Metatarsal Stress Fractures – Causes, Symptoms, Treatment

Diagnosis of Metatarsal Stress Fractures

During an interview, patients indicate that there is an inciting activity or exercise subjecting the patient to repetitive stress. Activity-related, insidious onset of pain at the site of fracture is often elicited from history. Pain may improve transiently with rest but increases again with activity. Pain often is described as dull and aching. It is important to obtain a thorough medical history with particular attention to potential intrinsic risk factors. This may include an interview on a patient’s diet, endocrine disorders, and menstrual history in female patients.

Physical examination consists of palpation of the pain site, eliciting boney tenderness. If the fracture is in the proximity of a joint, the joint motion will aggravate the pain. Patients may have a limping gait with weight-bearing.

History and Physical

• These patients typically present with pain about the lateral aspect of the forefoot that is worse with weight-bearing activity. This pain may occur in the setting of acute trauma or repetitive microtrauma over weeks to months. One should be suspicious of stress fracture with antecedent pain or pain of worsening quality or duration over time. The examiner must obtain a thorough past medical history and social history to make treatment decisions and optimize patients with surgical indications. It is important to evaluate the skin for open injuries that may require more urgent debridement.
• Physical examination may reveal tenderness to palpation, swelling, and ecchymosis at the site of injury. Patients will also have pain with resisted foot eversion. It is critical to evaluate the patient for other injuries, including injury to the lateral ankle ligamentous structures and Lisfranc injury.
• An exam of the circulatory system, feeling for pulses, and assessing how quickly blood returns to the tip of a toe after it is pressed and the toe turns white (capillary refill).
• A neurologic exam, assessing sensation such as light touch and pinprick sensations
• Motor function, asking the patient to move the injured area. This assists in assessing muscle and tendon function. The ability to move the foot means only that the muscles and tendons work, and does not guarantee bone integrity or stability. The concept that “it can’t be broken because I can move it” is not correct.
• A range of motion exam of the foot may be helpful in assessing ligament stability. However, if the fracture is obvious, the health care practitioner may choose to keep the foot immobilized to prevent further pain.

Imaging

• X-rays – are often taken to evaluate the status of the bones in the foot and to check for a fracture. Usually, three views are taken to help the health care professional and radiologist adequately view the bones. Special views may be taken if there is a concern for a fracture of the calcaneus. X-rays may not be taken for simple toe injuries, since the result may not affect the treatment plan.
• For some foot fractures, X-rays – may not be adequate to visualize the injury. This is often true for metatarsal stress fractures, where bone scans may be used if the history and physical examination suggest a potential stress fracture, but the plain X-rays are normal.
• Computerized tomography (CT) – may be used to assess fractures of the calcaneus and talus, since it may better be able to illustrate the anatomy of the ankle and midfoot joint and potential associated injuries. Magnetic resonance imaging (MRI) may be used in some cases of foot fractures.
• The Lisfranc joint describes  – the connection between the first, second, and third metatarsals and the three cuneiform bones. A Lisfranc fracture-dislocation often requires a CT scan to evaluate this region of the foot. While X-rays may hint at the damage in this type of injury, the CT scan delineates the numerous bones and joints that may be damaged.
• Clinical tests – such as the use of therapeutic ultrasound and tuning forks are also useful in diagnostic investigations on stress fractures.[rx] When used directly on the site of the suspected lesion, they may trigger or worsen the pain because of the great local osteoclastic reabsorption, which results in injury to the periosteum.[rx, rx] In addition, the skipping rope test (hop test) can be used: this consists of asking the patient to hop on the spot while putting weight on the limb that is under investigation. The test is positive when it triggers strong or incapacitating pain in the region injured.[rx, rx]
• Some laboratory tests – may be useful in investigating stress fractures: serum levels of calcium, phosphorus, creatinine, and 25(OH)D3. Nutritional markers should be requested in the presence of clinical conditions of weight loss and anorexia. Hormonal levels (FSH and estradiol) should be investigated when there is a history of dysmenorrhea.[rx]
• Computed tomography (CT) – is used mainly when there is a contraindication against using magnetic resonance imaging.[rx, rx, rx, rx] Chronic and quiescent lesions may be more evident in this examination than on magnetic resonance imaging or bone scintigraphy because they present low bone turnover.[rx] Single-photon emission CT (SPECT) has been particularly more useful in investigating stress fractures involving the dorsal spine, and specifically in pars interarticularis (spondylolysis).[rx, rx, rx]
• Nuclear medicine using triple-phase scintigraphy – (technetium-99 m) presents significant sensitivity (74–100%) to bone remodeling and shows imaging alterations three to five days after the start of symptoms. [rx, rx, rx, rx] The radiopharmaceutical becomes concentrated in the regions affected and detects areas of bone remodeling, microfractures of the trabecular bone, periosteal reaction, and formation of bone callus.[rx]
• Magnetic resonance imaging (MRI) – is the most sensitive and specific imaging examination for diagnosing stress fractures. It is recommended by the American College of Radiology as the preferred examination in the absence of radiographic alterations.[rx] The abnormalities caused by the fracture can be identified one to two days after the start of the symptoms, with early detection of edema in the bone tissue and adjacent areas.rx[, rx, rx] This examination makes it possible to differentiate medullary damage from cortical, endosteal, and periosteal damage allows gradation of the lesions regarding their severity and prognosis. Intramedullary endosteal edema is one of the first signs of bone remodeling and may continue to be present for up to six months after the fracture has been diagnosed and treated, while the cortical maturation and remodeling take place.[rx, rx] Medullary edema or signs of bone stress may also be present in asymptomatic physically active patients, without any correlation with an increased incidence of stress fractures, especially in the tibia in marathon runners. The fracture line is less commonly visible. It presents sensitivity slightly greater than or equal to that of scintigraphy, but it is considered to be a more specific examination.[rx, rx, rx]

Treatment of Metatarsal Stress Fractures

Fractures of the toe bones are almost always traumatic fractures. Treatment for traumatic fractures depends on the break itself and may include these options:

Initial Treatment Includes

• Get medical help immediately – If you fall on an outstretched leg, get into a car accident or are hit while playing a sport and feel intense pain in your leg area, then get medical care immediately. Cause significant pain in the front part of your leg closer to the base of your leg. You’ll innately know that something is seriously wrong because you won’t be able to lift your leg up above the heart level. Cleaning and treating any wounds on the skin of the injured hand.
• Aggressive wound care – as needed for contaminated wounds. Clear with disinfectant material [rx]
• ICE and elevation – It help for prevention swelling, edema
• Rest – Sometimes rest is all that is needed to treat a traumatic fracture of the toe.mSometimes rest is the only treatment needed to promote healing of a stress or traumatic fracture of a metatarsal bone.
• Elevation – Elevation initially aims to limit and reduce any swelling. For example, keep the foot up on a chair to at least hip level when you are sitting. When you are in bed, put your foot on a pillow. Sometimes rest is the only treatment that is needed, even in traumatic fracture.
• Splinting – The toe may be fitted with a splint to keep it in a fixed position.
• Rigid or stiff-soled shoes – Wearing a stiff-soled shoe protects the toe and helps keep it properly positioned. Use of a postoperative shoe or boot walker is also helpful.
• Buddy taping the fractured toe to another toe is sometimes appropriate, but in other cases, it may be harmful.
• Avoid the offending activity – Because stress fractures result from repetitive stress, it is important to avoid the activity that led to the fracture. Crutches or a wheelchair are sometimes required to offload weight from the foot to give it time to heal.
• Immobilization, casting, or rigid shoe – A stiff-soled shoe or another form of immobilization may be used to protect the fractured bone while it is healing. The use of a postoperative shoe or boot walker is also helpful.
  
• Casting, or rigid shoe – A stiff-soled shoe or another form of immobilization may be used to protect the fractured bone while it is healing. The use of a postoperative shoe or boot walker is also helpful.
• Stop stressing the foot – If you’ve been diagnosed with a stress fracture, avoiding the activity that caused it is important for healing. This may mean using crutches or even a wheelchair.

Medication

The following medications may be considered doctor to relieve acute and immediate pain

• Antibiotic – Cefuroxime or Azithromycin, or  Flucloxacillin or any others cephalosporin/quinolone antibiotic must be used to prevent infection or clotted blood remove to prevent furthers swelling and edema
•  Antidepressants – A drug that blocks pain messages from your brain and boosts the effects of endorphins (your body’s natural painkillers).
• Corticosteroids – Also known as oral steroids, these medications reduce inflammation. To healing the nerve inflammation and clotted blood in the joints.
• Muscle Relaxants –  These medications provide relief from associated muscle spasms.
• Neuropathic Agents – Drugs(pregabalin & gabapentin) that address neuropathic—or nerve-related—pain. This includes burning, numbness, and tingling.
• Opioids – Also known as narcotics, these medications are intense pain relievers that should only be used under a doctor’s careful supervision.
• Topical Medications – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation through the skin.
• NSAIDs – Prescription-strength drugs that reduce both pain and inflammation. Pain medicines and anti-inflammatory drugs help to relieve pain and stiffness, allowing for increased mobility and exercise. There are many common over-the-counter medicines called non-steroidal anti-inflammatory drugs (NSAIDs). They include  and Ketorolac, Aceclofenac, naproxen
• Calcium & vitamin D3 – to improve bone health and healing fracture.
• Glucosamine & Diacerein, Chondroitin sulfate – can be used to tightening the loose tension, cartilage, ligament, and cartilage, ligament regenerate cartilage or inhabit the further degeneration of cartilage, ligament
• Dietary supplement -to remove general weakness & improved health

Surgery

Treatment decisions have their basis on the anatomic zone of injury, the social and medical history of the injured patient, and evidence of radiographic signs of healing.

• Nondisplaced zone 1 injuries – can be treated conservatively with protected weight-bearing in a hard-soled shoe, walking boot, or walking cast. Progression to weight-bearing as tolerated can initiate as pain and discomfort subside over 3 to 6 weeks. Fractures involving 30% of the articular surface or with an articular step off over 2 mm have treatment with open reduction and internal fixation, closed reduction, and percutaneous pinning, or excision of the fragment.[rx]
• Nondisplaced zone 2 injuries or Jones fractures – may also be treated conservatively with 6 to 8 weeks of non-weight bearing in a short leg cast. The physician may advance weight-bearing status as radiographic evidence of bone healing appears. Indications for surgical interventions include the high-performance athlete, the informed patient who elects to proceed with surgical treatment, or displaced fractures. There are many forms of surgical interventions, including intramedullary screw fixation, tension band constructs, and low profile plates and screws. Surgical management of high-performance athletes minimizes the risk of nonunion and prevents prolonged restriction from physical activity.
• Diaphyseal zone 3 stress fractures – paint a more complicated picture for the patient and physician. A trial of conservative management with non-weight bearing in a short leg cast may be the initial therapy, however, immobilization for up to 20 weeks may be necessary before there is observable radiographic union, and even then, nonunion development is not uncommon. High-performance athletes or individuals with Torg Type II or III fractures may require surgical interventions. Surgical options include intramedullary screw fixation, bone grafting procedures, or a combination of the two.[rx]
• The bone grafting inlay technique – requires removing a 0.7 by 2.0 cm rectangular section of bone at the fracture site and replacing it with an autogenous cortical cancellous bone graft of the same dimensions taken from the anteromedial distal tibia. The medullary cavity must be curetted or drilled until all of the sclerotic bone has been removed and the medullary canal reestablished prior to inserting the donor graft.
• Nondisplaced dancer’s fractures – and other fractures of the fifth metatarsal shaft and neck receive the same treatment as nondisplaced zone 1 injuries. Weight-bearing status can advance as tolerated by pain. If evidence of delayed union or nonunion exists, surgical interventions may be required. If there is more than 3 mm of displacement or angulation exceeds 10 degrees, the fracture should be reduced and splinted.[rx] If the fracture remains mal reduced or there is evidence of loss of reduction on follow-up radiographs, surgical interventions with percutaneous pinning or plate and screw fixation should be a consideration.

Patients treated with intramedullary screw fixation or bone graft inlay technique should remain non-weight bearing in a plaster splint or short leg cast for six weeks with a gradual return to sport or activity.[rx]

Other Treatments