AUTHOR AND EDITOR INFORMATION

Section 1 of 9  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• MRI
• Nuclear Medicine
• Multimedia
• References

INTRODUCTION

Section 2 of 9  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• MRI
• Nuclear Medicine
• Multimedia
• References

Background

Fractures in the foot are common, and the metatarsals are among the bones most commonly fractured. The injury may be an acute fracture, which is usually due to dropping of heavy objects on foot, or due to a stress fracture secondary to abnormal repetitive trauma in normal bone. Alternatively, a foot fracture can be an insufficiency fracture due to normal stress on a deficient bone.

Acute fractures can be transverse, oblique, or comminuted and are easily recognized. Stress fractures are difficult to recognize in the early stages, when they are manifested only by a periosteal reaction. Bone scans are helpful in this situation. Recognition of fracture is crucial to guide appropriate management and to prevent complications.

For excellent patient education resources, visit eMedicine's Breaks, Fractures, and Dislocations Center. Also, see eMedicine's patient education articles Broken Foot, Broken Toe, and Crutches.

Pathophysiology

Types of metatarsal injuries

Jones and pseudo-Jones, or tennis, fractures

A Jones fracture is caused by inversion of foot, which produces tension on the peroneus brevis tendon and on the lateral cord of the plantar aponeurosis. In this type of fracture, significant displacement is absent. This type of fracture is more prone to nonunion.

A fracture of the metatarsal tuberosity is an avulsion fracture. This is also called a pseudo-Jones fracture or a tennis fracture. The mechanism of injury is forcible inversion of the foot in plantar flexion, which can happen when one steps on a curb or falls when climbing stairs. A direct blow to the tuberosity can cause a comminuted fracture.

Distal, or dancer's, fractures

Distal fractures, also called dancer's fractures, are caused by a rotational force caused by axial loading with the foot in a plantigrade position.

Lisfranc dislocation

The Lisfranc joints are the tarsometatarsal joints. A Lisfranc fracture dislocation is caused by falling from a height, falling down stairs, or stepping off a curb.

Mechanisms of injury are (1) rotation around a fixed forefoot (eg, falling from horse with the foot caught in the stirrup) or (2) longitudinal compression of foot. In this second mechanism, the metatarsal head is fixed, with weight of body on the hindfoot against the base of metatarsals along with rotation; these forces result in a distal dorsal dislocation of the metatarsal.

Stress fractures

Stress fractures are due to abnormal stress on a normal bone. Stress fractures of the foot are also called marcher's foot because of the high incidence of occurrence in military recruits and those who engage in heavy exercise for prolonged periods. This fracture is also common in ballet dancers, gymnasts, and athletes. Other predisposing factors include surgery, stress fractures in adjacent bones, neuropathic disease, and rheumatoid arthritis.

When a normal step is initiated, maximum force is placed on the head of the second or the third metatarsal. With increased activity, microinfarction takes place in the bones, resulting in a fracture.

Insufficiency fractures

Insufficiency fractures are due to normal stress on a weakened bone. This injury is seen in people with osteoporosis, and commonly affects postmenopausal women.

Classification systems

Simple classification

Many classifications apply to fracture of the fifth metatarsal.

A simple classification for fractures of the proximal end of fifth metatarsal divides them into (1) fractures of the tuberosity and (2) fractures of the proximal metatarsal within 1.5 of the tuberosity.

Acute fractures, Jones fractures, and stress fractures can be described as (1) early, (2) delayed union, or (3) nonunion fractures.

Torg classification

The Torg classification is used for fractures within 1.5 cm of the metatarsal tuberosity. Type I includes fractures with sharp margins and no widening, sclerosis, periosteal reaction, or cortical hypertrophy. Type II is a fracture with widening, periosteal reaction, and/or sclerosis. Type III is a fracture with widening, periosteal reaction, and/or complete sclerosis at the fracture line.

Stewart classification

The Stewart classification of fifth metatarsal fractures is as follows: type I, extra-articular fracture between the metatarsal base and diaphysis; type II, intra-articular fracture of the metatarsal base; type III, avulsion fracture of the base; type IV, comminuted fracture with intra-articular extension; and type V, partial avulsion of the metatarsal base with or without a fracture.

Zonal classification

The zonal classification reported by Dameron, Lawrence, and Botte categorizes metatarsal fractures by the region affected: Zone 1 corresponds to the tuberosity, zone 2 corresponds to Jones fractures, and zone 3 is the diaphysis.

Mortality/Morbidity

• Early diagnosis and no weight bearing are essential to prevent the complications of metatarsal fractures.
• Complications of metatarsal fractures include nonunion (more common in Jones fractures than in other types), delayed union, malunion, secondary osteoarthritis, and reflex sympathetic dystrophy.

Race

Metatarsal fracture has no racial predilection.

Sex

Metatarsal fracture has no particular sexual predilection.

Age

Stress fractures are more common in adults involved in prolonged exercises, especially military recruits, runners, dancers, and gymnasts, than in other groups.

Anatomy

There are 5 metatarsal bones in the foot. Each bone has a base, a shaft, and a head. The base is situated proximally and articulates with the distal row of tarsal bones. This articulation is called the Lisfranc joint. The first metatarsal articulates with the medial cuneiform bone; the second metatarsal, with intermediate cuneiform bone; the third, with lateral cuneiform bone; and the fourth and fifth metatarsals, with cuboid bone.

The base of the fifth metatarsal has a tuberosity that projects inferiorly in the plantar direction and attaches to the peroneus brevis tendon and the lateral band of plantar fascia. The head of the metatarsals articulates with the proximal phalanx of the corresponding digit.

The second metatarsal is the longest of all metatarsal bones, and first metatarsal is the shortest. . Two sesamoid bones are present in the tendon of flexor hallucis brevis, posterior to the first metatarsal bone.

Development of metatarsal bones

The primary centers of ossification of the metatarsal shaft appear by 9-10 weeks of intrauterine life. The epiphysis for the heads of the metatarsals appears by 3-4 years of postnatal life. The epiphysis at the base of the first metatarsal also appears by 3-4 years and unites by 18 years. Occasionally, the base of the fifth metatarsal can have a separate secondary ossification center; this may be confused with a fracture.

Radiologic anatomy

Regarding the alignment of metatarsal bones, the metatarsal bones and tarsal bones are connected by strong ligaments. Soft tissue support for the joints in the plantar aspect of foot is better than that in the dorsal aspect.

On the anteroposterior view, the lateral border of the first metatarsal should be aligned with the lateral border of the medial cuneiform. The medial border of the second metatarsal should be aligned with the medial border of the intermediate cuneiform bone.

On the oblique view, the medial and lateral border of the third metatarsal should be aligned with the medial and lateral borders of lateral cuneiform bone. The medial border of the fourth metatarsal should be aligned with the medial border of the cuboid bone. The fourth and fifth metatarsals are aligned with the cuboid bone, but the lateral part of the fifth metatarsal can project beyond the margin of the cuboid bone, up to 3 mm.

The distance between the base of the first and second metatarsals and the medial and intermediate cuneiform is more than the distance between other corresponding joints.

If a lateral image is obtained a line through the long axis of talus bone and the long axis of first metatarsal bone should be straight there is no dislocation.

Clinical Details

Signs, symptoms, and treatment

In a fracture of fifth metatarsal, pain and tenderness are present at the base of fifth metatarsal, along with swelling, ecchymosis, and difficulty in weight bearing. This fracture is sometime hard to differentiate from an ankle injury because the swelling can be near region of the lateral malleolus.

The head of the second metatarsal head is most commonly affected, though other bones can be involved as well.

Management depends on whether injury is an acute fracture or a stress fracture and on whether it is displaced or not.

Avulsion fractures of the tuberosity are managed conservatively with non–weight bearing casts. Jones fractures are managed according to their Torg classification: Type I is managed conservatively. Type II is managed conservatively or with surgery. Type III has more complications and is usually managed surgically.

Other problems to consider

Anatomic variants

A secondary ossification center at the base of the fifth metatarsal (apophysis) can be seen in girls aged 9-11 years and boys aged 11-14 years. This center is always longitudinal and parallel (not transverse) to the base of the fifth metatarsal; this can simulate a fracture. The apophysis is longitudinally oriented and smoothly corticated; these features differentiate it from a fracture at the same location.

The os peroneum is a sesamoid bone situated lateral to the cuboid the in peroneus longus tendon. It occurs at the groove of the tubercle on the lateral aspect of the cuboid.

The os vesalianum is an accessory ossicle proximal to base of fifth metatarsal. This is seen in the peroneus brevis tendon.

Apophysitis

This is a nonspecific inflammation of apophysis at the base of the fifth metatarsal. Apophysitis is also called Iselin disease. On clinical evaluation, pain, tenderness, and swelling are noted at the base of the fifth metatarsal. This self-limiting condition occurs in adolescents. Radiographs show an irregular apophysis but no fracture.

Stress fracture

Stress fractures are due to abnormal stresses on a bone with normal mineralization. In the foot, these fractures are common at the head of second and third metatarsals and frequently occur in military recruits and marchers. The injury manifests as a thin layer of periosteal reaction. If not treated in the early stages, the periosteal reaction becomes florid. In dancers, various bones can also be involved.

Insufficiency fracture

This is commonly seen in people with osteoporosis. The bones are osteopenic, and fractures can be seen through them.

Pathologic fractures

Pathologic fractures are secondary to bone lesions, including infections and tumors, such as metastases, lymphomas, plasmacytomas, bone cysts, lipomas, and osteoblastomas.

Osteomyelitis

Osteomyelitis of the foot is common in diabetics. Bone scanning is the most sensitive investigation for detecting this disease and shows a hot spot in the involved bone.

Radiographs are positive in 7-21 days, when about 50% of the bone is involved. The earliest finding is soft tissue swelling with distortion of the normal fat planes in the soft tissue. A periosteal reaction appears along the surface of the bones. Lytic destruction of the bone occurs when the disease is established. In patients with diabetes, gallium scanning or white blood cell scanning can be performed to differentiate neuropathic joints from osteomyelitis.

Freiberg disease

Freiberg disease is osteochondrosis involving the head of the metatarsals, usually the second and occasionally the third or fourth. Clinically, patients present with pain and tenderness. Radiographs show a flattened metatarsal head with increased opacity and occasional cystic lesions. In later stages, the joint is widened, and the head is sclerotic with a thick cortex.

Neuropathic joints

In the foot, neuropathic joints are commonly due to diabetes. Other causes include syphilis and spinal cord diseases. Clinically, the foot is swollen and usually painless, though occasionally pain is present. Radiographs show destruction of the bone, with deformity, sclerosis, osteophyte formation, loose bodies, and dislocation.

Patients with diabetes can have associated vascular calcification. Soft tissue swelling and ulcers can also occurs in diabetic foot. Frequently, neuropathic joints may coexist with osteomyelitis; in this case, a white blood cell scan is indicated for differentiating these conditions.

Preferred Examination

Proper history taking in patients with symptoms and suggestive mechanisms of injury is essential.

Physical examination reveals common signs and symptoms of swelling, tenderness, warmth, ecchymosis, limitation of movements, and an inability to bear weight.

Radiography is the first and often the only investigation required for the diagnosis of fractures. Radiographs can be used diagnose all acute fractures, dislocations, and established stress fractures.

Bone scanning is more sensitive than plain radiography and indicated when a stress or acute fracture is suspected and radiographs are negative. Bone scanning is not a specific investigation.

Although MRI is more sensitive than radiography and bone scanning, it is used only for the assessment of soft tissue structures and ligamentous injuries. MRI is the most sensitive technique for imaging stress fractures of the foot and can depict bone marrow edema even before increased uptake is seen on bone scans.

CT scanning is useful for finding avulsion fractures and comminuted fractures to assess for intra-articular extension.

Limitations of Techniques

Small avulsions can be missed on radiographs. In the early stages of stress fracture, radiographs can be normal, or they may show only subtle periosteal reaction, which can be easily missed. Radiography cannot be used to assess soft-tissue and ligamentous disruption.

Although CT and MRI are more sensitive than radiography, they are not cost-effective and not indicated for the diagnosis of fractures.

Although bone scanning is sensitive, it can still miss some stress fractures in the early stages.

DIFFERENTIALS

Section 3 of 9  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• MRI
• Nuclear Medicine
• Multimedia
• References

Other Problems to be Considered

Anatomic variants
Apophysitis
Stress fracture
Insufficiency fracture
Pathologic fractures
Osteomyelitis
Freiberg disease
Neuropathic joints

RADIOGRAPH

Section 4 of 9  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• MRI
• Nuclear Medicine
• Multimedia
• References

Findings

Metatarsal fractures

An acute fracture is seen as a linear lucency and a break in the cortical surface. Nondisplaced impacted fractures can be seen as an opaque line and confirmed on a different view.

Fractures can affect any metatarsal, but the fifth metatarsal is most commonly affected. The fracture can be transverse, oblique, comminuted. Longitudinal linear fractures are extremely rare.

The 2 most common fractures in the fifth metatarsal are a fracture at the tip of the tuberosity and a transverse fracture 1.5-2 cm from the tuberosity; the latter is called a Jones fracture. Small avulsions derived from the tip of the base of the fifth metatarsal may be only seen in the oblique projection of the ankle (Pao, 2000).

Stress fractures

The radiographic findings of a stress fracture depend on the bone involved and the stage of disease. Radiographs are normal in the early stages of the disease, and stress fractures appear as well-defined linear lucency or fluffy periosteal reactions by 7-10 days. The periosteal reaction is variable and is occasionally florid.

The head of the second metatarsal, and occasionally the third metatarsal, are commonly affected. The first metatarsal is injured in 10 % of metatarsal stress fractures and involves a different kind of reaction (the endosteal variety), with liner sclerosis. Periosteal reaction is not common in this type of injury. One third heal with only an intramedullary callus.

The base of second metatarsals can be affected in ballet dancers. The proximal aspect of the shaft of the fourth and fifth metatarsals is affected, and the pattern is that of a linear lucency, which is slow to heal. Fractures in the sesamoid bones are also seen in ballet dancers.

Lisfranc fracture-dislocation

A Lisfranc fracture-dislocation refers to a dislocation of the tarsometatarsal joints. Two types of Lisfranc dislocation have been described: homolateral and divergent.

In the homolateral type, all of the metatarsals are dislocated to one side. Usually, the second to fifth metatarsals are dislocated, but occasionally, all of the metatarsals are affected. Lateral displacement is more common than medial displacement.

A divergent dislocation is medial displacement of the first metatarsal and lateral displacement of the second to fifth metatarsals. A variant of this type is an isolated medial dislocation of the first metatarsal.

Lisfranc dislocations are associated with fractures of the base of the second metatarsal, fractures of the cuboid bone, fractures of the shaft of the other metatarsal bones, dislocations of the middle and medial cuneonavicular joints, and fractures of the navicular bone. The base of the second metatarsal is relatively fixed compared with the other metatarsal bones. Therefore, it is involved in both types.

This dislocation is overlooked in as many as 20% of cases if the alignment is not carefully evaluated. Lisfranc dislocations should be suspected if the gap of more than 5 mm is present between the bases of first and second metatarsals or between the medial and middle cuneiforms.

Degree of Confidence

Radiography is sensitive in the diagnosis of acute fractures.

False Positives/Negatives

Radiographs might not show stress fractures in early stages and as many as 50% of patients. In addition, nondisplaced fractures can be difficult to visualize. Associated ligamentous injuries and soft tissue changes are not depicted.

CT SCAN

Section 5 of 9  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• MRI
• Nuclear Medicine
• Multimedia
• References

Findings

CT scanning is not essential for diagnosing metatarsal fractures. If CT is planned, it should be performed in at least 2 planes: the coronal plane (perpendicular to the sole of foot) and the axial plane (parallel to the sole). With the modern multisection scanners, images can be acquired in 1 plane and reconstructed in other planes with fairly high degree of resolution.

Images are usually acquired with 5-mm sections, but 3- and 1.5-mm sections can also be acquired, with the thinner sections having better resolution. Coronal images are acquired with the patient in the supine position with his or her knees flexed and feet flat on the table. The heels of both feet are superimposed in the lateral position. Longitudinal images are acquired with the patient in the supine position with his or her knees extended and feet perpendicular to the table.

Degree of Confidence

CT scans can often depict fractures that are not visualized on plain radiographs and are useful in evaluating the following: comminuted fractures; intra-articular extension; soft tissue trapping, including that of tendons and muscle slips; underlying pathologic lesions, if any; displacement of the fragment in the axial plane; and bony complications.

CT is more sensitive than plain radiography in the detection of stress fractures. CT findings can also differentiate stress fractures and early degenerative changes. MRI is the only modality that is more sensitive than CT scanning because of its ability to depict soft tissue and joint structures.

MRI

Section 6 of 9  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• MRI
• Nuclear Medicine
• Multimedia
• References

Findings

MRIs of foot should include T1-weighted, T2-weighted, and short-tau inversion recovery (STIR) images in the axial, sagittal, and coronal planes.

The fracture line is visualized as a linear hypointensity in T1- and T2-weighted images, whereas STIR images can show hyperintensity. Edema of the bone has low signal intensity on T1-weighted images and high signal intensity on T2-weighted images. Soft tissue swelling, ligamentous injuries, plantar-late injuries are visualized better on MRIs than on other images.

MRI is useful in the assessment of fractures and dislocations, soft tissue, the plantar plate, structures of the capsule, the extent of marrow hyperemia, the exact number of bones involved, and small chip fractures.

Degree of Confidence

MRI is sensitive for diagnosis of fractures, but it is not required because as the plain radiographic findings are fairly sensitive and specific.

MRI is more sensitive than radiography and even scintigraphy in the early diagnosis of stress fractures because it shows the bone marrow edema exquisitely. MRI can be used to differentiate stress fractures from early degenerative changes and early stress fractures from synovitis.

NUCLEAR MEDICINE

Section 7 of 9  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• MRI
• Nuclear Medicine
• Multimedia
• References

Findings

Bone scanning is performed by using technetium methylene diphosphonate. Vascular flow and delayed images are obtained.

Acute fractures are seen as foci of increased uptake in the affected bone. However, scintigraphy is not routinely indicated for the diagnosis of acute fractures. This study is performed if the clinical findings suggest a fracture but the plain radiographs are negative.

Degree of Confidence

Bone scanning is highly sensitive, surpassed by only MRI in certain instances. For instance, MRI and CT are more sensitive than bone scanning for evaluating stress fractures because MRI and CT can depict bone marrow edema.

Bone scans are positive before the earliest radiographic findings appear.

False Positives/Negatives

Bone scanning is not specific. Hence, its results should not be reported in isolation. A hot spot can be seen in fractures, degenerative changes, or neoplasms. Nuclear medicine images must be correlated with plain radiographs.

MULTIMEDIA

Section 8 of 9  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• MRI
• Nuclear Medicine
• Multimedia
• References

Media file 1:  Fractured metatarsals. Normal anteroposterior view of the foot. Note the alignment of (1) the lateral border of the first metatarsal with the lateral border of the medial cuneiform and (2) the medial border of second metatarsal with the medial border of the middle cuneiform.
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Media file 2:  Fractured metatarsals. Oblique view of a normal foot shows that the medial and lateral borders of the third metatarsal are aligned with the corresponding borders of the lateral cuneiform bone. The medial border of the fourth metatarsal is aligned with the medial border of the cuboid bone. The lateral border of fifth metatarsal projects a few centimeters beyond the cuboid bone.
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Media file 3:  Fractured metatarsals. Image shows a bone fragment parallel to the base of the fifth metatarsal bone. This is not a fracture, but rather, the apophysis of the base of the fifth metatarsal bone, which is a secondary ossification center. This center is always parallel to the long axis of metatarsal and has smooth margins, unlike a fracture.
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Media file 4:  Fractured metatarsals. Spiral fracture through the distal shaft of the fifth metatarsal.
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Media file 5:  Fractured metatarsals. Another fracture of the fifth metatarsal, oblique, in the shaft.
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Media file 6:  Fractured metatarsals. Fracture at the base of the first metatarsal in a child.
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Media file 7:  Fractured metatarsals. Transverse fracture at the base of the fifth metatarsal in a male adolescent.
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Media file 8:  Fractured metatarsals. Fracture of the midshaft of the third metatarsal.
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Media file 9:  Fractured metatarsals. Magnified view of the foot shows a fracture with callus formation in the third metatarsal bone.
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Media file 10:  Fractured metatarsals. Fracture of the distal shaft of the third metatarsal.
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Media file 11:  Fractured metatarsals. Transverse fracture at the base of the fifth metatarsal; this is a Jones fracture.
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Media file 12:  Fractured metatarsals. Avulsion fracture of the tuberosity of the fifth metatarsal.
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Media file 13:  Fractured metatarsals. Another fracture of the tuberosity of the fifth metatarsal.
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Media file 14:  Fractured metatarsals. Oblique fracture of the metaphysis of the distal shaft of the fifth metatarsal.
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Media file 15:  Fractured metatarsals. Avulsion fracture at the base of the fifth metatarsal; this was due to the action of peroneus brevis tendon.
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Media file 16:  Fractured metatarsals. Fracture of the metatarsal tuberosity.
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Media file 17:  Fractured metatarsals. Fracture of the fifth metatarsal tuberosity with lateral displacement of the fracture fragment.
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Media file 18:  Fractured metatarsals. Transverse fracture of the base of the fifth metatarsal bone and associated features, including radiopaque foreign bodies in the soft tissue and the accessory ossicle lateral to the cuboid bone.
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Media file 19:  Fractured metatarsals. Comminuted fracture of the base of the fifth metatarsal bone.
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Media file 20:  Fractured metatarsals. Fracture of the distal shaft of the third metatarsal.
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Media file 21:  Fractured metatarsals. Fracture of the proximal shaft of the first metatarsal bone.
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Media file 22:  Fractured metatarsals. Image shows a thin layer of subtle, solid periosteal reaction on the medial side of the shaft of second metatarsal bone. This is an early stage of a stress fracture.
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Media file 23:  Fractured metatarsals. Image shows a stress fracture more florid than that shown in Image 22, with extensive periosteal reaction on either side of the third and fourth metatarsals.
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Media file 24:  Fractured metatarsals. Image shows a Lisfranc fracture-dislocation: a fracture of the base of the second metatarsal and a lateral dislocation of the second metatarsal.
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Media file 25:  Fractured metatarsals. Image shows a Lisfranc dislocation with a fracture of the base of the third and fourth metatarsals.
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REFERENCES

Section 9 of 9

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• MRI
• Nuclear Medicine
• Multimedia
• References

• DeLee JC, Evans JP, Julian J. Stress fracture of the fifth metatarsal. Am J Sports Med. Sep-Oct 1983;11(5):349-53. [Medline].
• Lawrence SJ, Botte MJ. Jones'' fractures and related fractures of the proximal fifth metatarsal. Foot Ankle. Jul-Aug 1993;14(6):358-65. [Medline].
• Pao DG, Keats TE, Dussault RG. Avulsion fracture of the base of the fifth metatarsal not seen on conventional radiography of the foot: the need for an additional projection. AJR Am J Roentgenol. Aug 2000;175(2):549-52. [Medline].
• Quill GE. Fractures of the proximal fifth metatarsal. Orthop Clin North Am. Apr 1995;26(2):353-61. [Medline].
• Stewart IM. Jones''s fracture: fracture of base of fifth metatarsal. Clin Orthop. 1960;16:190-8. [Medline].
• Stoller D. Ankle and Foot. Magnetic Resonance Imaging in Orthopaedics and Sports Medicine. 2nd ed. Philadelphia: Lippincott, Williams & Wilkins;1996: 568-9.
• Torg JS, Balduini FC, Zelko RR, et al. Fractures of the base of the fifth metatarsal distal to the tuberosity. Classification and guidelines for non-surgical and surgical management. J Bone Joint Surg Am. Feb 1984;66(2):209-14. [Medline].

Article Last Updated: Feb 4, 2005