What is the management approach for multiple tarsal and metatarsal fractures?

Management of Multiple Tarsal and Metatarsal Fractures

The management of multiple tarsal and metatarsal fractures requires a balanced approach between operative and non-operative treatment, with careful selection of fixation devices and techniques based on fracture location, displacement, and patient factors. 1

Initial Assessment and Classification

• Evaluate fracture location, displacement, comminution, and joint involvement to determine appropriate treatment strategy 1
• Assess for associated soft tissue injuries, which may influence treatment decisions 1
• Determine whether fractures are stable or unstable, as this guides management approach 1

Treatment Algorithm

Non-Operative Management

• Indicated for:

  • Non-displaced fractures of the second to fourth metatarsals 2
  • Fractures with displacement only in the horizontal plane 2
  • Stable fractures without significant deformity 1

• Non-operative protocol:

  • Protected weight-bearing in a cast shoe or orthosis for 4-6 weeks 2, 3
  • Activity modification and appropriate pain management 1

Operative Management

• Indicated for:
  • Displaced fractures (>3-4mm displacement or >10° angulation) 4
  • Fractures with joint involvement 2
  • Multiple fragment fractures 2
  • Unstable fracture patterns 1

Fixation Options Based on Fracture Type:

1. Metatarsal Shaft and Neck Fractures:

   • Percutaneous pinning with Kirschner wires for most displaced lesser metatarsal fractures 2, 5
   • Open reduction and plate fixation for markedly shortened and multifragment fractures 3
   • Interlocking plates (2.0-2.4mm) preferred to avoid soft tissue irritation 3
   • Long spiral fractures may be fixed with screws 3

2. Fifth Metatarsal Fractures:

   • Zone 1 (avulsion): Conservative treatment if minimally displaced; ORIF with tension-band wiring or screw fixation if displaced >2mm or >30% joint involvement 2
   • Zone 2 (Jones fractures): Intramedullary screw fixation recommended due to high non-union rates with conservative treatment 6
   • Zone 3 (diaphyseal stress fractures): Internal fixation recommended, particularly for athletes 4

3. Tarsal Fractures:

   • Anatomical reduction is crucial to rebuild foot arches and restore normal biomechanics 5
   • Screw fixation or K-wire fixation depending on fracture pattern and bone quality 5

4. Tarsometatarsal Joint Injuries with Metatarsal Fractures:

   • Open reduction and internal fixation to restore anatomical alignment 5
   • Rebuilding foot arches is essential to avoid pain and limping 5

Post-Operative Management

• Initial period (0-2 weeks):

  • Rest, elevation, and local cooling of the injured leg 3
  • Soft wrap and postoperative boot with non-weight-bearing 6
  • Keep incision clean and dry 6

• Progressive rehabilitation (2-6 weeks):

  • Partial weight-bearing (20kg) in foot orthosis or cast shoe for 6 weeks 3
  • Gradual weight-bearing progression: 25% at week 3,50% at week 4,75% at week 5,100% at week 6 6
  • Begin ankle range-of-motion exercises and strengthening 6

• Advanced rehabilitation (6-12 weeks):

  • Increase walking and physical therapy at weeks 6-8 6
  • Begin pool or treadmill activity at weeks 8-12 6
  • Radiographic union typically occurs between weeks 6-10 6

Special Considerations

• Elderly Patients: Require careful balance between operative and non-operative treatment due to frail bones and potential comorbidities 1
• Diabetic Patients: May require specialized offloading techniques, particularly with metatarsal head involvement 1
• Athletes: May benefit from more aggressive surgical management to facilitate earlier return to activity 4

Potential Complications

• Infection: Higher risk with high-energy trauma and open fractures 1, 4
• Non-union/Delayed Union: Most common in fifth metatarsal zone 3 fractures 4
• Malunion: Associated with poor functional outcomes due to altered foot biomechanics 4
• Post-traumatic Osteoarthritis: Particularly with joint involvement 4
• Transfer Lesions: Can occur after metatarsal head resection in diabetic patients 1

Follow-up Evaluation

• Regular radiographic assessment to monitor fracture healing 6
• Evaluate for subsequent fracture risk in patients over 50 years 1
• Consider implementing a Fracture Liaison Service for elderly patients to prevent future fractures 1

Common Pitfalls to Avoid

• Inadequate reduction of displaced fractures leading to malunion and altered foot biomechanics 5
• Insufficient immobilization of unstable fractures 2
• Allowing weight-bearing too early after fixation of unstable fractures 6
• Failure to address associated soft tissue injuries 1
• Overlooking the need for rehabilitation and fall prevention in elderly patients 1