II. Epidemiology

  1. Second and Third Metatarsals most commonly involved
    1. Military recruits (March Fracture)
    2. Ballet Dancers (associated with dance on toe tips)
    3. Sanderlin (2003) Am Fam Physician 68:1527-32 [PubMed]
  2. Fifth Metatarsal Stress Fractures are least common
    1. Associated with Genu Varum
    2. Differentiate from Jones Fracture
    3. Increased risk of nonunion
    4. Harmath (2001) Orthopedics 24:111 [PubMed]

III. Symptoms

  1. Localized pain at Fracture site
    1. Initially pain onset only with activity

IV. Signs

  1. Metatarsal Head Axial loading test positive (see Metatarsal Fracture)
  2. Point tenderness over Fracture site

V. Imaging

  1. XRay
    1. Fracture line usually not present for 2-6 weeks from onset of Fracture
  2. MRI or Bone Scan are more sensitive
    1. Not necessary if Stress Fracture treated empirically based on clinical findings

VI. Management

  1. Type 1: Acute Fracture without XRay changes
    1. Often heals well without immobilization
    2. Option 1
      1. Avoid offending activity for 4-8 weeks
    3. Option 2 (if painful ambulation despite Option 1)
      1. Crutch walking with partial weight bearing for 1-3 weeks
    4. Option 3 (if severe pain despite Option 2)
      1. Immobilize with short-leg cast and non-weight bearing for 1-3 weeks
  2. Type 2: Delayed union with wide Fracture line
  3. Type 3: Recurrent symptoms and established non-union
    1. Manage surgically with internal fixation

VII. Prevention

  1. See Stress Fracture
  2. Gradually return to prior activity
  3. Custom Orthotic may be considered in some cases (e.g. long second Metatarsal)

VIII. Course

  1. Variable healing by conservative methods in 8-70 weeks

IX. Complications: Non-union Fracture or Avascular Necrosis

  1. Proximal Fifth Metatarsal Fracture is highest risk
  2. Second Metatarsal Head AVN (Freiberg's Infarction)
    1. Seen in adolescents

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