Reader Comments: “I think a fracture like this has a high likelihood to heal without any intervention, and without any significant sequelae. Therefore, I would recommend to stop the anti-inflammatories and change to some other pain reliever (darvocet would be fine). I would recommend WBAT with a post-operative shoe, but if they are more comfortable with a CAM boot, that is fine. Don't do acute ORIF.” —J George DeVries, DPM �I would cast her non-weight bearing for four weeks followed by weight bearing in a removable cast brace for two more weeks. Her physical exam indicates she is not profoundly neuropathic, so I do not believe she is at risk for a Charcot flare.� —Sandra Martin, DPM “I would manipulate and conservatively cast” —David Wolfe, DPM “If concerned about healing of the incision, mini ex fix would not require an incision also allow distraction to reduce fracture and the compression. If incision healing not an issue, ORIF with locking plates” —Eric Miller,DPM “Recommendations: NON-SURGICAL Management? This fracture is minimally displaced? This fracture will heal regardless of almost any type of immobilization; unna boot with surgical shoe or BK CAM walker recommended. No need for ORIF as at times 5th metatarsal head may become prominent laterally.” —John Vanore, DPM “Pull to length under fluoroscopy & fixate with percutaneous mini-frag screw.” —Nyeoti Punni, DPM “Reduction of the simple oblique shaft fracture can be achieved with one to two 2.0mm cortical screws with or without an overlying buttress plate from the mini fragment set. Intraoperative assessment of the bone quality should dictate whether or not adjunctive plate fixation is necessary. Furthermore, a mini fragment locking plate could be utilized in the face of severely osteoporotic bone. The post-operative course should include non-weightbearing on the extremity for a minimum of 4-6 weeks depending on bone quality, as well as clinical and radiographic signs of healing. Tight glucose control is also advised to improve bone healing and decrease the chance of delayed/nonunion.” —Alan MacGill, DPM “Jones compression for approx. 2 weeks with no to partial weight-bearing. ORIF after edema is resolved.” —Timothy Sorensen, DPM “In years past I would open the fracture and run a .062 K-wire out the metatarsal head with the toe dorsiflexed and then reduce the fracture and send the K-wire down into the metatarsal base. The fracture would then be cerclage with mono-filament wire. I now use a locking plate from Ace DePuy (formerly Hand Inovations) F-3 Plating system. This is a low profile plate and you can bridge a severely comminuted region of the metatarsal shaft if necessary.” —William H.Simon, DPM “Place the patient in a posterior splint or jones compression and crutches. Ice could be applied to the popliteal region. Rx an NSAID..call it a day.” —Jeff C. Kass, DPM “Put the patient in a Cam-walker for 6-8 weeks, with repeat x-rays every 3 weeks just before the follow up visit. No need for surgery, mild displacement is ok, you should measure the displacement gap, up to 10mm displacement fractures still heal ok, this case is not an intra-articular fracture, so the patient should do well w/out ORIF.” —Henry Wu, DPM “This fx should be reduced and fixated...it can heal in a cast but not optimally. mid shaft met 5 fx's such as this tend to be more friable intra-operatively than one would expect....k-wire with one cortical screw has worked best for me. The screw can hold the alignment intra -op well, but the k wire insures rigidity.” —Dr. Martin, DPM ###

 

Treatment Plan

In our management of this patient, we initially attempted a closed reduction of the fracture, but found that the fracture was unstable and would not maintain a reduced position following manipulation.  The decision was made to bring the patient to the operating room to correct all deformity present and appropriately fixate the fracture in the corrected position.

Considering the degree of swelling present at the time, the patient was placed into a Jone’s compression dressing and posterior splint and instructed to remain non-weightbearing to the affected extremity.  The patient was scheduled to undergo surgery approximately one week later, thus allowing time to obtain medical clearance and to ensure that the swelling had appropriately been reduced prior to surgery.

Upon presentation on the day of surgery, the patient was noted to have significantly decreased edema, with a return of skin tension lines.  There were no fracture blisters noted, nor any skin sloughing which might suggest wound-healing issues post-operatively.   The fracture was fixated utilizing a 2.0 inter-fragmentary screw with a dorsally placed plate to provide further stability to the construct.  The deep tissues were closed utilizing 3-0 vicryl sutures, and the skin edges were co-apted and re-approximated utilizing 4-0 nylon sutures in a combination of simple interrupted and horizontal mattress suture technique. The patient was then placed into a modified Jone’s compression and posterior splint post-operatively, and was instructed to remain non-weight bearing to the left lower extremity.  The patient followed up 1-week post-operatively for a wound check and was placed into a short-leg non-weight bearing cast.  To date, the patient is approximately four weeks post-op, and continues to have no difficulties.

Click on the surgical images below for a larger view.
Fig. 1: Incision planning for surgical correction of the 5th metatarsal fracture.		Fig. 2: The fracture line is visible upon dissection.  There was mild hematoma formation noted which was evacuated and all bone debris was removed.
Fig. 3: The fracture is manually reduced prior to placement of temporary fixation.		Fig. 4: A 0.045-inch K-wire was utilized to provide temporary fixation at the fracture site.
Fig. 5: Following interfragmental screw placement, the K-wire was removed.		Fig. 6: A Stryker Variax plate was utilized along the dorsal surface of the metatarsal to provide further stability to the fracture site.

 

Click on the post op x-ray images below for a larger view.

 

Discussion

As is demonstrated from the number and varying degree of responses presented above, fracture management is an area of much discussion. In this case presentation, many readers opted for more conservative therapies, while others recommended surgical correction with either ORIF or external fixation, and depending on the circumstances, any of these recommendations has the potential to be an appropriate method for the management of this type of injury. A more conservative approach may be warranted in patients with limited deformity, who have demonstrated potential noncompliance, or in those patients who may have other medical issues that might preclude surgical correction. Patients who are more active, those who have a higher functional demand, or those who present with more significant deformity, may warrant more extensive correction than elderly patients with significant co-morbidities, and therefore it is vital that you know your patient.

When evaluating a fracture, the clinician must determine which course of action is appropriate for the patient at hand, either conservative or surgical. Largely, this determination is based upon a thorough evaluation of the stability of the fracture, and evaluation for any angular or length deformities that may be present. Generally speaking, fractures that are unstable upon closed reduction should be fixated to prevent malunion or nonunion formation. Furthermore, the presence of significant angular and length deformities should also be addressed to ensure the greatest functional outcome for the patient.

When discussing fracture management, swelling is of key importance, as many of your responses indicated. Edema at surgical site pre-operatively can create significant wound healing complications following surgery. It is vital that the edema be reduced prior to surgery via some sort of compressive dressing. In those cases in which fracture stabilization must be obtained early on despite swelling, external fixation provides an excellent modality to provide stability and reduction of the fracture fragments while having a relatively non-invasive application that limits the wound healing complications post-operatively. In those cases in which swelling is not a problem, ORIF can be utilized with screws, wires, pins, and plates (or any combination of these) to provide increased reduction and stability for the fracture during healing. In the case presented, the instability of the fracture following closed reduction, in addition to the shortening and angular deformity prompted surgical correction. Due to the significant edema upon the patient�s initial presentation, there were wound healing concerns, and therefore the procedure was delayed approximately 1 week to allow for reduction in swelling with the application of a compressive dressing. When the patient presented on the day of surgery, the swelling had reduced such that we were confident that ORIF could be attempted with limited concern for post-operative wound healing.

Intra-operatively, the patient�s bone was noted to be significantly osteoporotic, and therefore we decided to augment the correction obtained with the inter-fragmentary screw with the dorsally based, low profile locking plate. Due to the patient�s poor bone quality, we intend to maintain the patient in non-weight bearing until radiographic evidence of healing has been observed.

I appreciate the many great responses we received from those of you who participated in this case presentation. The greater discussion we can generate through case presentations, such as these, the stronger our collective knowledge base will become. As always I look forward to hearing from you, so please contact me if you have any comments, questions, or suggestions.  

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