It also has a strong attachment to the lateral band of the plantar fascia. The 5th metatarsal, like the 1st, has less soft tissue coverage than the middle metatarsals and has extrinsic muscle attachments, the peroneus brevis and tertius, which attach at its base. The flexor digitorum longus, flexor hallucis longus, and intrinsic muscles place plantar flexion stress on the metatarsal heads in distal fractures and can cause plantar flexion deformities. The tibialis anterior works to elevate the 1st metatarsal, while the peroneus longus plantar flexes.Įither of these muscles may act to deform a 1st metatarsal fracture. The 1st metatarsal is intimately associated with the sesamoids, which are held fixed in relation to the lesser metatarsals by attachments to the intermetatarsal ligaments and the 2 heads of the adductor hallucis.ĭisplacement of the 1st metatarsal head in any direction can alter the balance of the entire forefoot. There are no ligaments connecting the 1st metatarsal to the others.Ī low-energy metatarsal shaft fracture does not disrupt these proximal or distal stabilizers, so the metatarsal head remains in the appropriate location for weight bearing.Ī higher energy injury, with disruption of the stabilizing soft tissues proximally or distally, will elevate or depress the metatarsal head. The distal transverse intermetatarsal ligament runs from the 5th metatarsal head to the 4th, then the 3rd, then 2nd, and then finally to the lateral sesamoid. The proximal transverse metatarsal ligament runs from the 5th metatarsal base to the 4th, to the 3rd, then the 2nd, and then to the medial cuneiform. The metatarsal bases are rigidly stabilized to the cuneiforms and cuboid in the midfoot. The 2nd and 3rd frequently bear more than the 4th and 5th. The remainder is distributed among the lesser 4 metatarsals. The 1st metatarsal head and its 2 associated sesamoids bear ~ 1/3 of the body weight. The metatarsals are the major weight-bearing structure of the forefoot. They can cause significant morbidity and, rarely, even death. Lawn mower injuries are common with an incidence of between 50,000-160,000 each year. High-energy injuries, even when closed, have extensive soft tissue disruption and may require operative treatment. Thus, this may disrupt the normal distribution of weight in the forefoot.Īltered weight distribution may lead to metatarsalgia and painful plantar keratosis.ĭisplacement, shortening, or angulation of the 1st metatarsal in any plane anywhere along the bone can significantly alter the weight-bearing distribution of the foot and is therefore an indication for operative management.Īn isolated, nondisplaced metatarsal base fracture may be stable, but if any uncertainty exists, further evaluation of the midfoot with stress x-rays is necessary. The metatarsal head remains in the appropriate location for weight bearing.Ī high-energy injury, with disruption of the stabilizing soft tissues proximally or distally, will elevate or depress the metatarsal head. The intact soft tissues splint the fracture.Ī low-energy metatarsal shaft fracture typically does not disrupt proximal or distal stabilizing soft tissue structures. The metatarsals are affected by stress fractures more commonly than all other sites in the body.Ī majority of metatarsal fractures are low-energy injuries suitable for closed treatment. The 5th metatarsal is the most frequently fractured metatarsal (23%). There are a few other rare types that you should probably never include in a report, as almost no one will know what you are talking about.Toe and metatarsal fractures are the most common fractures of the foot with an incidence of 140 per 100,000 per year. Poor prognosis as the proliferative and reserve zones are interruptedĬrushing type injury does not displace the growth plate but damages it by direct compression Poorer prognosis as the proliferative and reserve zones are interruptedįracture plane passes directly through the metaphysis, growth plate and down through the epiphysis ClassificationĬonveniently the Salter-Harris types can be remembered by the mnemonic SALTR.įracture plane passes all the way through the growth plate, not involving boneĬannot occur if the growth plate is fused citįracture passes across most of the growth plate and up through the metaphysisįracture plane passes some distance along with the growth plate and down through the epiphysis The Salter-Harris classification was proposed by Salter and Harris in 1963 1 and, at the time of writing (January 2023) remains the most widely used system for describing physeal fractures.
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