Metatarsal Fractures, Foot Fracture, Broken Foot
Foot injuries are complicated due to the anatomy of the foot and the punishment we give our feet
Injuring the metatarsals
Metatarsal fractures are the most common foot injury, with many sufferers in professional sport every year. Many famous athletes have suffered metatarsal fracture, with David Beckham and Wayne Rooney leading the list in the ranks of professional footballers. The metatarsal bones are small but significant, a fracture condemning an athlete to several months of waiting and rehabilitation before he or she is back at their best.
The ankle bone, called the talus, is the bone between the tibia and fibula and together these three form the ankle joint. Under the talus is the heel bone (calcaneum) and this projects backwards to the heel. In front of the talus are the bones of the mid-foot which include the navicular and cuboid.
Further forward then come the metatarsal bones, of which there are five. They are referred to as the “first metatarsal”, “second metatarsal” etc. They are long bones and lead down to the phalange bones of the toes.
The metatarsals act as a rigid bar when we need to propel ourselves forwards in walking or running, and as a flexible structure to cope with the irregularities of the surface we are standing on.
Causes of Metatarsal Fractures
Metatarsal fractures may be caused by direct trauma, excessive rotational forces or overuse. Direct trauma is most often caused by someone kicking the sole of an opponent’s boot in sport such as football, or by stepping on a player’s foot. There is little soft tissue in this area to protect the top of the foot and so injuries to the bone are common. The second, third and fourth Metatarsals are frequently fractured in this way but fifth metatarsal fractures are very common in football.
Despite being a small bone, the fifth metatarsal is divided into four anatomical segments, the base, the junction of the base and the shaft, the shaft, and the neck. These distinctions are important as different kinds of fracture occur in different areas.
Fifth Metatarsal Fractures
The most common injury to the fifth metatarsal is an avulsion fracture of the base. This occurs usually as a consequence of a severe ankle sprain. A twisting injury of the foot or ankle occurs as the ankle rolls over and the outside of the foot is sprained. As there is a tendon (the white arrow in the picture) and a strong ligament attaching to the base of the metatarsal, this pulls hard on the bone, pulling off a small piece of bone in the process.
Surgery for this kind of fracture is not usually required unless the bones are displaced but some kind of immobilisation is necessary to reduce pain and allow mobility. This depends greatly on the amount of pain the person is suffering. I’ve seen people suffering badly and for whom complete immobilisation in plaster of paris and non-weight bearing is necessary. Others can be placed in a removable plastic boot and allowed to weight bear as comfortable with crutches.
Another type of fracture in this area is one about 1.5cm from the same end of the bone. This can occur if we step on the outer border of our foot when our heel is off the ground, putting all our body weight through the fifth metatarsal area. These fractures are often casted or put in walker boots, and weight-bearing may be restricted for a time.
The most difficult areas to heal in bones of the body are those places where the blood supply route is interrupted by the fracture. Certain bones are particularly susceptible to this kind of problem. These include the scaphoid bone in the wrist and the talus in the ankle.
The point where the base of the metatarsal meets the shaft is one of these areas and needs careful management. Landing after jumping with a twisting movement can cause this kind of fracture, occurring in dancers and sports people. Immobilisation is an effective treatment for these fractures.
Overuse injuries are common in sports and activities where repetitive actions are performed. A “stress fracture” can also occur in the metatarsals and occurred to me at the start of a several hour walk round The Lizard in Cornwall, England. I limped for two or three hours and it took several weeks for the foot pain to settle.
These fractures are often called “March” fractures as they are known to occur in army recruits who are not used to repetitive stress such as in sustained marching. A person may indicate a week or two of discomfort before the moment the acute pain came on with the fracture.
The second metatarsal is most commonly fractured, but the fifth is also common. In my case it was the fifth metatarsal which suffered the fracture while I was walking. The fifth can give more problems than the second, which usually progressed to union of the fracture without complications.
Signs and Symptoms of Metatarsal Fractures
You can’t have a metatarsal fracture and not be aware of it. It hurts. A lot. There is severe foot pain and you will find it difficult to walk. If someone presses on the fracture site it will hurt badly. Your foot will be very likely swollen and after a day or two bruising may be evident. The pain is very sharp, consistent over one area and related to weight bearing. Initially pain may be present even when resting but as it improves there is only pain on putting weight on the foot.
Treatment of metatarsal fractures
Once the fracture has occurred then evaluation at an emergency department and fracture clinic can be important. An x-ray is usually taken to confirm the diagnosis and some form of immobilisation or reduction in weight-bearing activity advised.
Pain-killing medication can be very helpful and should be taken regularly as prescribed to allow the person to be more comfortable and move about more easily. Applying an ice pack for 15-20 minutes every few hours can be useful to reduce the pain and swelling. I like the Cryocuff, a product from Aircast, which provided compression as well as cooling, up to a period of six hours.
Where the fracture is, how severe it is and whether there is any displacement of the fractured fragments determines what the treatment will be. Treatment varies greatly. If the fracture is simple, due to direct injury and in good alignment then immobilisation for 4 to 6 weeks is common. This can be in a plaster or a removable boot such as an Aircast walker.
Patients and therapists like the removable boots as they can be taken off in bed, for bathing and for exercise. This way the unaffected joints can be kept mobile while the fractures are healing.
The stress or “March” fractures can also be treated in a boot but fractures of the fifth metatarsal may need surgical fixation to unite successfully. A small screw, with a so-called Herbert Screw being popular, is used to fix the fragments. Healing time is still 6 to 8 weeks altogether.
Prevention of metatarsal fractures
It is difficult to prevent these kinds of fractures. If you are unused to a strenuous weight-bearing activity this might put you at higher risk, so graded exposure to the required stresses over time might prepare you for the performance you wish to achieve.
It may help to have good, supportive footwear so that the arch of the foot is supported to reduce the strain on the metatarsals. When I fractured my fifth metatarsal I was wearing old boots that had become flat and hard, giving me little arch support. I don’t know if that was a factor in my problems but it could have been.
Insoles can also be prescribed to correct and maintain the normal biomechanics of the foot and prevent abnormal stresses in poor positions.