Base of fourth metatarsal stress fracture: tendency for prolonged healing

Fourth metatarsal base stress fractures in athletes: a case series

BACKGROUND

Metatarsal stress fractures account for approximately 28% of all stress fractures reported in the literature. Second and third metatarsal stress fractures are most common, followed by fractures of the fourth and fifth metatarsal. Reports in the literature suggest that proximal fourth metatarsal stress fractures have the same propensity for delayed healing and nonunion as do fifth metatarsal stress fractures. There is a paucity of literature on operative management of fourth metatarsal fractures. This study reports the results of operative management of fourth metatarsal stress fractures in athletes.

METHODS

A retrospective review with prospectively collected data was undertaken to evaluate utility of operative care of fourth metatarsal stress fractures in an athletic population desiring early return to sports. Eleven athletes over a 13-year period were enrolled with proximal fourth metatarsal stress fractures. The American Orthopaedic Foot & Ankle Society (AOFAS) Midfoot scores were obtained pre- and postoperatively. Midfoot alignment, including the presence or absence of metatarsus adductus, radiographic time to healing, and time to return to sports were also recorded.

RESULTS

All patients were treated with operative open reduction and internal plate fixation with calcaneal autograft. Four of the 11 patients had metatarsus adductus. All had evidence of radiographic healing prior to return to activity, all returned to sports at an average of 12 weeks post surgery, and all would choose surgery again given the same injury. The AOFAS Midfoot scale improved from an average of 55 preoperatively to 94 postoperatively (P < .001) CONCLUSION: Our study suggests that operative repair of fourth metatarsal stress fractures hastens time of healing and return to sports in athletes. It also supports the theory that there is a correlation between metatarsus adductus lateral metatarsal stress fractures.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Stress fracture of the fourth metatarsal in a relapsed clubfoot of a 5.5-year-old child

Stress fractures are uncommon in skeletally immature patients and usually affect adolescents involved in competitive sports, whereas they are very rare in young children. Involvement of the fourth metatarsal is very infrequent and has been associated with metatarsus adductus deformities. The authors describe a stress fracture of the proximal fourth metatarsal occurred in a 5.5-year-old child with a relapsed clubfoot. Operative correction of the deformity and cast immobilization provided consolidation of the fracture. Stress fractures of lateral metatarsals may represent a possible source of pain in recurrent clubfeet, even in young children. In these cases, early correction of the deformity is required.

Stress fractures in the lower extremity. The importance of increasing awareness amongst radiologists

Stress fractures are fatigue injuries of bone usually caused by changes in training regimen in the population of military recruits and both professional and recreational athletes. Raised levels of sporting activity in today's population and refined imaging technologies have caused a rise in reported incidence of stress fractures in the past decades, now making up more than 10% of cases in a typical sports medicine practice. Background information (including etiology, epidemiology, clinical presentation and treatment and prevention) as well as state of the art imaging of stress fractures will be discussed to increase awareness amongst radiologists, providing the tools to play an important role in diagnosis and prognosis of stress fractures. Specific fracture sites in the lower extremity will be addressed, covering the far majority of stress fracture incidence. Proper communication between treating physician, physical therapist and radiologist is needed to obtain a high index of suspicion for this easily overlooked entity. Radiographs are not reliable for detection of stress fractures and radiologists should not falsely be comforted by them, which could result in delayed diagnosis and possibly permanent consequences for the patient. Although radiographs are mandatory to rule out differentials, they should be followed through when negative, preferably by magnetic resonance imaging (MRI), as this technique has proven to be superior to bone scintigraphy. CT can be beneficial in a limited number of patients, but should not be used routinely.