Which bone is in direct contact with the first metatarsal?

A metatarsal bone fracture is a complete or incomplete break in one of the five metatarsal bones in each foot. These long thin bones are located between the toes and the ankle (between the tarsal bones in the hindfoot and the phalanges in the forefoot).

The foot consists out of 5 metatarsal bones per foot. Every metatarsal bone consists out of three parts: caput ossis metatarsi, corpus ossis metarisi and the basis ossis metatarsi .  They form joints with at the proximal side: ossa cuneiformia and at the medial and lateral side the os cuboideum. At the distal side they articulate with the basis of the proximal phalanges. The tarsometatarsal joint is also called the line of Lisfranc. The tarsometatarsal joints have relatively flat articular surfaces and strong, short ligaments who admit small translations and tilting movements.  The basis of the os metatarsale 2 is surrounded the three ossae cuneïforme with strong ligaments. The strong dorsal ligament of lisfranc between the lateral side of C1 and the medial side of M2. Lateral is the ligament system with fibers between C2 and M2, just as crossed fibers between C3-M2 and C2-M3.

5 to 6% of all fractures treated in primary care are metatarsal fractures. It are the most common injuries of the foot. They are about ten times as frequent as Lisfranc-dislocations.They are equally amoung men and women and among all racial groups. 

The distribution of the fractures looks as follow (figure 1):

• First metatarsal: 5%
• Second metatarsal: 12%
• Third metatarsal: 14%
• Fourth metatarsal: 13%
• Fifth metatarsal: 56%
• Multiple metatarsal fractures: 15,6%

Metatarsal fractures are common in the pediatric population, accounting for close to 60% of all pediatric foot fractures. The highest rate of fracture in childhood involves the fifth metatarsal, followed by the third metatarsal. The lowest rate is the first metatarsal. Children under the age of 5 years are more likely to have first metatarsal fractures, with a frequency of isolated first metatarsal fractures of 51%, in contrast to those more than 5 years old, who are more likely to have fifth metatarsal fractures, depending on the age group, a frequency as high as 65%. The next most common fracture finding was a specific combination of second, third and fourth metatarsal fractures .

Injury to the metatarsals is common in both acute and chronic settings[16] and they are the most common site of stress fractures in the human skeleton. Among stress fractures of the metatarsal bones, the middle and the distal portions of the corpus ossis metatarsalis II or III are most common. Stress fractures at the base of the first or second metatarsals (or rately other metatarsal bones) are less common. Metatarsal stress fractures are a common occurrence in athletes, particularly in runners, in whom they account for 20% of lower extremity stress fractures. Given the increased stresses experienced by the second and third metatarsals during walking and running, these metatarsals are at greatest risk for stress fracture.

Metatarsal fractures may result either from direct or indirect violence, and they display a wide variety of injuries ranging from isolated, simple fractures of one metatarsal to crush injuries with serial fractures and severe soft tissue compromise. Direct trauma is common in industrial workers who have a heavy object fall on the foot. Indirect trauma occurs when the leg and hindfoot are twisted with the forefoot fixed. The percentages looks as follow:

• Supination injury: 48%
• Fall from height: 26%
• Crush injury: 12%

Athletes, individuals who are obese, and individuals with osteoporosis or rheumatoid arthritis or diabetes have an increased risk of developing metatarsal fractures.

It also appears in sports like jogging, ballet, gymnastics, and high-impact aerobic activities. Shoe shock attenuation can prevent metatarsal stress fractures.

The act of repetitive cyclic loading, especially in the setting of a young athlete or military recruit, can lead to a chronic overloading predisposing one to a stress reaction and ultimately fracture.

It has been shown that the fracture pattern and severity of injury vary according to age and mechanism of injury.( This association can further be correlated with both osseous development and the age-related levels of activity.

Specific causes of fractures:

• Most fractures of the corpus ossis metatarsalis are caused by direct blows or twisting forces. An abrupt increase in activity or chronic overload may cause a stress fracture of the metatarsal corpus.
• The most common mechanism of injury in fifth metatarsal fractures involves a fall from standing height or an ankle twist with the forefoot fixed. In this position, a pulling force from the lateral cord of the plantar aponeurosis along with tension from the peroneus brevis tendon causes a longitudinal and torsional strain.
• An avulsion fracture of the fifth metatarsal base (‘tennis fracture’) may occur as a result of inversion injuries to the foot, seen that the base of the fifth metatarsal is the endpoint of the ‘supination fracture line’.
• A Jones fracture is the most common fracture site and occurs as a result of inversion of the forefoot or from a vertical mediolateral force in the base of the fifth metatarsal, while the patient’s weight is over the lateral aspect of the plantar flexed foot  Another cause lies in overuse, repetitive stress, trauma or a sudden change in direction with the heel off the ground .
• A tuberosity avulsion fracture usually results from ankle inversion while the foot is in plantar flexion. The history often suggests a lateral ankle sprain, and these fractures are often missed.
• A diaphysial stress fracture is often due to a chronic overloading, especially from jumping and pivoting activities in younger athletes.
• Fractures of the corpus ossis metatarsalis are generally fatigue fractures and are related to chronic stress. It is the result from repetitive force, as seen in athletes, ballet dancers and soldiers. After all, more force is placed on the second and third metatarsal when walking and gives more stress. Therefore stress fractures and bone remodeling from stress are common in the second or third metatarsal. It also knows a high incidence with military recruits.
• Fractures from the first through the fourth metatarsals are the kind of fractures that are less common than other metatarsal fractures. They warrant special consideration, because they are often associated with injury to the Lisfranc ligament complex. These crucial ligaments hold the metatarsal bases rigidly in place, maintaining the arch of the foot and anchoring the metatarsals to the rest of the body.
• Proximal metatarsal fractures are usually caused by crush injuries or direct blows. They may also result from falling forward over a plantar-flexed foot. In athletes, the most common mechanism for a Lisfranc injury is an axial load placed on a plantar-flexed foot.
• Stress fractures are common in people who:
  • increase their activity level suddenly
  • do activities that put a lot of pressure on their feet, such as running, dancing, jumping, or marching (as in the military)
  • have a bone condition such as osteoporosis (thin, weak bones) or arthritis (inflamed joints)
  • have a nervous system disorder that causes loss of feeling in the feet
  • run more than 30km per week
    

The metatarsal can be fractured at 3 locations: on the caput, corpus or on the basis ossis metatarsalis. Like that we can differentiate multiple different fractures:

• Subcapital fracture.
• Fracture of the corpus ossis metatarsalis.
• Fracture of the basis ossis metatarsalis.
  

Three distinct fractures occur in the proximal fifth metatarsal. The joint between the basis ossis metatarsalis IV and V is a key landmark for classifying proximal fifth metatarsal fractures (figure 2).

• Avulsion fractures: An avulsion fracture on the 5th metatarsal bone is called a ‘dancer’s fracture’.
• Specifically, there are two types of fractures of the fifth metatarsal bone: The Jones fracture and the tuberosity avulsion (styloid) fracture. Currently, it is accepted that tuberosity avulsion fractures are ‘pseudo-Jones fractures’.
• The diaphyseal stress fracture: fracture of the unfused fifth metatarsal base apophysis.
• Marcher’s fracture:  This fracture is also called a fatigue fracture of os metatarsal II and/or III.

Further on, there are the fractures from the first through the fourth metatarsals.

The most common fracture site is at the base of the fifth metatarsal (Jones fracture) and occurs as a result of inversion of the forefoot.
The location of the fracture must be carefully evaluated since the treatment for a Jones fracture is radically different from fractures of the shaft of the fifth metatarsal.

More force is placed on the second and third metatarsals when walking; therefore, stress fractures and bone remodeling from stress are common in the second or third metatarsal, a condition sometimes called a “marcher’s fracture” after its high incidence among military recruits.

Characteristics/ clinical presentation[edit | edit source]

Common signs of metatarsal fractures are:

• Painful swelling
• Palpable trapje
• Axial pressure pain

Patients with metatarsal fractures complain about pain on ambulation or the impossibility of weight bearing. The forefoot is swollen and tender to palpation. Gross deformities are only seen with complex injury patterns including serial fractures and additional toe dislocations.

When the patient experiences pain in the metatarsal region there are a number of conditions which can explain this pain. Potential causes:

• bone tumors: uncommon in feet but when present usually cause pain, most common giant cell tumor of bone, chondromyxoid fibroma, osteochondroma
• benign soft-tissue tumors: most common lipoma, nerve sheath tumor
• malignant soft-tissue tumors: most common synovial sarcoma
  

Depending on the location of the metatarsal fracture, there are specific characteristics:

• Fractures from the first through fourth metatarsal: The growth center of the first metatarsal is located proximally in children. It can be misinterpreted as a fracture.
• Fractures of the proximal fifth metatarsal: Pain in the midfoot zone and one of the following: bone tenderness at the base of the fifth metatarsal, bone tenderness at the navicular and an inability to bear weight both immediately and in the ER for four steps. These are the Ottowa Foot Rules, which determine the need for radiographic evaluation of the foot.
• Shaft fractures: Typically are pain, swelling, ecchymosis and difficulty walking. In the beginning the pain only occurs with activity. Swelling is often severe, especially if the patient has not elevated the foot. Over the fracture site there is usually point tenderness. Applying an axial load to the head of a fractured metatarsal usually triggers pain at the fracture site. Patients with soft tissue injuries shouldn’t experience pain with this maneuver (figure 3). If the injury is not allowed to heal the pain will become worse, more swelling will appear and even frank fracture may occur.
• Tuberosity avulsion fracture, Jones fracture and diaphyseal stress fracture:All three fractures cause lateral foot pain and difficulty walking. Acute fractures typically have a sudden onset, with swelling and ecchymosis. Stress fractures usually cause a progressive increase in pain that is worse with activity. Recognizing the gradual onset of symptoms is key to correctly diagnosing fifth metatarsal stress fractures. Radiography may reveal accessory bones or growth plates which may mimic these fractures. Ossicles (small accessory bones) may cause pain in the same region.
• Stress fractures: Early signs are: pain during activity that goes away with resting and pain over a wide area of the foot. Over time the pain will be present constantly and stronger in one area of the foot. The area of the foot where the fracture is may be tender when you touch it. It might be swollen as well.
  

A physical exam of the foot along with x-rays and bone scans are used to diagnose metatarsal fractures. When the patient has a typical history and appropriate physical findings, a presumptive clinical diagnosis can be made.
Routine X-rays (anteroposterior, lateral and oblique) are usually sufficient to diagnose the fracture. A CT-scan or MRI is used to exclude other injuries when needed. Also a comparison with the other foot may be necessary.
When a stress fracture is expected a bone scan may be helpful.

Acute metatarsal fracture (fracture corpus ossis metatarsalis) (figure 4):  Patients usually present with pain, swelling, echymosis and difficulties with walking. Applying axial load to the head of a fractured metatarsal produces pain at the site. This should not be painful in patients with soft tissue injury alone.  Radiographic findings: Fracture position can be assessed by two views that lie at a 90° angle to each other. Oblique or modified lateral views are often more helpful. Fracture lines may not be visible on initial radiographs. In this case the clinical examination and the radiographs should be repeated one to two weeks after the initial injury. 

Fractures of the proximal first through fourth metatarsals (figure 5): Radiographic findings: Proximal fractures are generally transverse or oblique and often multiple. In case of Lisfranc ligament injury a standard foot series may be normal in fifty percent of the cases. In this case weight-bearing anteroposterior and lateral radiographs must be obtained: the anteroposterior view demonstrateswidening of the space between the first and second metatarsal heads (stage II or III) with a lost arch height on the lateral view in stage III injuries. Radionuclide bone scan: is extremely accurate for diagnosis in case of stage I injury with clinical suspicion and normal radiography.

A Fracture of the unfused fifth metatarsal base apophysis is a kind of fracture is typically present in 9- to 14 year-olds. Unlike fractures which occur is this area, the lucent line, associated with an unfused apophysis, is always longitudinally oriented. Comparison radiographs of the contralateral foot are helpful in equivocal cases.

Acute fractures of the proximal fifth diaphysis (figure 6):  Using the Ottawa ankle rule we can exclude a lateral ankle sprain from a tuberosity avulsion fracture.  When point tenderness is present over the fifth metatarsal and the foot appears to be normal, it could be a sprain or an ankle series.

Jones fracture (figure 7): Radiographic findings: Acute fracture of junction between the proximal diaphyse and the corpus ossis metatarsi quinti. The fracture line is sharp and extends into or towards the articulation between MT 4 and MT 5. A jones fracture can be a stress fracture (tiny hairline break that occurs over the time) or an acute (sudden) break.

Tuberosity (styloid) fracture (figure 8): Clinical findings: A radiolucency is seen perpendicular to the long axis of the fifth metatarsal. The fracture may be intra-or extraarticular (cuboid-metatarsal articulation) and never extend into the joint between the fourth or fith metatarsal (=different from Jones fractures). This kind of fracture always occurs proximal to the joint of the base of the fourth and fifth metatarsals. It involves the tip of the styloid process at the attachment of the plantar aponeurosis and peroneus brevis. The peroneus brevis tendon has a broad lateral insertion and may contribute to further dislocation .

Stress fractures (figure 9):  Patients with a typical history and appropriate findings may not need the tests. Radiographic findings: rarely visible on plain radiographs until symptoms have been present for two to six weeks. An MRI or bone scan can confirm the diagnosis.

Torg type II stress fracture of the metatarsal diaphysis An early stress fracture will demonstrate cortical thickening, an older stress fracture will demonstrate a widened fracture line and partial or complete obliteration of the medullary canal.

1) Acute metatarsal fracture :
Favourable
Displacement is often minimal unless more than one metatarsal is fractured,
Fractures of a single metatarsal shaft with lateral or medial displacement usually heal well without correction.
Unfavourable.
Displacement of more than three to four millimeters displacement in a dorsal or plantar direction or dorsal /plantar angulation exceeds ten degrees do require reduction.
Skin necrosis- due to crush injury- leading to an open fracture.
2) Fractures of the proximal first through fourth metatarsals
Injury to the Lisfranc ligament complex can cause long-term disability.
3) Acute fractures of the proximal fifth diaphysis: Jones fractures
With conservative treatment, patients frequently complain about the lenght of time for nonweight bearing and pain following the first weeks of rehabilitation as delayed union is surprisingly common. Complications like nonunion and refracture are reported in literature, but often conservative treatment is the first option in common population.
4) Tuberosity (styloid) fracture :
Nondisplaced avulsion fractures heal well within thirty to forty days with symptomatic therapy.
When the fracture is greater than tree millimeters of displacement or a step-off of more than one to two millimeters on the articular surface with the cuboid orthopedic referral is recommended.
5)Stress fracture
Stress fractures of the metatarsal shaft usually heal well in case of cessation of the causative activity for four to eight weeks.
After four to eight weeks pain typically resolves.

Rx is used to confirm the fracture and will also be used to show how the fracture evolves. 

Further, specific questionnaires can be used:
- The Foot Function Index (FFI) (Figure 10):
This questionnaire has five domains: pain score, stiffness score, difficulty score, activity score and social score.
- The Foot Health Status Questionnaire (FHSQ):
This questionnaire has four domains: pain, function, footwear and general Foot Health.

A neurovascular exam should be performed in every patient with a suspected metatarsal fracture.
The fracture usually cause bony tenderness. The skin needs to be carefully inspected for:
- wounds that may indicate an open fracture
- tenting of the skin over a displaced fracture
- devitalized skin that may necrose
- common fracture findings (swelling, etc) en less common findings (deformity etc.)

Specific per metatarsal fracture:
 Acute metatarsal fractures
Applying an axial load to the head of a fractured metatarsal usually produces pain at the fracture site (figure 3). This is done by holding the toe in line with its corresponding metatarsal, and pushing the toe in toward the metatarsal. Sequential palpation may reveal the fracture site.
Assessing pain while testing plantar and dorsal flexion of the toes is helpful from differentiating a fracture from a tendon injury. If a fracture is present, direct palpation should produce greater pain than testing tendon function by resisting plantar and dorsiflexion.

 Fractures of the proximal first through fourth metatarsals
The same as in acute metatarsal fractures. The key to detecting Lisfranc injury is to maintain a high index of suspicion whenever a patient presents with pain in the area of the Lisfranc ligament.

 Acute fractures of the proximal fifth diaphysis
Jones fracture: Pain on the lateral side of the foot anterior to the ankle; Edema and ecchymosis
Acute tuberosity (styloid) fracture: Tenderness at the base of the metatarsal as well as swelling and ecchymosis at
the site of maximal tenderness are found

 Stress fracture of the metatarsal shaft
Point tenderness over the fracture, pain in case of axial loading of the metatarsal head,
tenderness is present over the fracture site, edema and ecchymosis might be present.
Medical management
When there is a vascular compromise, an open fracture, a compartment syndrome, an associated neurologic deficit of a devitalizing of the skin or the skin is at risk to devitalize there should be an urgent referral.
A prompt referral with a displaced fracture of a single metatarsal when it is a shaft fracture near the metatarsal head, a displaced styloid fracture of metatarsal 5, an unacceptable position of shaft fracture. Also with a fracture of the first metatarsal (unless completely non-displaced), tenderness over the Lisfranc ligament so injury can’t be ruled out, multiple metatarsals are fractured, there are unsatisfactory results during the following treatment.
A surgical intervention is required when the bones have a disturbed alignment or when they are unlikely to stay in alignment. Surgery will hold the bones in place with plates, screws or similar devices. When a piece of the bone pierces the skin, surgery is required to clean the wound and bone fixation.

NON-DISPLACED FRACTURE OF THE CORPUS OSSIS METATARSI:
- first 24 hours: ice and elevation (higher than the heart). Progressive weight bearing.
- treating with soft elastic dressing or a firm supportive shoe (in case of pain: leg
walking cast for 2 to 3 weeks)
- immobilization in a posterior split and 3 to 5 days non-weight bearing

DISPLACED METATARSAL FRACTURES:
Displaced more than 3 to 4mm in dorsal or plantar direction:
- first 24 hours: ice and elevation (higher than the heart)
- reduction: under local anesthesia, using a regional or hematoma block. Placing the toes in Chinese finger traps and allowing gravity to accomplish the reduction. Applying light weights or manual traction to the distal tibia is sometimes helpful. The reduction should be maintained in a molded, bivalve, non-weight-bearing cast and postreduction radiographs should be obtained to confirm proper alignment.
OR
- referring: immobilization in a posterior split and non-weight bearing
Stress fractures:
Of the metatarsal shaft:
- responds well to cessation of the causative activity (4 to 8 weeks)
- walking causes pain? Crutches and partial-weight bearing
- walking causes severe pain? Non weight-bearing, short leg cast (1 to 3 weeks)
Rigid of long MT 2:
- custom orthotic
MT 5 fracture:
Tuberosity Avulsion:
Symptomatic therapy (3 to 6 weeks)
- soft protective dressing
- short leg cast
Too symptomatic
- a hard-soled shoe or wood-soled postoperative brace or cast
Jones fracture = dancer’s fracture :
- non-weight bearing cast (6 to 8 weeks), crutches are required
- weight bearing orthosis (8 to 12 weeks)

Surgical treatment of Jones Fracture :
- Flouoscopy : A K wire is inserted form determination of proper position and length Incision.
- Longitidunal incision is made over distal metatarsal.
- Local bone graft : Can be obtained from tuberosity and from bone bits from the drill.
- Implants :Consider indersertion of cancellous bone screw.
- Post-operative : patients will require protected weight bearing.
! consider early surgical fixation in athletes. This fracture doesn’t heal well, seen that the fracture is localized in a small area of MT 5 which receives less blood.
Diaphyseal stress Torg type I = type of march fracture
- non-weight bearing cast (6 to 8 weeks)
- weight bearing orthosis (8 to 12 weeks) tolerated
! consider early surgical fixation in athletes. These fractures heal poorly
Diaphyseal stress Torg type II
- early surgical fixation
- non-weightbearing cast for up to 20 weeks
Diaphyseal stress Torg type III
- surgical fixation
- pulsed electromagnetic fields and non-weight bearing cast (up to 16 weeks)

The duration of treatment of a metatarsal fracture depends on the location and type of fracture.
The first days are protection, rest, ice, compression and elevation important until the swelling is stabilized.

 Initial therapy exercises: focus on little to no weight-bearing on the affected limb as the bones continue to calcify and heal properly. Therapists will introduce manual therapy around the ankle and plantar of the foot to minimize inflammation and pain while also promoting increased ROM within the smaller metatarsal and tarsal joints. Ice needs to be applied to reduce swelling and inflammation.
The physical therapist could perform soft tissue massage, joint mobilizations, electrotherapy, hydrotherapy and later on excercises to increase strength, flexibility and balance.

Figure 11: Airex pad

The patient should be encouraged to perform active mobilizations: plantar and dorsal flexion of the foot and ankle, inversion and eversion of the foot and ankle (the patient should also do this at home!) .
 Mid-therapy exercises: depends on the severity and area of fracture. Promotion of flexion and extension within the ankle: stretching and strengthening exercises. Increased weight-bearing exercises.
Gaining strength and proprioception, possible exercercises:
- Put a weight on a towel, the towel is on the floor and the foot of the patient stands on the towel from the metatarsal joints. Ask the patient to bring the weight closer only by doing a toeflexion.
- Put the patients foot on an Airex pad and ask the patient to claw his toes in the Airex pad (see figure 11).
- Let the patient stand on his toes. The patient can do this while sitting on a chair (very low weight-bearing). By letting the patient perform this exercise standing, the weight-bearing is increased.
 End therapy and discharge: Patient should be able to have full use of the affects foot an should be able to walk completely unassisted for extended periods.
The stability and proprioception in the foot can be trained with the balance board (for example the Wobble board, Bosu ball), Airex pad, Sissel pillows, … (figure 12, 13 and 14[)

There are 2 types of treatment:

Conservative treatment:
- Multiple metatarsal fractures
- Avulsion fractures without dislocation (most common)
- Fractures of os metatarsal 1
Operative treatment:
- sevear dislocated fractures
- Avulsion fractures with dislocation (most common)
- Luxation fractures

A standard conservative treatment for jones fractures: this treatment is only applied when the bones are not too much dislocated.

1) For 2-3 days in a short leg cast with additional antiphlogistic medication.
2) After edema reduces, the leg cast gets replaced by an adapted Caligamed 11 brace for several weeks, followed by intense mobilization and walking therapy.

A standard operative treatment for Jones fractures.

1) Placing a propeller in the bone
2) If the bone does not cure with a propeller, a bone graft is possible.

According to studies, there is a high incidence of failure after cast treatment of acute Jones fractures. Early screw fixation results in quicker times to union and return to sports compared with cast treatment.

What bone articulates with the first metatarsal?

What connects to first metatarsal?

Which bones articulates with the metatarsal bones?

Which bones are distal to the metatarsals?