From the Guidelines
For a patient with psoriatic arthritis and a 5th metatarsal neck fracture, I recommend temporarily discontinuing celecoxib as it may impair bone healing, based on the most recent evidence from 1. Celecoxib, a COX-2 inhibitor, can delay fracture healing by inhibiting prostaglandin production necessary for bone formation.
- Hydroxychloroquine and ubrogepant can be continued as they don't significantly impact bone healing.
- For infliximab, continue administration as TNF inhibitors generally don't impair fracture healing and stopping it could worsen the underlying psoriatic arthritis, as suggested by the 2023 update of the EULAR recommendations for the management of psoriatic arthritis with pharmacological therapies 1. Consider adding vitamin D (1000-2000 IU daily) and calcium (1200-1500 mg daily) supplements to support bone healing.
- For pain management, replace celecoxib with acetaminophen (up to 3000 mg daily in divided doses) or short-term low-dose opioids if necessary.
- Resume celecoxib only after radiographic evidence of healing, typically 6-8 weeks post-fracture. Throughout treatment, ensure proper immobilization of the fracture, encourage non-weight bearing on the affected foot initially, and gradually increase weight-bearing as healing progresses under orthopedic guidance, taking into account the patient's individual characteristics and the balance between efficacy and safety, as emphasized in the EULAR recommendations 1.
From the Research
Management of 5th Metatarsal Neck Fracture
- The management of 5th metatarsal neck fractures can be conservative or surgical, depending on the fracture location and characteristics 2, 3.
- Conservative management with weight-bearing as pain allows and the use of an elasticated support or removable boot can be effective for many patients 4.
- However, some studies suggest that surgical treatment, such as intramedullary screw fixation, may be necessary for certain types of fractures, such as those in zone II and III 3.
Considerations for Patients with Psoriatic Arthritis
- Patients with psoriatic arthritis may have an increased risk of non-union or delayed healing due to their underlying condition 5.
- The use of medications such as Celecoxib, Hydroxychloroquine (HCQ), Infliximab, and Ubrogepant may also impact bone healing, although the exact effects are not well-studied in this context.
- Vitamin D insufficiency or deficiency may be a contributing factor to fractures in patients with psoriatic arthritis, and supplementation may be beneficial 6.
Monitoring and Follow-up
- Routine follow-up may not be necessary for all patients with 5th metatarsal fractures, and a standardized protocol with weight-bearing as pain allows and access to care if required may be sufficient 4.
- However, patients with psoriatic arthritis or other underlying conditions may require closer monitoring to ensure proper healing and to address any potential complications 5.