II. Epidemiology
- Second and Third Metatarsals most commonly involved
- Military recruits (March Fracture)
- Ballet Dancers (associated with dance on toe tips)
- Sanderlin (2003) Am Fam Physician 68:1527-32 [PubMed]
- Fifth Metatarsal Stress Fractures are least common
- Associated with Genu Varum
- Differentiate from Jones Fracture
- Increased risk of nonunion
- Harmath (2001) Orthopedics 24:111 [PubMed]
III. Symptoms
- Localized pain at Fracture site
- Initially pain onset only with activity
IV. Signs
- Metatarsal Head Axial loading test positive (see Metatarsal Fracture)
- Point tenderness over Fracture site
V. Imaging
- XRay
- MRI or Bone Scan are more sensitive
- Not necessary if Stress Fracture treated empirically based on clinical findings
VI. Management
- Type 1: Acute Fracture without XRay changes
- Often heals well without immobilization
- Option 1
- Avoid offending activity for 4-8 weeks
- Option 2 (if painful ambulation despite Option 1)
- Crutch walking with partial weight bearing for 1-3 weeks
- Option 3 (if severe pain despite Option 2)
- Immobilize with short-leg cast and non-weight bearing for 1-3 weeks
- Type 2: Delayed union with wide Fracture line
- Type 3: Recurrent symptoms and established non-union
- Manage surgically with internal fixation
VII. Prevention
- See Stress Fracture
- Gradually return to prior activity
- Custom Orthotic may be considered in some cases (e.g. long second Metatarsal)
VIII. Course
- Variable healing by conservative methods in 8-70 weeks
IX. Complications: Non-union Fracture or Avascular Necrosis
- Proximal Fifth Metatarsal Fracture is highest risk
- Second Metatarsal Head AVN (Freiberg's Infarction)
- Seen in adolescents