that it is the only academic meeting designed specifically for residents. Quite honestly we should be getting all of the residents from the Midwest to attend this. Of all the seminars and meetings I’ve lectured at, this I think is the most important for your education. I’ve got three talks today. I wanted to talk about metatarsal fractures because I think this is the most common type of trauma that you’re going to see even in private practice. I think it’s important for you to be aware of these conditions and recognize them and when to operate and how to fixate these fractures. Let me just see if I can advance this. Disclosures of course and learning objectives. These learning objectives vary depending on every time I review the lecture there’s something new I want to emphasize to you. But I think you get the gist of what we’re going to try to accomplish. Essentially give you more familiarity with metatarsal fractures. 20 year ago, even now in some parts of the country there’s this concept that any two metatarsals in the same room will heal. You don’t have to do anything with him. We know that’s really not the case study especially when you see some of the fracture patterns like this. I think we’re a little more sophisticated than that right now and we should be because we’re the specialist of the foot and ankle. We have no choice. We have to look at the epidemiology of metatarsal fractures. This is [Zwipp’s] [04:23] paper. They broke some of these down and they found that metatarsal fractures were 10 times more frequent than Lisfranc fracture dislocations. In children they comprise 61% of all foot fractures. 41% occur in the 5th metatarsal. 19% in the first ray and 1st metatarsal. Petrisor did a very good study. In fact if you only read one, read this study, 355 patients, 411 metatarsal fractures, and incidence of 6.7 fractures per 10,000 people.
This is what interest me. The first metatarsal fracture only occurred 1.5% of the time. We know that’s not a real common type of fracture. The middle metatarsal is 10% of the time and of course as you would expect, the 5th metatarsal is fractured 68% of the time. If you have to have like a favorite bone, one you like the most, for me it’s the 5th metatarsal and the fibula because everything happens to those two bones and they helped us train a lot of residents. We look at the mechanism of injury and Petrisor’s study. He found that 46% of the metatarsal fractures occur with a twisting injury. 18% with a fall. 10% of direct blow dropping of car battery, something like that on your foot. Sports injuries, more of the biomechanical inversion injury, 7.9%. Falling from a height or from stairs, about 12% of the time. We know these mechanisms of injury. The other thing I want to draw to your attention is this metatarsus adductus foot, because this foot is absolutely prone to multiple metatarsal fractures. We know in this cable type of varus foot, even if it’s subtle, even if you don’t see a significant rear foot varus deformity, this foot has got abnormal loading and stress to the 4th and 5th metatarsals. This predisposes these particular bones to fracture. We’ll talk a little bit more about that as we go on. If we look at some of these classifications, some of these don’t have easy implication in the real world but as residents you have to know these classifications. You have to study and memorize them and know them for your boards because you will be quizzed on. The Salter classifications sometimes is a little bit tricky to memorize. It can be a little bit cumbersome but it can be helpful to you. AO classification, the various types of bone fractures. This is the fracture types. This is taken from Foot and Ankle Trauma chapter 20. This reviews the type of fractures we see in the foot, whether it’s oblique avulsion fractures, spiral, transversed. We see all of these in metatarsal fractures, like we see here and here. These are not that rare. These are common types of injuries. When you evaluate this type of fracture pattern, you have to modify fixation for each of these types of fractures. Take a look at the image I believe on your left, the 2nd metatarsal fracture occurs on two places. The 3rd metatarsal fracture has a butterfly fragment. 4th metatarsal fracture is oblique. By the way those little oblique fractures like I have here on the 4th metatarsal, those can be sometimes a little nightmare to reduce and to stabilize. So when we talk about treatment criteria, there’s not much out there. We tend to look at the foot in this way. The external metatarsals, the 1st and the 5th metatarsals, and the middle three metatarsals, the internal metatarsals, because treatment criteria can be a little bit different for the same type of fracture but located on the external versus middle metatarsals. So if we look again at Zwipp’s paper, he certainly recommends for stress fractures like we all do, 4th, 2nd, 3rd metatarsals slightly displaced in the frontal plane with no shortening. We know we can treat this with immobilization. [Shariff] [08:59] has taken this a step further, and indicates that more than three to four millimeters of displacement or 10 degrees of angulation on the sagittal plane, you need to operate. When we talk about 10 degrees of angulation in the sagittal plane, we’re not talking about necessarily dorsiflexion because a lot of these metatarsals will plantar flex as well. But if we don’t reduce sagittal plane deformities, we can certainly get the bursitis under the metatarsal heads, calluses, metatarsalgia, neuroma pain, and you guys know this. You know that we have to do this. Shariff’s recommendations were not proven in a study. He didn’t go to the lab and do this. This was just his opinion about how we should address these and what we should do. I would probably disagree with the three to four millimeters of displacement. Like any fracture, we feel maybe two millimeters. But again, it varies on many things.
The age of the patient, the location of the fracture, the activity level of the patient and so on, just like with any fracture. So if we take a look here on the lateral view, you can see the 2nd metatarsal is plantar flexed with a fracture. That’s actually somewhat easy to reduce but it needs to be stabilized. If you take a look at the 3rd metatarsal, you see the displacement. I would fixate that. That certainly is displaced enough and I think it’s non-controversial to displace it. When we look at the external metatarsals number one and number five, they bear more weight, so were much faster to operate on those than we are on the middle metatarsals. Take a look at the spiral oblique fracture, the 5th metatarsal. Surprisingly the Orthopedic Literature does not emphasize operating on this type of fracture even though there were certain risks associated with this such as delayed healing because of a diaphyseal fracture. Dorsiflexion elevation because it is a non-stable fracture. The line of thinking is that the 5th ray has to much hypermobility that even if this dorsiflexes, it’s not going to be an issue down the road. We absolutely disagree with this. I have seen a number of these over the years that weren’t fixated and they get pain under the 4th metatarsal head. When we operate, if we can’t compensate for it with an orthotic, when we operate we have to do an osteotomy and plantar flex and try and return the 5th metatarsal to its pre-trauma level. So let’s look at the fixation of these. I know a lot of residents are really hot on using bones screws, big bolt 6.5, and everything to fixate these. Don’t forget about K-wires because with these small thin metatarsal bones, sometimes the only way to maintain reduction and stabilize the fracture so it can heal uneventfully. This is a good picture. This guy had several things going on. If you take a look, a neutralization plate was used dorsally on the 3rd metatarsal. Intramedullary K-wire was used on four and five. In addition on number five, that cerclage wire around the bone. That’s what cerclage looks like. I know sometimes residents think cerclage is when you drill holes in the bone and loop the wire through. That’s intraosseous fixation and this is cerclage. Here’s another one. We might agree that that’s probably ineffective of fixation. We wouldn’t do this today. This picture is about 20 years old. But for residents I kind of wanted to show you where we have evolved in our fixation in metatarsal fractures. The screws are two Os. They are probably too small for this fracture. We have nothing stabilizing the fracture distally or proximally enough to provide stability. When we do operate, if you take a look at this, this is incision placement. Sometimes this comes up. I know a lot of the orthopedic guys are worried if we make these incisions, there’s going to be wound dehiscence, ischemic changes, gangrenous changes. I have never seen that happen. This is typical if you have multiple metatarsal fractures or if all five are fractured. One incision is placed over the metatarsal. This other incision is between number two and three and then the other one is between four and five. That gives you a very good access to all five metatarsals. So don’t worry about the incision placement. I have not seen adverse sequel as a result of that, assuming that the patient doesn’t have pronounced PVD prior to operating. Take a look at this. This is a study, again, Petrisor study. He had determined that 63% of 3rd metatarsal fractures was associated with either the 2nd or 4th metatarsals and 28% were associated with both fractures. We see this practice in clinic. The residents always like this because everybody gets to drive a k-wire and do something on a case like this. I’m trying to show you some patterns now with these metatarsal fractures. You know that the metatarsus adductus forefoot can result in 4th and 5th metatarsal fractures time after time, not just one time. It can happen even after you repair it. Then when we see the third metatarsal it’s almost like the key. If that one goes, chances are there’s going to be another one that’s broken as well. How do we fixate these? Here’s a pediatric case. This is an old case I had done. These wires are done precariously and I don’t do this so much anymore because the kids freak out when they see the pins sticking out. This is hard to do by the way and I question the stability of something like this.
When you do try to drive these pins in, I think I’ve got a pointer here. I guess not. As you drive them, the K-wire will slide off of the metatarsals. So a tip for residents, take a drillbit, take something. Create a little notch right where you want the pin to go in, and then you have much better control over it. It’s not sliding around and then you can angle it in the direction you want to get the best degree of stability. This is old. We don’t do this so much. This is the technique we like the best. This is from Zwipp. This is retrograde intramedullary K-wire fixation. That’s an open procedure. I have tried a closed. Usually when you’re doing this, it’s because the fracture is displaced enough that you can’t get close reduction. But you make the incision. You drive the 6 2 K-wire from proximal to distal through the plantar aspect of the foot. Then another resident will then lock on to the K-wire. We reduce the fracture and then the fracture, the K-wire is driven proximally to stabilize it. This is what it should look like. By the way, if you do this and you see one of the toes are pushed up, that means the K-wire is right under the base of the proximal phalanx of the toe. Don’t go with that even if you’re struggling to get the K-wire where you need it. Because in the six weeks it might take for this to heal, that toe can become permanently contracted and then you have to deal with that later on. Let’s see what we have here. Again, this is another one. Again, this is an old one. I want to show you this. This is not bad. This worked but this is much better and this is what we do now. We’re driving the K-wires much more proximal. We’re getting better stability. The pins are not loosening like they used to do when we were just biting across the fracture site. This is all common sense and logical. This is how to fixate it. One pin is good. Sometimes two pins are much better. Transverse fractures tend to rotate a little bit as patients move their foot. So if you can get two pins in, that works out much better. But take a look at – this is a case I think I’ve shown you earlier. This metatarsal fracture is essentially diaphyseal. It’s proximal to metaphysis. These take a long time to heal. Here’s another one. 2nd metatarsal is broken in two places. So we have two K-wires. One for each of the fractures. Notice the long wire in the 2nd metatarsals anchored into the second cuneiform for greater stability. The 3rd has two K-wires. Take a look at that 4th. I tell you. This fracture, this oblique at the neck can really make you look bad. You know how we have that saying, nobody looks good taking screws out. It’s the same with this particular type of fracture. Usually what happens is the head of the metatarsals rotated. You’re going to try and slide it back up on to the metatarsal. But if you don’t recognize that rotation in metatarsal head, it always has that flare laterally and it makes you look bad. Sometimes I’ve restored the length and that little lip is there and I’ve tried to grind it off and everything because I don’t like my pictures to look ugly. So it’s a headsup to you. Just be aware, that head is rotated and it can give you a tough time. Pediatric fracture here, right through the growth plate. Never been a study that has indicated that a K-wire through the growth plate has caused premature closure, so this is absolutely an acceptable way to do this. The other thing here, if you take a look at that second metatarsal, you might say, “If I can just close reduce it, that might be fine.” If you’ve got the patient on the table, fixate and stabilize all three fractures. I’ve had a number of cases over the years where I left the one diaphyseal metatarsal fracture alone. I didn’t put a pin in. Everything healed and three, four months later, we were still trying to get the fracture healed but I didn’t put the fixation in. Neutralization plate, usually these are one quarter tubular plates. Two seven screws. If you do something like this on a pure transverse fracture, remember try and do some eccentric drilling to get some degree of compression across the fracture site. These are still pretty good. These are K-wires. These unfortunately are percutaneous but a very effective fixation to stabilize a fracture especially if you don’t want to open it up. So that looks pretty good. Here’s another one. These are multiple metatarsal-base fractures. Here, simple screws were used for stabilization. This may not be the strongest type of fixation but this is an acceptable type of fixation for stability. Here’s a great little case by the way. This is very rare. It’s called Bipolar type of fracture dislocation.
This is usually seen in MVAs or motorcycle accidents. This was a motorcycle accident. The first metatarsal is rigidly situated underneath the second metatarsal. You got to get like a crowbar and put it above the first metatarsal and under the second metatarsal and you have to pop that thing up. But the catch is you have to do that without breaking the second metatarsal. Once that does reduce itself, then we just stabilize the fracture for seven weeks or so and heals uneventfully and off he goes. I show you this because this is rare. I think there’s only been one other in the literature. Always meant to write this stuff but just never had the time. Now the first metatarsal, I got to show you something with this. Comminuted fracture like this is easy enough to treat. We all know how to handle that with one third tubular plate. But if you take a look at these and look at the first metatarsal base, these are tricky little fractures to reduce. Theoretically, possibly caused by the peroneus longus undergoing sudden tension, pulling off the plantar lateral aspect of the first metatarsal base. Don’t be deceived by these. These are very tricky little fractures. Really this is just about what you have to do to get to. You’ve got to almost pull that base out. There’s just no other way to get to it to reduce the fracture. Once you have it out like this, then you can stabilize it and reduce it and pop that back in place and fixate it with any modality that you want. You’re getting a good lecture on Jones fractures this weekend. But I wanted to review a couple of things with him. This is a study we’re doing at our facility. Patel [phonetic] is doing this. This is 110 5th metatarsal fractures that we have looked at. 12 of them were neck fractures. 52 were diaphyseal. 46 were base of the base.17 Jones and 29 avulsion. I think what’s significant here is that literature doesn’t really address diaphyseal 5th metatarsal fractures and that it is a very common injury. I think we’re the first study to show just how common this is. It’s an easy enough fracture to fixate but this gives you an idea of the distribution. What we see in just our little practice outside of Detroit. How do we fixate that? By the way that should say one quarter tubular plate, 2.7 millimeter screws. Essentially we’re using a neutralization plate to stabilize this. These fracture line are small. In other words, spike as thin. So you really can’t get a screw to achieve interfragmentary compression. Sometimes you can get lucky and do it but that spike that you’re looking at that’s touching down towards the fourth metatarsal is very thin. It can only be a couple millimeters wide. I have broken that trying to run a screw through that. If you can go more proximal, good. Then that would be successful. See here’s one that’s comminuted fragments in it. Significant shortening in displacement. You have to fixate these. Any type of plate would be effective at reducing that. Here’s another one. This is a shorter oblique fracture. But again, they’re shortening. It’s displaced. Here we have used a six-hole one quarter tubular plate, two seven screws. But for greater stability, we’ve shot a K-wire through and the K-wire is coming out underneath the 5th toe. This helps resist axial loading and unnatural fracture. There’s just no way we could really get a screw to achieve any degree of interfragmentary compression. This is called a cage. It’s a technique we had taken from the literature. We use it on the fibula. We use this especially in our senior citizens. People with osteoporosis, people with – well, they’re elder and they can’t use crutches. They’re going to have to bear weight on it. So we make this as strong as we can. This is very effective type of fixation. The avulsion fractures. Well, if you take a look at this, if they’re not displaced, we don’t operate. These things heal pretty good but many times they are displaced and here’s one that comminuted. It’s a small fracture. This is ideal for tension-band wire. This tension-band is great because it counteracts the tension of the peroneus brevis tendon. By the way, we like to think that the peroneus brevis is the cause of these fractures. It’s nice to say. It’s easy to say. It’s logical but in a lab that has never been reproduced by pulling on the brevis, avulsion fractures have not occurred. So it’s probably the lateral band of the plantar aponeurosis that results in these fractures, or combination of both of them.
Either way, the tension-band wire is very effective for counteracting the pull of those structures. This is percutaneous screw fixation, the advantages. Just a small incision big enough to get the screw in. There’s no periosteal stripping. So theoretically we should get faster healing. There should be minimal post op pain. It’s a funny thing we do this procedure. The patients will have like a four millimeter incision and the guys just cry like babies after surgery. “God you’ve killed me.” Women just, “Oh yeah. Can I go shopping today?” This is what it looks like, Intramedullary screw fixation. As you look at this x-ray with the screw on place, you really can’t go longer than that. So picture if I had a longer screw and I’m trying to advance it. It’s hitting that medial wall of cortical bone. If I keep driving it, it’s going to displace the fracture. Unless you can drill through that wall which is sometimes is not the easiest thing to do. Here is another one. Here’s a larger screw. If you notice, there’s no lateral bowing on the 5th metatarsal. This is primarily a straight shot right in the canal. This still works for these proximal fractures or Jones fractures. Two cross K-wires by cortical fixation. Very effective way of providing stability. Here is a small neutralization plate. This is a one quarter tubular plate two seven screws. Now the problem with this is because it’s transverse and that darn bone is so small, you can’t always get an interfrag screw through there. If you can’t, then maybe and you think you’re going to need further stability, then maybe consider the K-wire technique that I have shown you. Here’s repair of a non-union. A bone was taken out of the distal tibial metaphysis and put into the fracture site. This is protected with a neutralization type plate to seal then patient did find here. We are able to get a little interfrag screw across the fracture site. Then even with that, we still did eccentric drilling to try and maintain that. This is a locking plate. It’s a hook plate. It doesn’t quite always fit. You got to bend it. It looks like a rat’s nest quite honestly. I mean it worked but looks like I found that out in the parking lot and we put it in. It was just a little hard to contour. Since I had used that, there are other hook bites out there for the 5th metatarsal. I think that fit a little better than that did. Here’s another one and I wanted to show you this. Here we’re advancing the K-wire. Sometimes the K-wire will hit the inside of the cortical bone and it won’t follow the canal. So in that case, take the drill off and just tap it in like this. If you tap it gently and slowly, the wire will follow the canal. The other thing, as residents, when you’re getting ready to drive this, you have C-arm there, take the wire out of the driver. Just hold it there with your hand like this. Get the x-rays. Once you’re good, then put the driver on. It’s just as faster. It’s easier if you do something like that. It’s a little tip to maybe speed this process up. Now here’s another one. This is a solid bone screw 5.5 millimeters. I love this screw. This is tight. When you drive it in, you can hear it squeaking as you’re biting the bone. Very strong intermedullary fixation. But the key is on x-ray, pre op x-ray, you have to measure the distance of the canal where you’re going to put the screw. So you’re going on the inside diameter of the canal and to make sure that you have the right screw. So if you have five millimeters space in there and you’re putting a 5.5, you can crack the cortex. So a good type of fixation but be aware of that precaution. Just a couple of case reports and we’ll be done with this talk. This was a young guy we had just seen. I believe 25 years old. He injured his foot but was not aware of previous injury to his foot. So he’s got a fine diaphyseal fracture, the 5th metatarsal, and he’s got an obvious non-union of the 4th metatarsal. So for fixation, it’s a calcaneal autogenous graft. We’re using a trephine. We’re getting it out of the calcaneus. Take a look where we’re taking the graph from. That’s on the superior lateral aspect of the calcaneus and there’s very little tension in that area safe site to harvest the bone graph from.
We then use a trephine and we remove the plug, the bone that holds the non-union site. Then we camp the plug in and we fixate it with one quarter tubular plates and of course two seven bone screws. I think this is a very strong type of fixation for him. Ideally he should have metatarsal osteotomies to correct the deformity but at least now for treating the fracture this is how we approach that. Here’s a malunion. This was a 22 year old kid. He installed garage doors for living. Garage door fell down, broke his metatarsals. He saw his PCP and he said, “You’ll be fine. It will heal.” It healed but it healed in malunion position. Now take a look at his motion. You see the dorsiflexion is very limited. Look at plantar flexion. He’s got virtually no plantar flexion and very painful on that area. Physical therapy does not help for something like this. So he needs to have an operation and we need to correct the angulation deformities that we have of these metatarsals. This is taken during the procedure and I want to show you the fixation. Osteotomies were made. The metatarsal heads were realigned. On the second metatarsal, plate was used. But look at the intermedullary K-wires we have for the 3rd and 4th in addition because the fractures were oblique and I recreated the fracture to reduce that. I used additional K-wires perpendicular to the fracture site. No significant degree of interfrag compression. Just whatever the coefficient of friction is so the K-wires and the bone is all we would achieve with that. But at one year route, he’s fine. He returned to his job. Metatarsal length has been restored and off he goes with something like that. So complications, certainly metatarsalgia, bursitis, neuroma, all of the things that you would expect to see with displaced malunion metatarsal fractures. Synostosis can occur. Surprisingly that was not painful. That really frustrated me. I just had the need to get that bar out of there. But these are things that can happen. I think my slides are scrambled a little bit but that was the end of my talk. I hope that he’s given you some information about metatarsal fractures, the recognition of them, assessing the importance of the fracture, when we operate and what type of fixation that we use to …