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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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Foot Health and Elevated Body Mass Index

by H.F. Jelinek 1 , D. Fox 2 

The Foot and Ankle Online Journal 2 (8): 4

Objective: Investigate the relationship between the subcategories included in the Foot Health Status Questionnaire (FSHQ) and body mass index (BMI).
Design: Cross-sectional study of people attending a general health screening clinic.
Subjects: Fifty participants aged between 40 and 60 years filled out the FHSQ and were included in this study. These were divided into the three groups according to the BMI classification of underweight to Class 3 obesity.
Measurements: Demographic variables, blood pressure, BMI as well as medical history were recorded. Relationships between the subcategories of the FSHQ and BMI were investigated. All statistics were deemed significant if p < 0.05.
Results: We found that there is a significant correlation between BMI and foot pain (p = 0.047), foot function (p = 0.004), footwear (p = 0.007) and general foot health (p = 0.013).
Conclusion: The foot health questionnaire is an internally consistent, all in one foot health and function assessment tool, which indicated significant impact of BMI on pain, foot function and foot health, as well as choice of foot wear. These issues can ideally be addressed by primary care physicians to improve health and quality of life for people that are overweight through effective weight loss programs.

Keywords: Obesity, foot health, Body Mass Index, Foot Health Status Questionnaire.

This is an Open Access article distributed under the terms of the Creative Commons Attribution License.  It permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. ©The Foot and Ankle Online Journal (www.faoj.org)

Accepted: July, 2009
Published: August, 2009

ISSN 1941-6806
doi: 10.3827/faoj.2009.0208.0004

Obesity is a significant health problem and the incidence of the condition is increasing. Studies by the World Health Organization have found more than one billion adults are overweight (body mass index [BMI] >25) and at least 300 million of them are clinically obese (BMI > 30). [1] In Australia, the levels of obesity have been increasing by about one percent per year since 1980.

Effect of obesity on the foot

Obesity leads to an increase in the occurrence of diverse diseases either independently or in association with other diseases and exacerbates disease progression as well as adversely affecting foot function. [2,3] Increased weight on the feet significantly increases contact areas, with increased pressure on these areas leading to increased foot problems such as pain, vascular and neuropathic disease, deformity and joint mobility. [4,5,6] The Foot Health Status Questionnaire (FHSQ) measures foot specific health related quality of life incorporating the domains of functional ability, social functioning psychological wellbeing, somatic sensation (e.g. pain), and life satisfaction. [7]

The advantage of this questionnaire is that it is internally consistent and includes both physical and psychological variables. The focus of this project was to identify if an association exists between an increased body mass index and the four domains of the Foot Health Status Questionnaire.

Foot Health Status Questionnaire

The FHSQ is comprised of three sections. Questions in section one span the four domains of foot health: foot pain, foot function, footwear, and general foot health. Psychometric evaluation of the FHSQ found that the tool demonstrated a high degree of content, criterion, and construct validity and test retest reliability. [7]


The research project was approved by the Charles Sturt University Ethics in Human Research Committee. Participants were selected via stratified random sampling from the Allied Health and Diabetes Screening Program database. Individuals had the questionnaire explained and any other questions answered prior to completing the FHSQ.

Participants completed the FHSQ version 1.03. [7] Missing items in the questionnaires (when fewer than 50% of the items for any one scale were missing) were assigned with the average value of the completed items for that scale as suggested in the instructions. [8] Statistical analysis was undertaken using Spearman’s correlation coefficient for non-normally distributed data. Significance level was set at p < 0.05 for a one tailed test.


Data from 50 participants who had completed the FHSQ was analysed. Overweight was taken as a BMI greater than 25. Participant’s characteristics are presented in Table 1.

Table 1 Participant characteristics.

Body Mass Index and FHSQ scores

The relationship between BMI divisions and FHSQ domain scores were analysed using Spearman’s rho correlation coefficient as the data was not normally distributed. There was a significant negative Spearman’s rho correlation coefficient between increased BMI and foot pain, r(47) = 27, p < 0.05, foot function, r(47) = 37, p<0.01, footwear, r(47) = 34, P < 0.01, and general foot health, r(47) = 31, P < 0.05 (Table 2). These results indicate that as BMI increases the foot health domain scores decrease.

Table 2  Correlation between FHSQ domains and BMI.


Several studies and different questionnaires have addressed foot function and foot health. However previous work has not utilised the FHSQ as a tool, which combines both function and psychological aspects of foot health.

Landorf and Keenan compared the Foot Function Index to the FHSQ, as measures of health related quality of life. These authors suggested that the FHSQ be viewed as the preferred questionnaire when evaluating health related quality of life where there is no marked impairment or disability. [9]

The findings of the study reported here suggest that obesity has a significant effect on the level of foot pain independent of condition (p<0.05). An increased BMI was also found to be associated with a reduction in perceived foot function by the participants using the FHSQ (p<0.01). This is in line with previous work but does not require separate test batteries to be performed for foot pain and foot function. [4,10] Han, et al., quantified the impairment of quality of life attributable to body fatness using the SF 36 Health Survey and concluded that quality of life measures were related to body mass index, and that participants with a high body mass index were more likely to have poor physical functions that limited many common basic activities of daily living. [11] The current study showed that comfortable and appropriate footwear was perceived as more difficult to find as BMI increased as extra wide shoe fittings are not always commercially available (p< 0.01). [12] Finally, BMI has an impact on general health as reported by previous authors. [13,14]

The relationship between obesity and foot specific health is unclear. The FHSQ is capable of measuring physical and social functioning as subjectively reported by individual, therefore the four domains of the FHSQ may be considered suitable to determine if a relationship exists between obesity, as measured by BMI, and foot specific health. Similarly covariates, such as age, gender, BMI and diabetes mellitus, account for much more of the variance explained by the foot function domain of the FHSQ than do foot disorders themselves. [10]


The findings of the present study and similar findings from other authors clearly support the concept that obesity influences foot function. The main aim of this study was to identify if a relationship existed between increased BMI and foot health as measured by the four domains of the FHSQ, foot pain, foot function, footwear, and general foot health.

This study showed that obesity has a significant effect on the level of foot pain, normal foot function, the adequate fit of footwear, and general foot health as determined by the FHSQ.


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6. van Schie CHM, Boulton AJM: The effect of arch height and body mass on plantar pressure. Wounds 12 (4): 88 – 95, 2000.
7. Bennett PJ, Patterson CP, Wearing S, Baglioni T: Development and validation of a questionnaire designed to measure foot-health status. Journal of the American Podiatric Medical Association 88: 419 – 428, 1998.
8. Bennett PJ, Patterson CP, Dunn JE: Health related quality of life following podiatric surgery. Australasian Journal of Podiatric Medicine 32 (3): 164 – 173, 2001.
9. Landorf KB, Keenan A-M: An evaluation of two foot-specific, health-related quality-of-life measuring instruments. Foot and Ankle International. 23: 538 – 546, 2002.
10. Badlissi F, Dunn JE, Link CL, Keysor JJ, McKinlay JB, Felson DT: Foot musculoskeletal disorders, pain and foot-related functional limitation in older persons. Journal of the American Geriatrics Society 53: 1029 – 1033, 2005.
11. Han TS, Tijhuis MAR, Lean MEJ, Seidell JC: Quality of life in relation to overweight and body fat distribution American Journal of Public Health 88: 1814 – 1820, 1998.
12. Burns SL, Leese GP, McMurdo ME: Older people and ill fitting shoes. Postgraduate Medical Journal 78: 344 – 346, 2002.
13. Fontaine KR, Bartlett SJ, Barofsky I. Health-related quality of life among obese persons seeking and not currently seeking treatment. International Journal of Eating Disorders 27: 101 – 105, 2000.
14. Hakim Z, Wolf A, Garrison LP: Estimating the effect of changes in body mass index on health state preferences. Pharmacoeconomics 20: 393 – 404, 2002.

Address correspondence to: Herbert F. Jelinek, email: hjelinek@csu.edu.au

1,2  School of Community Health.  Diabetes Complications Screening Research Initiative (DiScRi)
Charles Sturt University, Albury, NSW 2640,Australia.

© The Foot and Ankle Online Journal, 2009