Surgical treatment of shortened metatarsals in children and adolescents

Metatarsal bones are part of the group of small tubular bones of the human skeleton. Metatarsal fractures are the most common bone fractures in the foot. Namely, fractures of the base of the fifth metatarsal bone that occur as a result of inversion of the foot. The location of the fracture should be carefully analyzed by a doctor, since the treatment of fractures of different location and nature varies quite a lot.

Types of fractures of the metatarsal bones of the foot

There are two main types of metatarsal fractures:

• Traumatic fractures - due to acute (sudden) injury to the middle and forefoot.
• Stress fractures are due to excessive long-term stress or repeated minor trauma against a background of completely normal metatarsals.

Fractures of the metatarsal bone of the foot are also classified according to location, nature of the fracture and the presence of displacement:

• Fractures of the base, body or subcapitate fractures of the metatarsal bones;
• Fractures of the metatarsal bone with or without displacement;
• Fractures are oblique, transverse, helical, comminuted.

Prevalence

Metatarsal fractures account for 5% to 6% of all skeletal fractures. They are equally common among men and women of the planet.

To understand the mechanism of metatarsal fractures, it is probably best to start with a brief explanation of the anatomy of the foot.

The human foot consists of 26 bones:

• 5 metatarsal bones. These are tubular bones that are located between the tarsal bones and the phalanges of the fingers. Functionally, the metatarsal bones play an important role in movement, acting as a lever during foot movements (steps, running, jumping).
• 14 phalanges of fingers. The first finger consists of two phalanges, the remaining fingers - of three.
• 3 sphenoid bones. Located between the navicular bone and the first three metatarsal bones.
• Cuboid
• Scaphoid
• Talus
• Calcaneus

Together, the bones of the foot form a very complex mechanism that compensates for the enormous loads throughout the day and helps absorb the shock of every step.

Evolutionary development [edit | edit code]

In the first land vertebrates (stegocephalians), the tarsus consisted of many small bones, inactively connected both to each other and to the bones of the lower leg. In connection with the adaptation to jumping, the ankle joint gradually formed, while the two proximal bones (corresponding in humans to the talus and calcaneus) lengthened somewhat to form an additional lever for the foot.

In reptiles and birds, the proximal bones of the tarsus are again motionlessly connected to the bones of the lower leg (in birds they even fuse), and the distal bones of the tarsus are also motionlessly articulated to the bones of the metatarsus. In this case, to ensure mobility between the lower leg and foot, a special intertarsal joint is formed between the tarsal bones.

In mammals, the tarsus often consists of seven bones (as in humans); in ungulates, as an adaptation to running, the number of tarsal bones is reduced to five.

Symptoms of fractures

• Pain that develops gradually and increases with exercise
• Foot swelling
• Subcutaneous hemorrhage (bruise)

Patients with these symptoms typically experience a sudden onset of sharp, intense pain following an injury. Sometimes the patient may hear a crunching or clicking sound at the time of injury. The pain causes the patient to limp. Patients with a metatarsal fracture are also accompanied by swelling, which increases during the day and decreases at night. In severe displaced metatarsal fractures, obvious deformity may not be noticeable.

Diagnosis of metatarsal fractures

For a more detailed understanding of the problem, the doctor finds out from the patient the mechanism of injury, including the force, location and direction of the blow.

Stress fractures are usually associated with increased intensity or duration of repetitive movements such as running, ballroom dancing, and others.

Examination: Careful examination and examination of the entire foot and ankle is critical in identifying associated injuries. Deformity, swelling and hemorrhage are easily visualized.

X-rays in 2 projections are usually sufficient to diagnose a fracture. But with stress fractures without displacement, sometimes it is impossible to determine them even for a very experienced doctor.

In such cases, control radiographs are prescribed after 10-14 days, when bone tissue resorption occurs at the fracture site. Stress fractures are also difficult to see on x-rays until they begin to heal and callus begins to form. This is exactly what is clearly visible on x-rays. A CT scan or MRI may be necessary to rule out stress fractures and other foot pathologies.

First aid for metatarsal fractures

• Limiting loads and movements. It is important to limit movement and stress on the foot to prevent further damage.
• Cold locally. Using ice will help slow or reduce swelling and provide a numbing sensation that will relieve pain. It makes sense to apply ice to the injury site for the first 48 hours after the injury. Never hold ice for more than 20 minutes at a time to prevent frostbite. A break of 1.5 hours before repeated exposure to ice, this allows the tissues to return to normal temperature and trophism, repeat as necessary. You can wrap any frozen product in a towel and apply it to the damaged area. Ice should be applied as soon as possible after the injury. (Do not place ice directly on your skin. Also, do not leave ice on while you sleep, or leave it on for more than 30 minutes. This may cause frostbite.)
• Elastic bandaging. You need to bandage your leg with an elastic bandage. But bandage it correctly, not too tightly. If your fingers become cold or numb, it means the bandage is too tight. An elastic bandage will limit swelling and limit movement in the joint. You can sleep without a bandage. But be sure to move around with your leg wrapped in an elastic bandage.
• Elevated position. Elevate the injured leg, such as resting your leg on a pillow while lying on a sofa or bed. If you are sitting, you can rest your leg on a chair to reduce swelling and pain.

Avoid: heating the damaged area during the first week, rubbing with alcohol and massage, which can aggravate the swelling. For example, exclude hot baths and saunas. Heat has the opposite effect compared to ice. That is, it stimulates blood flow.

It is important to limit the load when walking (do not rely entirely on the foot) until the injury has been diagnosed by a doctor.

Examples of results of treatment and rehabilitation of a non-union fracture.

Over the past few years, more than 180 patients have been treated with a diagnosis of delayed fracture consolidation and pseudarthrosis. In all cases, the treatment resulted in the formation of a bone callus. There were also patients whose fracture did not heal for several years. These patients also developed callus formation after undergoing a course of shock wave therapy using the patented Avatage technique and modern Storz Medical equipment.

Patient R. Comminuted closed fracture of the left humerus with delayed consolidation of the fracture and contracture of the left shoulder joint. The patient refused surgical treatment and underwent outpatient treatment for 5 months. There were no signs of bone fusion. The patient was sent for rehabilitation to the Avatage MC. A course of rehabilitation was carried out using shockwave therapy, biomechanical muscle stimulation, kinesiotherapy, and myostimulation. The result is complete consolidation of the fracture, reduction of pain and restoration of range of motion in the shoulder 1.5 months after the start of the recovery course.

Patient P., Complex fracture of both bones of the forearm, an operation was performed to fix the bone fragments using plates. Over the next year, the bones did not heal. The patient was recommended to undergo a course of radial shock wave therapy. 6 sessions of shockwave therapy were performed with an interval of 1 week.

Example 2: Delayed fracture consolidation. Operational stabilization of the fragments was not carried out. There was no bone fusion within 8 months. After 5 sessions of shock wave therapy, bone fusion is observed.

Example 3. Patient diagnosed with: Open gunshot fracture of the lower third of the right tibia with displacement of fragments. Granulating wound of the anterior surface of the lower third of the right leg. X-ray shows delayed consolidation of bone fragments. 7 procedures of radial shock wave therapy were performed with an interval of 7 days. After the course, the X-ray image clearly shows the formation of callus.

Fracture of the tibia. Delayed consolidation of the fracture. State before shock wave therapy.

Condition of the bone after a course of shock wave therapy. Consolidation of the bone and disappearance of fracture lines are noted.

Example 4. Patient, 75 years old. Delayed consolidation after a fracture of the lower third of the humerus. Condition after metal osteosynthesis.

Delayed consolidation of the fracture in the lower part of the humerus. Before treatment with shock wave therapy.

Fusion of bone fragments of the humerus after a course of shock wave therapy. The arrows indicate the places where bone compaction and callus have formed at the site of the fracture line.

Example 4. A patient with long-term (more than 3 years) non-union of fractures, which was complicated by osteomyelitis. After 3 repeated operations and installation of an external fixation device, bone fusion did not occur. The patient was sent to the Avatage MC to undergo a course of shock wave therapy and rehabilitation. After completing a course of shockwave therapy consisting of 10 procedures, manifestations of osteomyelitis and bone disappeared and a bone callus formed. After 2 months, the external fixation device was removed.

Repeated surgery to stabilize the fragments, an external structure was installed. Before treatment with UVT.

Delayed consolidation of the fracture. The debris was stabilized. Before treatment with UVT.

After a course of radial shock wave therapy, bone consolidation occurred and metal structures were removed.

Treatment of fractures of the metatarsal bones of the foot

Conservative treatment of moldy bone

Treatment tactics will depend on the location of the fracture and its severity.

The goal of any treatment for metatarsal fractures is to help the patient return to a full life. Following your doctor's recommendations will help you quickly restore foot function and prevent further problems in the future.

We are convinced that for non-displaced fractures, adult patients do not need to apply plaster, as this causes a lot of inconvenience, and they are able to understand that it is necessary to limit the load in order for the fracture to heal as quickly as possible. Displacement of bone fragments does not occur without load. But it is difficult to explain to our young patients that they should not step on their feet or walk only with support on their heels. That's why we cast children.

As a rule, in case of traumatic fractures, it is recommended to walk only with support on the heel or without any support at all, moving with crutches.

In case of stress fractures, it is recommended to walk with partial weight bearing on the foot, but always in individual orthopedic insoles, which “unload” the damaged area.

If the metatarsal fracture is slightly displaced, an attempt is made to reduce it and fix it with a plaster splint.

If the fracture is accompanied by a significant displacement of bone fragments (more than half the width of the metatarsal bone), the issue of surgery is decided.

Cattle diseases

The tarsal bones - ossa tarsi - are located in three rows. In the proximal row, the calcaneus is located on the lateral side, and the talus is located on the medial side. In the middle row in the medial section of the tarsus there is only one central bone. In the distal row there are 3-4 bones: I, II, III and IV tarsal bones (counting from the medial side), of which the largest bones are III and IV (Fig. 43).

Rice. 43. Hind paw skeleton:

A – dog’s paw in front; B – dog’s tarsus from the medial surface; B - tarsus of a pig from the medial and G - from the lateral surface; D—tarsus of the cow in front; E - skeleton of a cow's paw from the medial surface; F - tarsus of the horse from the medial surface and 3 - in front; I - transverse sections of the metacarpus and K - metatarsals of the dog; L - pasterns and M - metatarsals of the horse. t—tibia (tibia); f—fibula (fibula); tf—os tarsi fibulare (calcaneus bone). 1 – tuber calcanei (tubercle of the calcaneus); 2 - sustentaculum tali (holder of the talus); 3 processus malleolaris (malleolar process); tt-os tarsi tibiale (talus bone); 4—trochlea tali (talus block); 5—caput tali (head of the talus); 6 - medial ligamentous tubercle; t-os tarsi centrale (central tarsal bone); t I—IV—os tarsi I—IV (I, II, III, IV—tarsal bones); 7— sinus tarsi (tarsal canal); mt I-IV—os metatarsi I—IV (I, II, III, IV and V metatarsal bones); 9 - os malleolare (ankle bone); ph I-III -phalanx I-III (I, II, III - phalanges); 10 - os sesamoideum ph. I (sesamoid bones); mc II-IV -os metacarpi II-IV (II, III and IV metacarpal bones).

Heel bone - calcaneus, s. os tarsi fibulare - the longest in the joint, lies laterally in the proximal row. It distinguishes: the body, the muscular process ending in the calcaneal tuber - tuber calcanei, and the medial process - the holder of the talus - sustentaculum tali, along the posterior surface of which there is a groove for the deep digital flexor tendon. On the dorsal surface of the body and holder of the talus, a facet for the talus is noticeable - facies articularis tali. Distally, the calcaneus articulates with the IV tarsal bone.

Features: In the dog, the calcaneal tubercle bears a groove facing proximally. The facet for the tarsal bone is flat and set horizontally.

In pigs and cattle, the heel bone is long and compressed from the sides. The holder of the talus is massive, its medial edge is pointed in the pig, and in cattle it bears two ribs. The dorsolateral edge of the body of the calcaneus continues into the ankle process - processus malleolaris - for the ankle bone or fibula.

In a horse, the calcaneus is short and massive: the holder of the talus is strongly developed and is equipped with two ribs along the edge.

Talus - talus, s. os tarsi tibiale - the most massive tarsal bone, short; lies mediodorsally in the proximal row and is characterized by the presence of a block for the tibia - trochlea tali. The block is directed dorsoproximally. On the latero-plantar bone, a deep notch with a facet for the heel bone is visible - facies articularis. When the talus connects with the calcaneus, a tarsal sinus is formed - sinus tarsi - for the tarsal perforating artery. Distally, the bone articulates with the central tarsal bone.

Features: In a dog, the head of the talus, caput tali, separated from the trochlea by a neck, is used to connect to the central bone. In pigs and cattle, the talus block for the tibia carries a deep groove, and the head for the central tarsal bone is also in the form of a block, but with a shallower groove. The articular surface for the calcaneus is extensive and convex; in pigs with two headbands - proximal and distal, in ruminants with one proximal headband. On the proximal ridge of the trochlea on the lateral side there is a facet for the ankle of the fibula (in cattle - for the ankle bone). In a horse, the ridges of the talus trochlea are set obliquely. The head bears a flat, loop-shaped, extensive facet for the central bone. A strongly developed ligamentous tubercle protrudes from the medial side of the talus.

The central tarsal bone - os tarsi centrale - is located between the talus and the I, II and III tarsal bones. Lies medial to the fourth tarsal bone.

Features: The dog has a scoop-shaped central part, with a proximal pit-shaped facet for the head of the talus. Three facets for the I, II and III tarsals lie side by side on the distal surface.

In a pig, the bone is similar to the IV tarsal bone, but is more compressed laterally. Proximally, it shows a concave grooved facet for the trochlea of ​​the talus.

In cattle, the central bone is fused with the IV tarsal and is the third largest bone. On its proximal surface there is a medially concave grooved facet for the talus, and on its lateral surface there is a convex narrow facet for the calcaneus. On the distal surface, from the medial edge, there is a notch for the third tarsal. In a horse, the central bone has the appearance of a rounded quadrangular plate. The proximal surface is a loop-shaped facet for the talus; distal surface with two facets.

IV tarsal bone - os tarsi quartum - lies in the lateral part of the joint between the calcaneus and metatarsal bones.

Peculiarities. The dog has a cuboid bone, elongated proximo-distally. The proximal facet is flat. On the distal surface, the two facets are placed side by side. A tubercle protrudes on the lateral surface and is hooked distally. The tendon of the peroneus longus muscle passes under it. In pig IV, the tarsal bone is similar to the central bone, but more massive; on the proximal surface there are two facets: the medial one is concave for the trochlea of ​​the talus and the lateral one is convex for the calcaneus. There are three distal facets, two medial ones. In cattle, the IV tarsal bone is fused to the central one. The horse has a massive, cuboidal bone, somewhat elongated from front to back. On the proximal surface there is a convex facet for the calcaneus, and on the distal surface there are two flat facets for the metatarsals; there are four facets on the medial surface, of which the plantar ones lie side by side and the dorsal ones separately.

III tarsal bone - os tarsi tertium - occupies the place between the central tarsal and metatarsal bones.

Features: The dog has a wedge-shaped bone with its base facing dorsally. The pig's body is flattened and square. In cattle, it merges with the second tarsal bone into a rounded-quadrangular flat bone, extended from front to back. In the horse III, the tarsal is shaped like a triangular plate with a proximal loop-shaped flat facet. There are two distal facets.

The second tarsal bone - os tarsi secundum - in a dog is wedge-shaped, with its base facing plantar. The pig's body is wedge-shaped, extended from top to bottom. In cattle it is fused with the third tarsal bone. In the horse, it often merges with the first tarsal bone, and then it has an irregular hook-shaped shape. The medial part of the bone is similar to a tetrahedral prism, the lateral part is compressed from front to back, wide, hooked distally. Sometimes both bones are separated from each other. They lie on the back surface of the joint.

The first tarsal bone - os tarsi primum - in a dog is flat, boot-shaped; in a pig it is flat, extended from top to bottom; in cattle, pisiform; in the horse it often fuses with the second tarsal .

Metatarsus bones

The metatarsal bones - ossa metatarsi - are similar to the metacarpal bones, but differ in greater length and massiveness.

Features: In a dog, the proximal facets on the metatarsal bones are flatter compared to the metacarpals. The first metatarsal bone is short, cone-shaped. The II bone is connected to the III bone by triangular facets. In the IV metatarsal bone, the proximal facet is elongated, quadrangular, characterized by a lateral ligamentous tubercle protruding laterally from the facet.

V pigs III and IV metatarsals differ from the metacarpals by highly developed plantar ligamentous tubercles at the proximal ends.

The III metatarsal bone is slightly shorter than the IV bone. The proximal fossa-shaped articular surface of the third metatarsal bone is divided in two by a crest,

and on IV without a crest. The II and V metatarsals are similar to the corresponding metacarpal bones.

In cattle, the metatarsal bone is more massive than the metacarpal; it is longer and tetrahedral in cross section. At its proximal end there is a vascular canal, and at its distal end there is an interosseous canal. The second metatarsal bone is small, in the form of a lenticular bone.

In the horse, the third metatarsal bone is massive, round in cross section and longer; on its proximal surface a flat facet is visible, divided by a ridge into a larger, medial, and smaller, lateral, section. The block on the medial side is thicker. The II and IV metatarsal bones differ from the corresponding metacarpal bones by well-defined roughness for the ligaments.

Finger bones

The phalanges of the fingers of the pelvic and thoracic limbs are quite similar.
The first and second phalanges of the horse are shorter than those of the thoracic limb; in other animals, on the contrary, they are longer. In the horse, the dorsal wall of the third phalanx is steeper. The plantar surface is laterally compressed. Tags: tarsus, bone, paw, tarsus, calcaneus, talus, facet

Surgery for a metatarsal fracture

The indication for surgery for a fracture is displacement of metatarsal bone fragments by more than half the width of the bone.

Percutaneous pin fixation

It has been popular for many years and continues to be one of the most popular methods internationally.

First, the doctor closes the displacement of the fragments, then wires are drilled through the fragments in certain (taking into account the nature of the fracture) directions.

Pros: low trauma, speed, ease, low cost, absence of an incision and, as a consequence, a postoperative scar.

Disadvantages: the ends of the wires remain above the skin so that the wire can be removed after the fracture has healed; the risk of wound infection and penetration of infection into the fracture area; long-term wearing of a plaster cast for 1 month; inconveniences in everyday life.

Open fracture reduction

Open reduction for a fracture of the metatarsal bone of the foot, external osteosynthesis with a plate and screws. The operation involves a surgical incision, access to the broken metatarsal bone by carefully retracting the tendons, vessels and nerves, mobilization of bone fragments, elimination of displacement and fixation in the correct position.

Plaster immobilization is not carried out, since the metal structure fixes the fragments.

Walking with support on the heel area is allowed for a month.

Rehabilitation after a metatarsal fracture

As soon as the fracture of the metatarsal bone heals and the pain decreases, the doctor will allow you to step on the foot in doses and gradually increase the load.

Don't self-medicate!

Only a doctor can determine the diagnosis and prescribe the correct treatment. If you have any questions, you can call or ask a question by email.