Management of Radiographically Occult Metatarsal and Cuneiform Fractures
A postoperative shoe is sufficient for managing radiographically occult fractures of the left second metatarsal base, lateral cuneiform, and fourth metatarsal base. 1
Assessment of Occult Foot Fractures
- Radiographically occult fractures are those that are not visible on initial radiographs but are clinically suspected based on symptoms and mechanism of injury 2
- These fractures are often misdiagnosed as sprains or contusions when additional imaging is not performed 3
- MRI is the preferred advanced imaging modality for detecting occult fractures when radiographs are negative but clinical suspicion remains high 1
Treatment Approach
Immobilization Options
- For stable, non-displaced metatarsal and midfoot fractures, a postoperative shoe provides adequate protection and immobilization 4
- Rigid splinting is generally reserved for displaced fractures or those with joint involvement 5
- The American Heart Association guidelines do not recommend moving or trying to straighten an injured extremity in the first aid setting 1
Specific Management for Metatarsal Base and Cuneiform Fractures
- Nondisplaced fractures of the metatarsals can be treated conservatively with protected weight bearing in a postoperative shoe for 4-6 weeks 4
- Isolated cuneiform fractures are rare and, when non-displaced, can be managed with protected weight bearing rather than rigid immobilization 3
- For midfoot fractures without displacement, a postoperative shoe allows for adequate stability while permitting some functional movement 1
Follow-up Recommendations
- Clinical and radiographic follow-up is typically recommended at approximately 3 weeks to assess healing progress 5
- Early motion of unaffected joints should be encouraged to prevent stiffness 6
- Weight-bearing status should be determined based on fracture stability and healing progress, with stable occult fractures generally allowing weight-bearing as tolerated in a protective shoe 6
Special Considerations
- If the fractured extremity appears blue or extremely pale, immediate medical attention is required as this indicates vascular compromise 1
- For patients with persistent pain despite appropriate immobilization, reassessment with advanced imaging may be warranted 2
- Patients should be educated about the importance of compliance with weight-bearing restrictions to prevent displacement of initially stable fractures 5
Potential Complications
- Persistent displacement of midfoot fractures may result in post-traumatic arthritis due to the multiple articulations in this region 3
- Overtightening of compression wraps can compromise circulation and should be avoided 6
- Prolonged immobilization can lead to joint stiffness and muscle atrophy, which is why a less restrictive option like a postoperative shoe is preferred when appropriate 6