![]() Anatomic reduction of Lisfranc injuries is critical, and inadequately treated injuries can lead to severe disability. Tenderness in this area raises the possibility of a Lisfranc injury, and referral to an orthopedist should be made. The tarso-metatarsal (ie, Lisfranc) joint area should be palpated in all patients with foot injuries. If a metatarsal fracture is present, direct palpation over the fracture site should produce greater pain than testing tendon function by resisting plantar and dorsiflexion. Īssessing pain while testing plantar and dorsal flexion of the toes is helpful for differentiating a fracture from tendon injury. This maneuver should produce pain if the metatarsal is fractured, but not with soft tissue injury alone. This is done by holding the toe in line with its corresponding metatarsal (ie, without angulation), and pushing the toe in toward the metatarsal. Gently applying an axial load to the metatarsal heads can help differentiate fractures from soft tissue injuries. Furthermore, soft tissue injury may simulate the point tenderness of a fracture, especially when the injury was caused by an object dropped on the foot. Point tenderness over the site is the norm, but swelling may make it difficult to localize the fracture on physical examination. Sequential palpation along each metatarsal can reveal the fracture site. However, a neurovascular exam should be performed and documented on every patient with a suspected metatarsal fracture. The injured skin may then necrose, leading to an open fracture.Įxamination - Neurovascular injury of the foot is uncommon without significant trauma or a penetrating injury. Crush injuries, a common cause of metatarsal fractures, may devitalize the skin. If there is any wound near the fracture, the injury should be treated as an open fracture until proven otherwise. Inspection - One should inspect for any signs of significant skin damage. Dorsal swelling and ecchymosis can develop rapidly due to the foot's dependent position, if the injured area is not elevated. ĬLINICAL PRESENTATION AND EXAMINATION - Patients with metatarsal fractures typically present with foot pain and have trouble walking. Greater force is required to fracture the first metatarsal due to its large size. Common mechanisms include heavy objects dropped on the foot and violent blows to the sole of the foot (as may occur during falls or auto accidents). MECHANISM OF INJURY - Most metatarsal shaft fractures are caused by direct blows or twisting forces. They may become necrotic when crushed or rubbed repeatedly by the apex of a fractured metatarsal, leading to an open fracture. The dorsal soft tissues of the foot are thin compared with the plantar soft tissues. This is caused by the downward traction of the intrinsic muscles and flexor tendons that insert distal to the fracture. If displacement occurs, the metatarsal head usually displaces in a plantar direction. ![]() The likelihood of displacement increases if multiple metatarsals are fractured or the fracture is near the metatarsal head. Most fractures of a single metatarsal shaft are minimally displaced due to the splinting action of adjacent metatarsals and their abundant ligamentous and muscle attachments. Therefore, malalignment of a first metatarsal shaft fracture is not tolerated as well as malalignment of other metatarsal fractures. ![]() The first metatarsal is larger than the others and more important for weight-bearing and balance ( figure 1A-C and figure 2 and figure 3).
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