From the Guidelines
Fractures between the first and second metatarsals, known as Lisfranc injuries, require prompt medical attention and treatment depends on the severity of the fracture.
Treatment Approach
The treatment approach for Lisfranc injuries can be conservative or surgical, depending on the severity and displacement of the fracture.
- Non-displaced fractures can often be managed conservatively using a non-weight bearing cast for 6-8 weeks, followed by a walking boot for 4 weeks and gradual return to activities, as suggested by 1.
- Displaced fractures usually require surgical intervention with internal fixation using screws or plates to restore proper alignment, which is a common practice in orthopedic surgery.
Pain Management
Pain management typically includes NSAIDs like ibuprofen (400-600mg every 6-8 hours) or naproxen (500mg twice daily) for 1-2 weeks.
Post-Surgery Protocol
Post-surgery, patients follow a similar non-weight bearing protocol for 6-8 weeks, which is crucial for proper healing and recovery.
Physical Therapy
Physical therapy is essential for recovery, focusing on range of motion exercises, strengthening, and proprioception training, as it helps in restoring foot function and preventing long-term complications.
Complications
These fractures are serious because the Lisfranc joint complex is crucial for foot stability and normal gait, and complications can include chronic pain, post-traumatic arthritis, and arch collapse if not properly treated, as highlighted by 1.
Recent Guidelines
Recent guidelines, such as those discussed in 1 and 1, emphasize the importance of proper treatment and management of foot fractures, including Lisfranc injuries, to prevent long-term complications and improve patient outcomes.
Recommendation
Based on the most recent and highest quality study, 1, the recommended treatment approach for fractures between the first and second metatarsals is to prioritize conservative management for non-displaced fractures and surgical intervention for displaced fractures, with a focus on proper pain management, post-surgery protocol, and physical therapy to ensure optimal recovery and prevent long-term complications.
From the Research
Foot Fractures Between First and Second Metatarsals
- Foot fractures account for about one-third of lower extremity fractures in adults and are typically caused by a crush injury or an axial or twisting force on the foot 2.
- Patients usually present with bony point tenderness and swelling of the affected area, and weight-bearing varies based on the extent of the fracture and the patient's pain tolerance 2.
- Metatarsal shaft fractures, which include those between the first and second metatarsals, are managed with a boot or hard-soled shoe for three to six weeks 2, 3.
- Nondisplaced fractures of the metatarsal shaft usually require only a soft dressing followed by a firm, supportive shoe and progressive weight bearing 4.
- Stress fractures of the first to fourth metatarsal shafts typically heal well with rest alone and usually do not require immobilization 4.
Diagnosis and Treatment
- Diagnosis requires radiographic evaluation, although emerging evidence demonstrates that ultrasonography may be just as accurate 3.
- Management is determined by the location of the fracture and its effect on balance and weight bearing 3.
- Metatarsal shaft fractures are initially treated with a posterior splint and avoidance of weight-bearing activities; subsequent treatment consists of a short leg walking cast or boot for four to six weeks 3.
- Referral is generally indicated for intra-articular or displaced metatarsal fractures, as well as most fractures that involve the first metatarsal or multiple metatarsals 4.
Specific Considerations
- Fractures of the fifth metatarsal have varied rates of healing due to poor blood supply, and management is based on the fracture zone 2.
- Functional treatment for metatarsal fractures provides earlier healing and fewer adverse effects than conventional therapies, and becomes first choice for non-displaced fractures and most displaced fractures of the fifth metatarsal 5.
- Proximal fifth metatarsal fractures that are distal to the tuberosity have a poorer prognosis, and treatment should be individualized based on the characteristics of the fracture and patient preference 4.