This document summarizes forefoot fractures, including anatomy, biomechanics, classification, and treatment principles. It describes fractures of the metatarsals, sesamoids, and phalanges. Treatment often involves closed or open reduction with pinning or plating to restore alignment and allow weight bearing. More comminuted fractures sometimes require bone grafting. Proximal fifth metatarsal fractures are classified into zones with implications for healing and management approaches.

1. Forefoot Fractures
Sean E. Nork, MD
Harborview Medical Center

2. Foot Trauma and Outcomes
Turchin et al, JOT, 1999
28 patients: Polytrauma +/- foot injury
Age, gender, ISS matched
Results SF-36 5/8 components worse with foot injury
WOMAC All 3 components worse with foot injury
Jurkovich et al, JT, 1995
Highest Sickness Impact Profile (SIP) @ 6 & 12 months
Patients with foot trauma (compared to other lower extremity injuries)

3. Foot Function
Hindfoot: Shock absorption, propulsion,
deceleration
Midfoot: Controls relationship between
hindfoot and forefoot
Forefoot: Platform for standing and lever for
push off

4. Forefoot Function
• Platform for weight
bearing
• Lever for propulsion

5. Anatomy
First Metatarsal
Shorter & wider
Bears 1/3 body weight
Tendon attachments:
(Tibialis Anterior & Peroneus
Longus)
Tibialis Anterior: varus,
supination, elevation
Peroneus Longus: valgus,
pronation, depression
Lesser Metatarsals
More mobile medial
to lateral
Bear 1/6 weight each
Intermetatarsal ligaments
(2-3, 3-4, 4-5)

6. Sesamoids
Medial (tibial) & Lateral (fibular)
Within FHB tendons
Articulate with 1st MT head
Weight bearing through sesamoids
Tibial Sesamoid: Tibial FHB
Abductor Hallucis
Fibular Sesamoid: Fibular FHB
Adductor Hallucis
Deep Tverse MT ligament

7. Phalanges
Great toe (2)
Lesser toes (3)
FDB attaches @
intermediate
FDL/EDL attaches @ distal

8. Biomechanics
Metatarsal heads in
contact with floor 60-
80% of stance phase
Toes in contact with
floor 75% of stance
phase
Cavanagh, PR, F&A, 1987
Hughes, J, JBJS[Br], 1990

9. Mechanism
Industrial accidents
MVA (airbags)
Indirect (twisting injuries)
Other

10. Physical Examination
Gross deformity
Dislocations
Sensation
Capillary refill
Foot Compartments

11. Radiographs
Foot trauma series
AP/lat/oblique
Don’t forget oblique
Sesamoid view
Tangential view (MT heads)
Contralateral foot films (comparison)
CT Scan (occasionally)

12. Treatment Principles
Hindfoot: Protect subtalar, ankle and
talonavicular joints
Midfoot: restore length and alignment of
medial and lateral “columns”
Forefoot: Even weight distribution

13. Treatment
Border Rays
First metatarsal
Fifth metatarsal
Dislocations
Multiple metatarsal shafts
Intraarticular fractures

14. First MT Shaft Fractures
Nondisplaced
Consider conservative treatment
Immobilization with toe plate
Displaced
Most require ORIF
Strong muscle forces (TA, PL)
Deformity common
Bears 2/6 body weight
ORIF
Plate and screws
Anatomically reduce
May cross first MTP joint (temp)

15. Articular injuries
Frequently require ORIF
Fixation:
Spans TMT
Doesn’t span TMT
Temporarily Spans TMT
First MT Base Fractures

16. 36 year old male
s/p MVC
Active
Note articular
comminution

17. After
ORIF
Fixation Strategy
Direct ORIF of comminuted
first MT base fractre
Temporary spanning across
first TMT joint

18. 43 year old male injured in a MVC
Observe the articular segment impaction of the base of the first.
The first MT is shortened and dorsally displaced while the
plantar ligaments remain attached.

19. The patient underwent ORIF of the
base of the first metatarsal with
spanning of the first TMT, given
the level of comminution observed.
Additionally, temporary spanning
external fixation was used.

20. Radiographic
appearance at 3 months
after removal of the
external fixator and
metatarsal neck k-wire
fixations.

21. Non-displaced Metatarsal Fractures 2-4
Single metatarsal fractures
Treatment usually nonoperative
Symptomatic: hard shoe vs AFO vs cast
Multiple metatarsal fractures
Usually symptomatic treatment (as above)
May require ORIF if other associated injuries

22. Displaced Metatarsal Shaft Fractures
Sagittal plane displacement & angulation is most important.
Reestablish length, rotation, & declination
Dorsal deformity can produce transfer metatarsalgia
Plantar deformity can produce increased load at affected metatarsal
Treatment Options
Closed Reduction
Intramedullary pinning with k-wire (0.054” or 0.062”)
Pinning of distal segment to adjacent metatarsal
ORIF with dorsal plate fixation

23. This patient sustained an open
second metatarsal fracture in a
crush injury. Given the soft
tissue injury and continued
pressure on the dorsal skin,
operative fixation was elected.

24. Fixation consisted of a dorsal
2.0 mm plate application after
appropriate irrigation of the
open fracture.

25. This patient was
treated with ORIF
of multiple
metatarsal
fractures (3,4,5)
through a dorsal
approach.
Fixation consisted
of a 2.7 mm DCP
on the fifth and
2.0 mm plates on
the third and
fourth
metatarsals.

26. Medullary K-wires
in Lesser MTs
Exit wire distally through
the proximal phalanx
Plantar wire exit may
produce a hyperextension
deformity of the MTP
ST Hansen,
Skeletal Trauma

27. Stress Fractures of Metatarsals 2 - 4
Identify Cause
First ray hypermobility
Short first ray
Tight gastrocnemius
Long metatarsal
Treatment
Treat cause if identifiable
If overuse, activity restriction
Reserve ORIF for displaced fractures

28. Usually displace plantarly
May require reduction and
fixation:
Closed reduction and pinning
Open reduction and pinning
ORIF (dorsal plate)
Metatarsal Neck Fractures

29. This patient sustained
multiple metatarsal neck
fractures after an MVA.
Note additional fractures at
the first and fifth metatarsals

30. Medullary wire
fixation of
metatarsal neck
fractures 2, 3, 4
Compliments of S.K. Benirschke

31. Unusual
Articular injuries
May require ORIF
(especially if first MT)
Metatarsal Head Fractures
Circular saw injury to the
articular surface of the first MT head

32. Fifth Metatarsal Fractures
Mid diaphyseal fractures
Stress fractures (proximal diaphysis)
Jones fractures (metadiaphyseal jxn)
Tuberosity fractures

33. Proximal Fifth Metatarsal Fractures
Dameron, TB, JAAOS, 1995
Zone 1 cancellous tuberosity
insertion of PB & plantar fascia
involve metatarsocuboid joint
Zone 2 distal to tuberosity
extend to 4/5 articulation
Zone 3 distal to proximal ligaments
usually stress fractures
extend to diaphysis for 1.5 cm

34. Proximal Fifth Metatarsal Fractures
Dameron, TB, JAAOS, 1995
Relative Frequency
Zone 1 93%
Zone 2 4%
Zone 3 3%

35. Fifth Metatarsal Blood Supply
Smith, J et al, F&A, 1992
Cadaver Arterial Injection
Study (n = 10)
Nutrient artery with intramedullary
branches (retrograde flow to
proximal fifth metatarsal)
Multiple metaphyseal arteries
Conclusions: Fracture distal to the
tuberosity disrupts the nutrient
arterial supply and creates relative
avascularity
Shereff, M et al, F&A, 1991
Fresh leg specimens (after
BKA) (n = 15)
Extraosseus circulation:
dorsal metatarsal artery
plantar metatarsal artery
fibular plantar marginal artery
Intraosseus circulation:
Nutrient artery
Metaphyseal vessels
Periosteal complex

36. Fifth Metatarsal Blood Supply
Smith et al, Foot Ankle 1993

37. Zone 1 Fractures: Tuberosity
Etiology
Avulsion from lateral plantar aponeurosis
(Richli & Rosenthal, AJR, 1984)
Treatment
Symptomatic
Hard shoe
Healing usually uneventful
(Dameron, T, JBJS, 1975)
Lawrence, SL, Foot
Ankle, 1993

38. Zone 1 Fractures: Tuberosity
Weiner, et al, F & A Int, 1997
60 patients
Randomized to short leg cast vs soft dressing only
Weight bearing in hard shoe in all
Healing in 44(average) - 65(all) days
Soft dressing only: shorter recuperation (33 vs 46
days) and similar foot score (92 vs 86)
Conclusions: Faster return to function without
compromising radiographic union or clinical
outcome in patients treated without casting.

39. Zone 2 Fractures: Metadiaphyseal

40. Treatment Controversial
Union frequently a concern
Early weight bearing associated with increased nonunion (Torg,
Ortho, 1990; Zogby, AJSM, 1987)
Nondisplaced Fractures: Treatment
Cast with non weight bearing
(Shereff, Ortho, 1990; Heckman, 1984; Hens, 1990; Lawrence, 1993)
Cast with weight bearing
(Kavanaugh, 1978; Dameron, 1975)
Zone 2 Fractures: Metadiaphyseal

41. Operative Treatment
Medullary Screw Stabilization
(Delee, 1983; Kavanaugh, 1978; Dameron, 1975)
Bone Graft Stabilization
(Dameron, 1975; Hens, 1990; Torg, 1984)
Zone 2 Fractures: Metadiaphyseal

42. Zone 2 Fractures: Metadiaphyseal
Operative
Treatment
Medullary
Screw
Stabilization
Bone Graft
Stabilization
Lehman,
Foot Ankle 1987

43. Comminuted fracture
of the base of the fifth
metatarsal

44. After ORIF of the
fifth metatarsal

45. MTP Joint Injuries
Sprains
“Turf Toe”: hyperextension with injury to thee
plantar plate
Hyperflexion sprains
Dislocations

46. First MTP Dislocations
Jahss, F&A, 1980
Type I: Hallux dislocation without disrupting sesamoid
Irreducible closed!
MT incarcerated by conjoined tendons and intact
sesamoid
Open reduction required (dorsal, plantar, or medial
approach)
Type II: Disruption of intersesamoid ligament (type A)
Transverse fracture of one of the sesamoids (type B)
Usually stable after reduction
Treatment usually conservative and symptomatic
(hard shoe for 4-6 weeks)

47. Lesser MTP Dislocations
Uncommon
Dorsal vs Lateral
Usually stable post reduction
Rarely require open reduction
If unstable post reduction, consider k-wire fixation

48. Proximal Phalanx Fractures
ORIF for transverse & displaced (?)
ORIF intraarticular fractures (?)
Interphalangeal Joint Fractures
Nonoperative treatment usually
Distal Phalanx Fractures
Taping usually adequate
Hard shoe
Fractures of the
Great Toe

49. Sesamoid Injuries
Sesamoiditis
Acute fractures
Stress fractures in dancers and runners
Treatment
Acute: padding
strap MTP @ neutral or slight flexion
immobilization in cast/shoe
Chronic: consider bone grafting
sesamoidectomy: not a simple procedure, assoc
with hallux drift and transfer lesions, requires tendon
(FHB) repair.

50. Fractures of the LesserToes
Correct alignment & rotation
Attempt taping to adjacent
toe
May require open reduction
and pinning if adequate
reduction not obtained
ST Hansen,
Skeletal Trauma

51. The Crushed Foot
Soft Tissue Evaluation
Assess whether salvageable
sensate, perfused, adequate plantar tissue
Wash open wounds
Reposition bone deformity that
threatens the skin
Reduce dislocations
Release compartments as needed

52. Recommended Readings
Cavanaugh, PR, et al. Pressure Distribution Patterns under Symptom-free
Feet during barefoot standing. Foot Ankle, 7:262-276, 1987
Dameron, TB, Fractures of the Proximal Fifth Metatarsal: Selecting the Best
Treatment Option. J Acad Orthop Surg, 3(2): 110-114, 1995.
Holmes, James. AAOS Monograph “The Traumatized Foot”, pages 55-75,
2002.
Lawrence, SJ, and Botte, MJ. Foot Fellow’s Review: Jones’ Fractures and
Related Fractures of the Proximal Fifth Metatarsal. Foot & Ankle, 14(6),
358-365, 1987.
Smith, JW, et al. The Intraosseus Blood Supply of the Fifth Metatarsal:
Implications for Proximal Fracture Healing. Foot & Ankle, 13(3), 143-
152, 1992

53. Thank You
Sean E. Nork, MD
Harborview Medical Center
University of Washington
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