Forefoot fractures can begin as very small injuries that do not cause severe pain. However, if the bone continues to experience stress, the crack will often deepen and widen, becoming gradually more painful. Eventually, in the worst-case scenario, the stress fracture may progress to become a full fracture. If a forefoot fracture is not treated correctly, serious conditions can develop which can affect your ability to walk and can lead to other complications such as arthritis, chronic pain, and deformity or failure to heal, leading to subsequent surgery. Before it gets to that point, you should see one of the skilled and experienced orthopedic specialists at Colorado Center of Orthopaedic Excellence in Colorado Springs, Colorado. To get the best treatment, put your forefoot fracture into their talented hands.

OVERVIEW

In simple terms, a forefoot fracture is a break in the metatarsal bones. The forefoot is the most distal (furthest) part of the ankle-foot unit. Along with the midfoot and rearfoot, the human forefoot carries the body weight. The forefoot is designed to receive significant force. It plays a major role in maintaining the body position and balance in standing and during ambulation.

About 5% to 6% of fractures seen by U.S. healthcare providers are metatarsal fractures. Most metatarsal fractures occur in younger people, as they are more likely to be involved in the kinds of sports and activities that are at higher risk. However, as one becomes older the ‘springiness’ and padding of the feet tend to reduce. This means that the feet absorb impact less well and it is easier to fracture bones. Overall, this type of fracture peaks for men in their 30s and women in their 70s.

ABOUT THE FOOT

The foot is a complex mechanical structure of the human body composed of 33 joints,

26 bones, and more than a hundred muscles, tendons, and ligaments that all work together to bear weight, allow for locomotion, and transmit force. The joints of the foot are made wherever two or more of the foot bones meet. The forefoot is one of the three primary regions of the foot, in addition to the midfoot and the rearfoot (or hindfoot). The forefoot contains the most bones of the three areas of the foot. The forefoot bones include :

Phalanges: these are the toes. They are made up of a total of 14 bones—two for the big toe and three for each of the other four toes.

Metatarsals: also referred to as the metatarsus are the five long bones that go out from the base of each toe to the midfoot.

Sesamoid bones: these are two small oval-shaped bones beneath the first metatarsal on the underside (plantar surface) of the foot. They are embedded in a tendon at the head of the bone (closest part to the big toe). The fifth metatarsal is the outer bone that connects to the little toe. It is the most commonly fractured metatarsal bone.  The first, second, and fifth metatarsals are the most commonly injured in sports. The forefoot also has a complex network of ligaments crossing and running along the length of the foot. These ligaments connect bones and skin, support and insulate the foot by holding fat in place to act as cushions, help nerves, tendons, and blood vessels pass beneath the heads of the metatarsal bones, and tie the arches. The forefoot carries and balances nearly half of the body’s total weight and is designed to handle significant force and wear and tear.

WHAT IS A FOREFOOT FRACTURE? 

A metatarsal (forefoot) break may be open or closed, and displaced or not displaced:

• Open or closed: a closed fracture is far more common – this is where the bone is broken but the skin and other tissues remain intact over and around the broken bone. An open fracture is one where the skin is broken over the fracture. This is a more serious type of fracture, with more damage to the soft tissues around it making treatment and healing more complicated. There is also a route of possible infection from the outside into the broken metatarsal bone. Specialist assessment is always needed for an open fracture.
• Displaced or not displaced: A non-displaced fractured metatarsal is much more common than displaced. A displaced fracture is one where, following the break, the bones have slipped out of line. A displaced fracture needs specialist care, as the bones will need to be properly lined up and stabilized.

There are three types of fifth (one of the most common) metatarsal fractures classified into three zones:

• Zone 1 (avulsion fracture): these fractures make up 93% of all fifth metatarsal fractures. In an avulsion fracture, a small piece of bone is pulled off the main portion of the bone by a tendon or ligament. They are often overlooked when they occur with an ankle sprain
• Zone 2 (Jones fracture): these occur in a small area of the fifth metatarsal that receives less blood. Because of this, they are more prone to difficulties in healing. A Jones fracture can be either a stress fracture (a tiny hairline break that occurs over time) or an acute (sudden) break. Jones fractures are caused by overuse, repetitive stress, or trauma. They are less common and more difficult to treat than avulsion fractures
• Zone 3 (mid-shaft fracture or dancer’s fracture): these usually result from trauma or twisting. These breaks occur at the metatarsal head and neck

CAUSES

Multiple causes put people at risk for forefoot fractures:

• Dropping something heavy on the foot
• Running directly into an object with the foot
• Kicking something hard
• Twisting the foot on landing from a jump (common in ballet dancers)
• Gymnastics
• High arches

They are more common in runners who:

• Suddenly increase their running mileage or intensity
• Run in poor footwear that doesn’t suit their feet
• Have a sudden change in footwear and have not “broken them in” carefully
• Continue to exercise despite having foot pain

Additionally:

• Abnormalities of the structure of the foot, and abnormalities of the bones and joints, such as rheumatoid arthritis or ‘thinning’ of the bones (osteoporosis), can make stress fractures more likely.
• They can also occur in people who have lost nerve sensation in their feet due to neurological problems – for example, diabetes that has affected the feet.

SYMPTOMS

• Pain is often described as “pinpoint pain” as it is usually well-localized at the site of impact to the bone
• Hearing a sound at the time of the break
• Swelling
• Bruising
• Tenderness
• Crooked or abnormal appearance of the toe
• Difficulty walking
• Reduced range of motion
• Numbness or tingling

NON-SURGICAL TREATMENTS

• Over-the-counter non-steroidal anti-inflammatory pain meds such as ibuprofen (NSAIDS)
• RICE therapy: rest, ice, compression, elevation
• Immobilization: The use of a postoperative shoe or boot walker is helpful
• Splinting
• Crutches or a wheelchair are sometimes required to offload weight from the foot to give it time to heal

WHEN IS SURGERY INDICATED?

All foot fractures are different, but generally speaking, if a forefoot fracture is significantly displaced it is likely to benefit from surgery. This is especially true if a fracture enters a joint and the joint surface is disrupted and displaced. Restoring the alignment and stabilizing the fracture in its correct position will decrease the risk of future problems, such as pain, swelling, deformity, and arthritis.  In some cases, surgery may be appropriate for non-displaced or minimally displaced forefoot fractures if the broken bones are likely to be unstable. In such cases, surgery can maintain the alignment and encourage healing in the right position. Even some non-displaced and stable fractures may benefit from surgery. Multiple forefoot fractures can leave the foot unstable and can lead to deformity. Fifth metatarsal fractures—dancer’s fractures and Jones fractures require surgery to keep the bones in place. Jones fractures are often treated surgically in active and athletic individuals because it is likely to get them back to their activities more quickly than non-surgical treatments. Often, plates, pins, and screws are inserted to hold the bones in place and allow the fracture to heal properly.

GETTING THE RIGHT DIAGNOSIS.  GETTING THE RIGHT DOCTOR.

Because there are many different types of forefoot fractures, it is key to find an orthopedic specialist who has had years of experience treating them. At Colorado Center of Orthopaedic Excellence in Colorado Springs, Colorado, they are recognized for their knowledge, skill, and excellent outcomes. Different forefoot fractures require different treatments and it all starts with an accurate diagnosis. For example, stress fractures do not show up as easily on X-ray, particularly not at first. Half of them never show up on a normal X-ray. A specialized ultrasound may show one of these fractures. MRI scanning is also sometimes used to find stress fractures. A Jones fracture is often misdiagnosed as an ankle sprain, and misdiagnosis can have serious consequences since sprains and fractures require different treatments. The foot and ankle surgeons at CCOE are experts in correctly identifying these conditions as well as other problems of the foot. No matter what the injury, they make the future care of their patients a priority, helping them get back to a pain-free life.