Tag Archives: stress fracture

Dual plating technique for comminuted second metatarsal fracture in the diabetic obese patient: A case report

by Sham Persaud DPM, MS1*, Anthony Chesser DPM1, Karl Saltrick DPM1

The Foot and Ankle Online Journal 10 (4): 4

Metatarsal fractures represent a common fracture type accounting for 35% of all fractures within the foot and 5% of total skeletal fractures annually. Central metatarsal fractures are caused by excess torsional force applied to the bone or direct trauma, with most fractures being attributed to the latter. As with most fractures, minimally displaced fractures of the central metatarsals are amenable to conservative treatment including protected immobilization and RICE therapy. In general, physicians may be accepting of subtle displacement of central metatarsal fractures accepting up to 10 degrees of displacement and 3mm of translation in any direction. When displacement is too great, metatarsal fractures are treated with closed reduction with percutaneous pin fixation or ORIF with pin or single plate fixation. This case report presents a case of a gentleman who suffered from a comminuted metatarsal with a unique fracture pattern that required dual plating technique for proper reduction of the fracture. With this unique fracture type, dual plate technique optimized fixation in order to stabilize an unstable fracture of a second metatarsal in an obese patient with diabetes.

Keywords: metatarsal fracture, stress fracture, diabetes, obesity, metatarsal plate

ISSN 1941-6806
doi: 10.3827/faoj.2017.1004.0004

1 – West Penn Hospital Foot and Ankle Institute, 4800 Friendship Ave, Pittsburgh, PA 15224
* – Corresponding author: shamjoseph.persaud@ahn.org

Metatarsal fractures represent a common fracture type accounting for 35% of all fractures within the foot and 5% of total skeletal fractures annually [1]. These fractures can be isolated injuries, simultaneous fractures with other metatarsals and foot fractures with ligamentous Lisfranc injuries. They can also be either traumatic or caused by prolonged stress across the bone. Most metatarsal fractures are generally a result of low energy trauma, however high energy crush injuries may occur [2].

Metatarsal fractures occur in multiple locations and are generally divided by location into proximal metaphyseal, diaphyseal/shaft, and head/neck fractures. Proximal fractures are generally associated with Lisfranc injuries. Proximal metatarsal fractures generally remain stable and well aligned secondary to the multiple ligamentous and tendinous structures which stabilize the metatarsals [2-4]. Diaphyseal fractures are generally oblique in nature, but can present in many fracture patterns. These fractures are less stable and should be evaluated for shortening and displacement [5]. The diaphyseal region is the most common site for stress fractures of metatarsals, especially the central metatarsals. Stress fractures, if untreated, can progress to complete transverse or oblique fractures. If displacement is present with diaphyseal fractures, it typically occurs plantarly and laterally [1].

Central metatarsal fractures occur considerably more than first metatarsal fractures. These fractures can affect more than one metatarsal as metatarsal 2-4 generally act as a unit. The literature states that 63% of third metatarsal fractures occur with either a second or fourth metatarsal fracture or 28% with both. Therefore, extensive evaluation of radiographs and possibly the use of other imaging modalities should be used if an isolated metatarsal fracture is identified in metatarsals 2-4 [2].

Central metatarsal fractures are caused by excess torsional force applied to the bone or direct trauma, with most fractures being attributed to the latter [1,2]. Direct trauma includes crush injuries or penetrating injuries to the foot. Spiral or oblique fractures are produced by a twisting injury over a fixed forefoot. Secondary to central metatarsal lack of motion, soft tissue attachments, and stable articulations, these fractures are intrinsically stable. However, when displacement occurs, the central metatarsals are more likely to displace as a unit [1,2].

As with most fractures, minimally displaced fractures of the central metatarsals are amenable to conservative treatment including protected immobilization and RICE therapy. In general, physicians may be accepting of subtle displacement of central metatarsal fractures accepting up to 10 degrees of displacement and 3mm of translation in any direction [6-9]. Plantar displacement is often tolerated the least out of all planes of deformity secondary to excessive plantar pressures. Dorsally displaced fractures can cause excessive strain on adjacent metatarsals leading to transfer plantar lesions and possible adjacent stress fractures. Frontal and transverse plane deformity, generally are well tolerated. However, it has been shown that displacement in the frontal or transverse plane may cause nerve irritation in the metatarsal interspaces, as well as, digital deformity over time [6-9].

The goal of central metatarsal fractures is to achieve anatomic alignment of the metatarsal using stable fixation. This goal can be achieved using both open and closed techniques. In patients with significant comorbidities or vascular compromise achieving extra stable reduction utilizing minimally invasive techniques is idea [1].

Percutaneous Kirschner (K-wire) wire pinning can be performed with a variety of techniques for adequate fixation. The most common method includes intramedullary fixation across the fracture site with use of a large diameter k-wire. Crossing multiple k-wires may also be an acceptable technique for fixating metatarsal fractures [10]. Advantages of k-wire fixation include the ability to maintain vascularity to the fractured bone with minimal dissection and soft tissue disruption. The main disadvantage is the inability for direct visualization and manipulation of the fracture [1].

Open reduction internal fixation (ORIF) is also a viable option for treatment of metatarsal fractures, especially if the fracture is significantly displaced or comminution is present. ORIF technique has the advantage of being able to visualize the fracture site in order to achieve complete anatomic reduction with application of more stable fixation [1]. In terms of fixation, screw fixation is possible for oblique type fractures, however, use of screws for central metatarsal fractures may be challenging. If ORIF technique is used, fixation generally consists of either k-wire fixation, or the use of dorsal plate fixation using mini or small fragment plates and screws. Locking plates may also be beneficial in patients with significant comorbidities or poor bone stock [1].  

Complications are relatively uncommon with either technique. Common complications with fixation of central metatarsal fractures include delayed or non-union, malunion, metatarsalgia, or digital deformity. In general delayed union or malunion complications are secondary to poor blood supply due to dissection techniques or comorbidities, or excess stress secondary to chronic stress fracture and foot deformity [1].

Biomechanical studies have shown that biplane fixation has increased stiffness as well as a decrease chance of hardware failure resulting in a more stable construct. Dayton et al in their biomechanical study showed that biplane plating showed to have superior or equivalent stability in multiplanar orientations as compared to a single plate with interfragmentary screw. However, dual plating is not without its drawbacks; Increased soft tissue dissection, periosteal stripping, theoretical increased operating room time, increased chance of hardware irritation, and increased cost are several disadvantages to dual plating [11].

There have been numerous studies that reference orthogonal/dual plating throughout the body for fracture reduction and stabilization [11-23]. However; there have been no studies for dual plating lesser metatarsals for acute fractures. The purpose of this case study was to provide a scenario where the application of dual plating technique to an unstable lesser metatarsal fracture was warranted.

Case Report

A 52-year-old male presented with acute tenderness to the 2nd metatarsal of the right foot. The pain began approximately one week prior to presenting to us. He denied any injury to his recollection. He initially thought it was a gout flare up secondary to his history of gout flare ups and was prescribed a Medrol dose pack by his PCP which provided no relief. Therefore, the patient went to the emergency room in which radiographs were taken which demonstrated the patient had a displaced mid-diaphyseal fracture to the second metatarsal of the right foot (Figure 1). The patient also stated that within the last week he had also noticed lateral deviation of his second digit which was progressive. This was confirmed via physical exam as a flexible deformity secondary to displacement of the metatarsal fracture site. Physical exam revealed acute swelling and warmth about the midfoot and forefoot of the right foot focused about the second metatarsal. No ecchymosis was present. There was also point tenderness to the second metatarsal with reducible lateral deviation of the second digit at the level of the second metatarsophalangeal joint (MTPJ). With the radiographic displacement present and the patient’s medical history including diabetes, obesity, gout and other associated medical ailments it was decided the best course of action for the patient was to schedule the patient for ORIF of the second metatarsal with capsulotomy and extensor tendon lengthening to the second digit all right foot. Until the surgery the patient was placed in a Jones compression dressing and placed in a CAM walking boot.

Figure 1 Pre-operative radiographs AP, oblique, lateral.

One week after initial presentation, the patient underwent ORIF of the second metatarsal with capsulotomy and extensor tendon lengthening of the second MTPJ of the right foot. Incision placement was made on the dorsal aspect of the second metatarsal beginning at level of the proximal third of the metatarsal extending distally past the second MTPJ. Dissection was carried down to the level of the extensor tendons in which a Z-tenotomy of the extensor digitorum longus tendon, as well as, a complete tenotomy of the extensor digitorum brevis tendon was performed.

At this time, attention was focused to the fracture site. Using standard techniques all bone callus was debrided and the fracture was reduced by joystick technique utilizing a 0.062 K-wire in the capital fragment in order reduce the fracture and pull the metatarsal out to length. Once adequate reduction was achieved, the fracture sites were fixated provisionally with 0.045 K-wires. With further evaluation and thought, it was determined that two plate fixation would be optimal fixation with the current fracture pattern. This was achieved utilizing two 6-hole mini-fragment locking plates oriented obliquely into the bone and staggered for proper locking screw placement (Figure 2). With the two plate construct, both medial and lateral dorsal fragments were fixated to the constant plantar fragment achieving stable fixation.

Figure 2 Intraoperative radiographs AP, oblique, lateral.

After fixating the fracture site, soft tissue balancing for the lateral deviation of the second digit was performed. With reduction of the fracture, the digit deviation had decreased dramatically. The remaining deformity was addressed by performing a lateral capsulotomy at the level of the MTPJ and repairing the extensor longus tendon in an elongated state providing no tension to the digit at the level of the second MTPJ.

Post-operatively the patient remained non-weight bearing in a CAM walking boot for 4 weeks. After 4 weeks, the patient began to progressively bear weight on his right foot in a CAM boot only. After 2 weeks of weight bearing in a CAM boot the patient was transitioned into a tennis shoe comfortably. At that time, serial radiographs were obtained showing adequate consolidation of the fracture site with maintained reduction and position (Figure 3). The patient was able to return to work in full capacity at 8 weeks with no restrictions.  

Figure 3 Post-op clinical pictures and radiographs AP, oblique and lateral.


Comminuted fractures of any long bone can be challenging to treat surgically. Though there are many techniques which have been shown to be viable options for such fracture types, dual plating has been shown to provide adequate stability and maintain correction of complex fractures of long bones.

As stated, Dayton et al were able to show that a dual locking plate technique with single cortex locking screws, when compared to single locking plate with interfragmentary screw fixation, showed superior or equivalent stability in multiplanar orientations of force application in both static and fatigue testing. Though this study was used primarily to show stability at fusion sites such as the first tarsometatarsal joint, the results are very applicable to complex fractures of long bones [11].

Dual plating has also been documented as a viable option for fracture fixation within the literature. There have been many studies within orthopedic literature showing the successful use of dual plating technique for fracture ORIF of fractures not within the foot and ankle [18-23]. However, there is also extensive literature is the use of dual plating for complex ankle fractures [12-17].

Kwaadu et al. evaluated the use of dual plate technique for the repair of complex fibular fractures on 25 patients. All 25 patients underwent benign postoperative courses with eight patients having complications all of which were wound complications. No additional operations were performed as a result of this technique. No patient undergoing this technique complained of any hardware irritation, and no hardware removal was required. The average time to radiological healing confirmed via radiograph was 7.5 weeks [12]. Vance et al. reviewed 12 consecutive patients who underwent ORIF of fibular fractures utilizing two 1/3 tubular plates for fixation. All fractures healed both clinically and radiographically. Only one patient required hardware removal. FAOS scores were obtained at a mean of 25.6 months after surgery and showed results of pain (87.6, SD = 9.5), activities of daily living (90.4, SD = 14.5), symptoms (93.3, SD = 9.5), sports (89.5, SD = 18.1), and quality of life (57.4, SD = 21.3) [13].

Our case report demonstrated successful use of dual plating technique for ORIF of a comminuted metatarsal fracture. It is our belief that this technique provides added support which was needed secondary to the fracture pattern presented. Dual plating is warranted in cases when traditional fixation techniques (i.e. K-wire fixation, screw, single plate) will not allow for appropriate reduction or stabilization of the fracture segment. This fixation technique can be another tool in the surgeon’s armamentarium.  While this case study was not the first to incorporate dual plating in fracture cases, it is the first to document dual plate technique for lesser metatarsal fractures.


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Early Identification of Foot and Lower Limb Stress Fractures using Diagnostic Ultrasonography: A review of 3 cases

by Sara L Jones PhD1  , Maureen Phillips MSc2

The Foot and Ankle Online Journal 3 (4): 3

Early identification of the presence of stress fractures of the foot is often dependent upon clinical history and pattern of symptoms. The delay between presentation with symptoms and the confirmation of positive findings using plain film radiograph, or the invasive and more complex nature of bone scans or magnetic resonance imaging (MRI) can act as a deterrent to investigation. In contrast, the use of diagnostic ultrasonography in early detection of stress fractures of the foot and lower limb may offer a rapid and non-invasive technique for assessment and identification.

Key words: Diagnostic ultrasonography, Stress fracture.

Accepted: March, 2010
Published: April, 2010

ISSN 1941-6806
doi: 10.3827/faoj.2010.0304.0003

The treatment of stress fractures within clinical practice typically features a symptomatic approach to diagnosis. A history of high levels of activity and pain in a specific site are hallmarks of the likely presence of this pathology. Differential diagnosis may include contusion, Morton’s neuroma and bone cyst or tumour.

Plain film radiographs involving stress fractures commonly show sclerosis and/or periosteal reaction approximately six weeks after the initial onset of pain. Evidence of fracture may not show up on radiograph for up to ten weeks. [1,2]

By the time the diagnosis may be confirmed in this manner, many patients have become asymptomatic, or (of more concern) gone on to develop chronic symptoms. In most cases, earlier diagnosis will require more complex and invasive interventions, such as magnetic resonance imaging (MRI) or bone scans.

The literature shows that there has been extensive research into the use of diagnostic ultrasonography in investigation of soft tissue lesions [3,4], but there appears to be little evidence of its use in the detection of stress fractures within the foot or lower limbs. The use of ultrasound in the diagnosis of stress fracture has been reported, but certainly not frequently. [5] Case reports provide evidence that ultrasound imaging can be used in the detection of occult fractures. [6] There are reports in the literature of the use of diagnostic ultrasonography to detect subperiosteal haematoma, periosteal elevation and metaphyseal injuries. [7]

Another study8 reported the use of ultrasound in imaging forearm fractures in children and found that ultrasound imaging appeared to be a viable alternative to radiography in simple fractures. More recently, Banal, et al., [9] reported a case of stress fracture of the second metatarsal which was diagnosed by diagnostic ultrasound. They discussed that ultrasound investigation for stress fracture should be studied further because its non-invasiveness, low cost and ease of access could allow it to become the preferred method of diagnosis. Therapeutic ultrasound, with its potential to cause pain at a fracture site has proved both undesirable and also unreliable in detection of fractures. [10,12]

Imaging with ultrasound should yield good results. Bone is a natural obstacle to the transmission of sound at high frequency. [8] There is a large difference in acoustic impedance between the soft tissue and bone resulting in a strong reflection from the bone. However, this presents an ideal situation for imaging the bony contour. Any imperfections (for example, steps, breaks, periosteal reactions) should therefore be easily visible. [11] In cases where there is doubt as to the aetiology of the pain, and a need for differentiation of bony from soft tissue injury, diagnostic ultrasound can provide a good alternative to more invasive techniques such as X-ray or nuclear medicine.

As an added benefit in clinical practice, diagnostic ultrasound has the capability of demonstrating increased blood flow in periosteal reactions with the use of Doppler measures. [11] We present a series of stress fracture cases which were diagnosed using diagnostic ultrasound. In each case, sonography was performed using a Siemen’s Antares Sonoline ultrasound machine (Siemen’s Medical Solutions, USA Inc, Ultrasound group, Issaquah, WA). A 13-5 MHz linear array transducer was used, with the frequency generally used between 10MHz and 11.5 MHz. All subjects gave consent for use of the material relating to their case.

Case 1: Tibial stress fracture

A 22 year-old male athlete presented to the podiatry clinic complaining of a six week history of anterior tibial pain, right leg only, with worsening pain. Originally self-diagnosed (and self treated) as a soft tissue injury, treatment comprised icing, NSAIDs, changes in footwear and modifications in activity levels (but not complete rest).

On examination, the region of pain was localised. No evidence of swelling or bruising was noted. The area was tender to direct pressure. A stress fracture was suspected, but the patient was unconvinced. A diagnostic ultrasound scan was performed, as a non-invasive, low-radiation alternative to plain films or bone scan in order to more definitively identify the cause. Periosteal thickening was observed at the point of maximal tenderness on the anterior tibia, with underlying cortical irregularity. (Fig. 1) Power Doppler was negative, however, this was not considered unusual at six weeks post onset.

Figure 1   Periosteal thickening on ultrasound.

In this instance, identification of the presence of stress fracture by ultrasound and subsequent confirmation through bone scan (Fig. 2) resulted in a significant change in activity levels on the part of the athlete, with greater adherence to the recommended management regime. As a consequence, the injury fully resolved and there has been no recurrence to date.

Figure 2   Bone scan findings, clearly showing an increase in uptake levels at the site of the stress fracture. 

Case 2: Metatarsal Stress Fracture

A 16 year-old female presented with a five week history of foot pain, localised to the midfoot region, particularly around the third and fourth metatarsal shafts. Despite reporting pain, the patient had not altered her activity levels, which included netball, tennis and rock climbing. She reported a variable pattern of pain intensity, with reduction during periods of rest and exacerbation following activity. She sought treatment at the point when increased pain was experienced during as well as following activity, with an extended duration of symptoms. Previous radiograph examination had proved negative. The ultrasound findings show marked periosteal reaction with a strongly positive power doppler signal.

A cortical fracture with callus formation is evident. (Fig. 3) Plain film radiographs were taken four weeks following the ultrasound examination. The films clearly show callus formation and confirmed the earlier diagnosis. (Fig 4)

Management in this case comprised a combination of activity modification, footwear changes and the use of orthoses, with gradual resolution of all symptoms and return to full sporting activity.

Figure 3  Diagnostic ultrasound findings. (Note the periosteal reaction)

Figure 4  Plain film views showing the site of the stress fracture on the third metatarsal.

Case 3: Metatarsal Head Fracture

A 21 year-old female distance runner presented with a five day history of increasing pain under the fifth metatarsal head region during training. No change to footwear or activity levels in the period leading up to the onset of pain was reported. There was no history of trauma to the area. On examination, a clearly demarcated area of redness was visible in the area of the reported pain, which appeared to be consistent with a soft tissue, rather than bony injury.

However, the reported symptoms and pattern of pain were not consistent with this diagnosis and a diagnostic ultrasound was therefore performed. (Fig 5) A clear break can be seen in the cortical bone (arrowed) with accompanying periosteal reaction and a positive power doppler signal. (Fig 6)

As a consequence, the injury was treated as a stress fracture, with cessation of the sporting activities and footwear management. The injury resolved over a six week period, with a return to competitive running at the end of this time without further symptoms. The area of inflammation noted on initial examination completely disappeared within two days of the initial consultation.

Figure 5 Clinical presentation. (Note the area of redness)

Figure 6  Site of stress fracture on ultrasound.


Ultrasound has been previously recognised as a valuable tool in the identification of soft tissue pathologies affecting the foot, notably in the detection of tissue trauma, neuroma and other intermetatarsal masses. [12] There is less evidence of its use as a means to identify bony pathology.

Previous trials using ultrasound to detect fractures have used therapeutic rather than imaging frequencies, that is 1 MHz rather than 7.5 MHz or greater. Therapeutic wavelengths often – but not consistently – elicit pain at a fracture site [13,14], which is often perceived as a disincentive for the use of ultrasound in this setting. Pain with the use of therapeutic ultrasound is caused by the vibrations from the transducer head. However, there were no reports of pain or discomfort from patients while using high resolution linear probe over the suspected fracture sites, suggesting that this should not be an issue in undertaking the diagnostic procedure.

The significance of the utilization of diagnostic ultrasound is in its ability to identify and localize the presence of stress fractures much earlier than other modalities. In Case 3, this identification was possible within days of onset of pain, allowing clear identification to the patient of the causes and the necessary management strategy.

This provision of clear evidence assisted greatly in patient compliance to the recommended management strategy by dispelling any belief that it was a soft tissue injury that could be “run out”.

The increasing availability of office-based diagnostic ultrasound units for medical and allied health practices in recent years means that ready access to this technology may assist practitioners to provide earlier identification and implementation of treatment.


Use of diagnostic ultrasound in the diagnosis of stress fracture allows for an early diagnosis using a low cost, non-invasive modality. Its use in identification of both soft tissue and bony injury makes it a useful tool in diagnosis and subsequent management. The lack of reported clinical studies focusing upon the reliability and application of this technique in comparison with plain film and MRI suggests that it may be an area worthy of further investigation.


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Address correspondence to : School of Health Sciences, University of South Australia, GPO Box 2471, Adelaide South Australia 5001 .
E-mail: .. sara.jones@unisa.edu.au , maureen.phillips@unisa.edu.au

1,2  School of Health Sciences, University of South Australia, GPO Box 2471, Adelaide South Australia 5001 .

© The Foot and Ankle Online Journal, 2010