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Sports Medicine

5th Metatarsal FX: Aggressive or Conservative

08/01/2008

Question:

3 weeks ago I had a slip on shoe come off, tripped on it and twisted my foot. While every step hurt badly immediately after the event, the pain was intermittent (almost no pain with sneakers that did not allow my foot to bend). No "unusual" swelling--although that foot is capable of extreme pitting edema if I sit at the computer all day--and no obvious bruising. It is quite tender at the site of the actual break. 2.5 weeks after the event I decided it could be more than a sprain and sought medical intervention.

X-rays reveal a fracture of the 5th metatarsal--not on the ends, but in the proximal shaft of the bone (Jones Fracture?). There is a break w/ gap visible in the bone that I can see with my untrained eye, but the fracture is not complete. It is not a "line" fracture. The foot is not casted but in a boot that I already had after a stress fracture of the 3-4th metatarsals in the same foot. (I rotate my foot outward and the body weight is primarily supported by the outer bones. I was new to walking barefoot on tile floors 6 years ago) I am now on crutches with orders to wear the boot at all times except when sleeping. No weight bearing allowed for at least 2 weeks--which would be first checkup.

I have 2 major concerns that I would like an opinion about. I have only been on crutches for 4.5 days, but I have had 2-3 occassions where the foot was mildly cyanotic--usually unwrapped and keeping it off the floor maneuvering short distances without the boot on crutches. Rotating my foot at the ankle allows it to "pink up". I am not sure that moving the foot is recommended, but neither is no blood flow--especially in this fracture.

The other concern is that there appears to be a high non-unite rate of the bone even after 6-8 weeks of immobilization--(Internet research). I am wondering if I need to discuss more aggressive treatment. As a self-employed pilot required to hold up to 180 ft. lbs of pressure for single engine work in jets, I can`t afford an extremely long recovery period nor a re-break of the bone. I have no sick pay nor disability pay, so "down time" needs to be minimal. (50+ y/o, female, controlled longterm hypertensive, HRT; 1st class FAA physical q 6 months) Thanks!

Answer:

Thank you for your inquiry. It is impossible to give you an accurate second opinion without actually seeing your foot and x-ray’s however I can give you some general advice concerning your questions. First the cyanosis you describe is a bit troubling and your treating physician needs to know about that right away. The fact that it “pink’s up” when you move it is good and as long as you are not weight bearing or excessively aggressive with the range of motion I see no particular problem doing so. Your second concern about non union is patient dependent. The fact that your fracture is not complete (all the way through) may help reduce your risk of non-union. In my experience weight bearing on the affected foot is the most common reason for non-union. That said your job and life style do not lend themselves to a lot of time off. Surgical intervention would require the same type of reduction in weight bearing and for the same period of time. A fracture caused intentionally by surgical intervention is still a fracture and takes the same amount of time to heal. In addition surgical intervention is no guarantee that there will not be a non-union of bone.

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Response by:

Jeffrey M Robbins, DPM Jeffrey M Robbins, DPM
Clinical Assistant Professor of Surgery
School of Medicine
Case Western Reserve University