Case Study 8.1: Acute Metatarsal Fracture
Karen M. Myrick
SETTING: ORTHOPEDIC URGENT CARE
Definition and Incidence
Metatarsal fractures are common in both children and adults (Boutefnouchet, Budair, Backshayesh, & Ali, 2014). Special attention needs to be paid to the fifth metatarsal bone, as it is the most commonly injured metatarsal bone, and can have surgical implications for repair (Boutefnouchet et al., 2014).
Patient presents with the chief complaint of left foot pain. He describes a history of playing baseball at his high school earlier in the day. He states, “I was running down the first base line when I was tagged out. I stepped on first base, landing slightly off to the side. I felt a sharp pain, and I fell to the ground.” He was helped off the field by the athletic trainer and another player, stating he was unable to bear weight. He describes the swelling as immediate, and ice was placed. He watched the end of the game and presents for evaluation. Discomfort is well located in the left foot and moderate, rated as a 6 out of 10. Pain is worse with weight bearing, and associated with a significant limp, favoring the left leg, when attempted.
This 19-year-old male is in his senior year of high school, and he plans on playing at an intramural level in college.
Avulsion fractures are common in the skeletally immature patient with separation at the apophysis as the most frequent injury (Mehlhorn, Zwingmann, Hirschmüller, Südkamp, & Schmal, 2014). An avulsion fracture is commonly treated in a short-leg walking cast for 3 weeks.
The patient is a 19-year-old male who is in no acute distress, but demonstrates hesitancy and some discomfort throughout the physical examination. He is 6′3″ and weighs 203 lb. His gait is antalgic, demonstrating a shortened stance phase on the left, and pain with any pressure on the left foot. On inspection, there is a moderate joint effusion and no open cuts or abrasions. With palpation, there is bony point tenderness over the midshaft of the fifth metatarsal on the left foot. Range of motion in the left ankle is full and pain free. There are no focal neurological deficits in the left lower extremity.
A radiograph was obtained and demonstrates a midshaft metatarsal fracture on the left foot (see Figure 8.1).
Midshaft metatarsal fracture left foot.
The patient was placed into a posterior splint, and provided crutches. He was instructed to maintain a nonweight-bearing status until he follows up in 7 to 10 days.
Educate the patient and his family to avoid activity, especially weight bearing, until they follow up for repeat x-rays and definitive management.
The patient was seen in follow-up at 8 days. At that point, his radiographs were repeated, and they demonstrated no change in alignment of the fracture, with fragments well approximated. A firm, supportive shoe was placed and used for the next 4 weeks. And the patient progressively added weight bearing until full within 1 week out from this visit. Four weeks later, radiographs were obtained and demonstrated good healing of the fracture with callus formation, and the patient was provided a prescription for physical therapy at a rate of two to three times a week for the next 4 to 6 weeks with progression back to activity and a home exercise program.
Boutefnouchet, T., Budair, B., Backshayesh, P., & Ali, S. A. (2014). Metatarsal fractures: A review and current concepts. Trauma, 16(3), 147–163. doi:10.1177/1460408614525738
Mehlhorn, A. T., Zwingmann, J., Hirschmüller, A., Südkamp, N. P., & Schmal, H. (2014). Radiographic classification for fractures of the fifth metatarsal base. Skeletal Radiology, 43(4), 467–474. doi:10.1007/s00256-013-1810-5
Case Study 8.2: Acute Lisfranc Dislocation
Vinayak M. Sathe, Teja Karukonda, and Daniel Witmer
SETTING: OUTPATIENT CLINIC FOLLOW-UP FROM URGENT CARE CENTER
Definition and Incidence
The Lisfranc complex in the midfoot is an intricate interaction between the first and second metatarsals, the medial and middle cuneiforms, and the ligamentous supports that traverse these joints (Seybold & Coetzee, 2015). High-energy mechanisms of injury or trauma and low-energy injuries in the athlete are the most common mechanisms of injury (Seybold & Coetzee, 2015).
A 50-year-old female patient presents with right foot pain and swelling of several weeks’ duration. It began when she sustained a fall while ambulating; however, she could not recall the exact position of her right foot at the time of the injury. She immediately noticed significant pain, swelling, and bruising over the dorsum of her right foot. She initially presented to an urgent care clinic and was advised that her injury was a benign soft tissue injury and that she could remain weight bearing as tolerated on the right lower extremity in a walking boot with crutches. Over the next 2 weeks, the patient’s swelling and ecchymosis partially improved; however, she continued to experience significant pain aggravated by weight bearing and activity as well as persistent swelling at the end of the day. Her pain was localized over the dorsum of the right midfoot and was unresponsive to anti-inflammatory medications or pain relievers. She felt relief when she was not bearing weight on the right foot. In addition, she reported mild numbness over the dorsum of the foot. She denied any other associated symptoms including fevers, chills, or any other musculoskeletal pain or weakness.
Patient is a college professor at a local community college. She is married and has two adult children.
The patient was in no acute distress. She had normal standing alignment with an antalgic gait favoring the left lower extremity. She avoided full weight bearing on the right lower extremity on gait analysis. On focused assessment of her right lower extremity, she was found to have significant swelling and ecchymosis over the dorsum of her right midfoot as well as plantar ecchymosis in the arch of the foot. Her skin was intact with no abrasions or lacerations. She had tenderness to palpation localized over the bases of the first and second metatarsals as well as over the medial and middle cuneiforms. There was no crepitus or bony step off on palpation. There was no gross instability noted on attempted motion of the first and second tarsometatarsal (TMT) joints; however, motion at the first and second TMT joints elicited pain. She had full active range of motion of the ankle, subtalar joint, and the toes with full motor strength throughout the right foot and ankle. Her sensation to light touch was preserved in all nerve distributions; however, she reported some mild diminishment overlying the area of dorsal midfoot swelling. She had good distal pulses and brisk capillary refill.
Initial nonweight-bearing x-rays of the right foot revealed no concerning abnormalities including no evidence of fracture, dislocation, or subluxation. Weight-bearing x-rays of the right foot revealed slight widening between the bases of the first and second metatarsals and the second metatarsal (see Figures 8.2 and 8.3) and medial cuneiform with a small avulsion fracture of the superolateral aspect of the medial cuneiform. MRI of the right foot revealed diastasis of the medial cuneiform and second metatarsal base with disruption of the interosseous and dorsal components of the Lisfranc ligament. No frank dislocation of the TMT articulations was present. In addition, a bone contusion within the navicular was noted.
Lisfranc fracture dislocation, right foot.
All unstable Lisfranc injuries should be managed surgically as this area of the foot is susceptible to posttraumatic arthritis and adverse functional outcomes with nonanatomic alignment of the midfoot TMT joints (Watson, Shurnas, & Denker, 2010). Ideally, these injuries are best managed within the first few weeks following onset; however, surgical intervention must be delayed until resolution of swelling, which is typical with these injuries.
The patient was placed into a posterior splint, and given crutches. She was instructed to be nonweight bearing, and she was provided with a referral to an orthopedic surgeon within 5 days. The patient elected to proceed with operative intervention. The risks and benefits of open reduction and internal fixation (ORIF) with possible midfoot fusion of her right foot Lisfranc fracture-dislocation were discussed. In the preoperative period, she was advised to remain nonweight bearing on the right lower extremity and was provided with a controlled ankle movement (CAM) walker boot as well as a knee scooter.
If a nonoperative treatment course is pursued, patients should be advised that it takes approximately 4 months for a Lisfranc injury to heal nonsurgically and that during this time frame they will be nonweight bearing on the extremity. Typically, a walking boot or a rocker sole shoe is used after this time frame for a few months to provide additional support and off load the midfoot. Additionally, patients may be referred to physical therapy to work on gait training and balance.
It is important to note that her injury was missed at initial presentation to an urgent care center with nonweight-bearing x-rays. A high suspicion for this injury should prompt the clinician to obtain weight-bearing x-rays and/or additional imaging studies such as MRI and CT scan in order to rule out or fully elucidate the nature of this injury.
Approximately 4 months after her procedure, her hardware (two screws) was removed in the operating room. Her Lisfranc joint remained well reduced on x-ray and after 3 to 4 weeks of nonweight bearing, the patient was finally transitioned to weight bearing as tolerated on the right lower extremity. She was referred to physical therapy and remained asymptomatic.
Seybold, J., & Coetzee, J. (2015). Lisfranc injuries: When to observe, fix, or fuse. Clinics in Sports Medicine, 34(4), 705–709.
Watson, T. S., Shurnas, P. S., & Denker, J. (2010). Treatment of Lisfranc joint injury: Current concepts. Journal of the American Academy of Orthopaedic Surgeons, 18, 718–728.