Cases of partial displacements of the navicular and cuneiforms have been reported but the mechanism is not clear. It should be remembered that the tibialis anticus and tibialis posticus, two powerful muscles, find their main insertions on the cuneiforms and navicular. The cuboid, navicular and cuneiforms are all composed of can- cellous tissue internally, while the surface is made up of a thin layer of compact bone. They are firmly bound together by heavy ligaments and are usually fractured by direct violence to the dorsum of the foot. The soft tissues covering the dorsum of the foot are scant and the lesion is often compound. AVhen the frac- ture is not compound from the first, it often becomes so later, as a result of sloughing of the integument on the dorsum of the foot. A crushing of the tarsal or metatarsal bones is an accident not uncommonly seen among railroad employees. The foot is caught beneath the wheels of a car and more or less severely crushed. If the train is moving with much speed the foot is crushed and amputated. If the rate at which the train is moving is slow the foot may be pushed aside and only partially crushed. <Callout type="important" title="Important">Treatment should focus on immobilizing the foot to prevent further damage.</Callout> In fractures of the anterior bones of the tarsus, whatever deformity is present should be corrected and the foot immobilized on a plaster sole as shown in Fig. 787. This splint should extend from the middle of the leg to a point beyond the toes. A plaster cast should not be used since secondary sloughing is not uncommon and the skin on the dorsum of the foot should <Callout type="warning" title="Warning">be kept open for inspection during after-treatment.</Callout> The damage to the soft tissues is often more important than the fracture. If sloughing occurs the parts should be frequently dressed and the sloughing area kept as aseptic as possible. Granulations should be cultivated and stimulated by balsam of Peru and in removing the dressings the surgeon should avoid injury to these delicate granulations. 712 FRACTURES AND DISLOCATIONS The use of antiseptics such as bichlorid of mercury will do more harm than good. While healing and union are taking place the surgeon should see to it that the plaster sole properly maintains the arch of the foot. Operative Treatment. — Operation is frequently indicated because the fracture is compound but rarely to accomplish reduction. The treatment of compound cases is the same in fractures of these bones as has already been indicated under the heading of "The Treat- ment of Compound Fractures" on page 789. In severe crushes of the foot immediate amputation is not infrequently demanded. After-Treatment. — The length of the period of immobilization varies greatly with the severity of the fracture and whether or not it is compound. If the arch of the foot has been involved, by the fracture or luxation, weight should not be borne on the injured member inside of six weeks. In instances in which this has not occurred the patient may begin the gradual resumption of func- tion at the end of three or four weeks. If sloughing of the tissues on the dorsum of the foot takes place union is usually delayed and the period of fixation should be prolonged accordingly. Prognosis. — In severe crushes of the foot amputation may be necessary. In instances in which the trauma has not been severe, with little displacement, and no sloughing of the soft tissues, com- plete restoration of function is the rule. Surprisingly good func- tion not infrequently follows even in compound cases and in instances in which the soft tissues have sloughed.
<Callout type="risk" title="Risk">Crush injuries can lead to severe damage and may require amputation.</Callout> The metatarsal bones are classed among the long bones. The extremities are composed largely of cancellous tissue encased in a thin layer of compact bone. The shafts consist of a heavy tube of compact tissue. Accordingly, the nature of the fracture varies with the region of the bone broken. The outer four metatarsals are ossified by two centers, one for the shaft and one for the head (the distal end). That for the shaft appears about the seventh week, while the epiphyseal center is first seen during the third year. Ossification of the epiphyseal cartilage occurs be- tween the eighteenth and twentieth years. The first metatarsal is different from the other four. The head and shaft are ossified from one center which makes its appearance in the seventh week. The base is the epiphysis and its center is first seen during the fifth year. Fusion occurs between the eighteenth and twentieth years. Not uncommonly there is also an epiphysis for the head of the bone. AVhen the first metatarsal shows two epiphyses it re- sembles both metatarsal and phalanx. These facts concerning the ossification of the metatarsals are of importance in examining Rontgenograms of this region in persons under twenty years of age. The bases of the metatarsals are firml}- bound to the distal tar- sals and to each other by heavy ligaments, and like the tarsals are seldom luxated. The long plantar ligament is attached to the ventral aspect of the bases of the second, third and fourth meta- tarsals. The distal ends of the metatarsals do not articulate with each other but are held in position by the transverse metatarsal ligament. This ligament tends to prevent overriding deformity of the shaft in the presence of fracture of one of the metatarsals. Aside from the tendons of the long extensors playing over the dorsum of the foot the metatarsals are practically subcutaneous. The scant, soft tissues covering the bones in this region offer little protection from direct violence when applied to the dorsum of the foot.
Fractures of the metatarsals are almost invariably the result of direct blows and are frequently seen in crushes of the foot. Frac- ture from indirect violence does, however, occasionally occur, espe- cially of the first and fifth. A misstep or twist of the foot may produce fracture of one of the metatarsals. The injury has been noted in soldiers at the end of long, forced marches. The base of the fifth metatarsal is prominent, and falls on the foot, with the member inverted, not uncommonly result in fracture of the 716 FRACTURES AND DISLOCATIONS proximal portion of this bone. Fracture of the metatarsals is not, as a rule, accompanied by impaction and displacement, as is the case when the metacarpals are broken.
<Callout type="tip" title="Tip">Immobilization with a plaster sole helps maintain the arch of the foot.</Callout> Fig. 782. Figs. 781 and 782. — Show fractures of the bases of the fifth metatarsals. Symptoms. — The symptoms vary greatly with the severity of the injur} In cases produced by comparatively slight trauma, and in those due to muscular action the symptoms will be moderate FRACTURES OF THE METATARSALS 717 and more or less typical. In severe crushes of the foot it is not uncommon to be able to see the fractured bones in among the lacerated and mano-led tissues of the foot. In such instances the Fig. 786. — Method of detecting fractures in the metacarpals. Pressure on the metacarpal head in the line of the long axis of the bone will elicit pain in the presence of fracture. Fig. 787. — Crushing injury of the foot. An eight-ton girder fell on the foot as it was resting on the edge of a curb, prodaciug eight fractures in the metacarpal bones. (See X-ray, Fig. 785.) The wound seen in the plate resulted from subsequent slough- ing and it was possible at one time to see four of the fractures of the metatarsals. Wound healed by cultivation of granulation tissue rather than attention to antisepsis. Result: union in all the fractures with closure of the wound and perfect recovery of function. Patient walks without limp.
<Callout type="important" title="Important">Deformity should be corrected before applying a plaster sole.</Callout> Fractures present are only of secondary importance as compared with the damage done to the soft parts. Sloughing of the tissues on the dorsum of the foot is not an uncommon sequel when the causative trauma has been severe and direct. In crushes of the 718 FRACTURES AND DISLOCATIONS foot there will, of course, be complete loss of function. In simple cases pain, tenderness, swelling, crepitus and abnormal mobility will be present. The suffering is increased if the patient attempts to stand on the foot, and in some instances the fragments may be heard grating against one another as the attempt is made. De- formity is rarely pronounced. In one exceptional compound case seen by the author there was a fracture of the shaft of the first metatarsal, a little below the middle, and the distal fragment was turned completely around on a transverse axis, so that the articular end rested against the distal end of the proximal fragment.
Diagnosis. — There is usually little difficulty in recognizing a frac- ture of one or more of these bones. Their dorsal surfaces are practically subcutaneous, and if the case is seen early much can be learned by direct palpation. If the swelling and traumatic reaction are well advanced before the surgeon is called, the parts may be exquisitely tender, and under such circumstances it is preferable to determine the presence of fracture by the use of the X-ray, rather than to administer an anesthetic and establish the diagnosis by palpation and manipulation. If pressure is made on the ball of the foot (between the toes and the ball) and toward the base of the bone (that is, in the direction of the axis of the metatarsal) pain may be produced at the seat of fracture in the corresponding bone. Pressure should be made in this way over the head of each metatarsal.
Treatment. — The foot should be placed on a plaster sole which is moulded so that it properly supports the arch of the foot. This splint should extend from the middle of the leg to a point beyond the toes. Traumatic reaction should be controlled by the inter- mittent application of the ice cap, and by keeping the foot in the elevated position. If deformity exists it should be corrected be- fore the plaster sole is applied.
Operative Treatment. — Compound cases are common and the operative treatment in these cases is practically the same as that given on page 712 under "Fractures and Dislocations of the Cuboid, Scaphoid and Cuneiforms." Open treatment to correct deformity in simple cases is practically never indicated.
After-Treatment. — Union takes place in simple cases in three to four weeks. Weight bearing should be only gradually resumed, since ventral bowing may occur if the first metatarsal alone or more than one of the other metatarsals has been broken, and the FRACTURES OF THE METATARSALS 719 patient walks too soon. Hot applications, passive motion and mas- sage will hasten the time w^hen the patient will be able to enjoy free use of the foot.
Prognosis. — The severity of these lesions varies greatly, and ac- cordingly the outlook will depend on the amount of damage done. Simple, uncomplicated injuries should be followed by complete restoration of function. Severe crushing injuries may require im- mediate amputation.
<Callout type="risk" title="Risk">Crush injuries can lead to severe damage and may result in amputation.</Callout> The structure of the bones of the toes is similar to that found in the fingers. The toes may be broken in crushes of the foot, and resemble the condition as occurring in the metatarsals. The toes are practically alwaj^s broken by direct vio- lence. The accident is common among laborers and results from heavy objects being dropped on the foot. A not uncommon form of injury is one in which the toes are caught in a moving elevator. The great toe usually sutiPers most and the crushing of the parts is scA^ere when produced in this way. Stubbing of the toes against some projecting object, w^hile the patient is barefooted, is fre- quently responsible for fracture of one or more of the phalanges, especially that of the little toe. Luxations of the toes are rare and resemble those seen in the fingers.
Symptoms. — The amount of disability is almost entirely de- pendent on the severity of the causative trauma. In simple frac- ture of the little toe the patient is usually able to get about with little difficulty although pain may be severe immediately following the accident. On the other hand severe crushing injuries, such as sustained in the usual elevator accident, completely disable the pa- tient. Crepitus, pain and swelling are present. Crepitus may be difficult to elicit if the fracture is in the distal phalanx, because of the splinting effect of the nail.
Treatment. — The parts should be immobilized on a plantar splint. The displacement is usually moderate and can be corrected without difficulty. In fractures of the great toe the patient should be pre- vented from bearing weight on the foot until union is solid. In fracture of the smaller toes the patient may be allowed about as soon as the traumatic reaction has subsided. The great toe is an important factor in walking but the lesser toes have little to do with the usefulness of the foot. If fibrous union takes place in one of the smaller toes there will be no subsequent disturbance in function. When the little toe alone is fractured it will usually 720 FRACTURES AND LUXATIONS OF PHALANGES 721 not be necessary to employ a splint in the treatment of the condi- tion. If cotton is placed between the little toe and the adjoining digit, and the injured toe strapped in position with adhesive, the necessary immobilization will have been accomplished. In com- pound, crushing injuries the important element is the damage done to the soft tissues, and the case must be treated accordingly. Gan- grene may develop in one or more of the toes if the crushing has been severe, and amputation may be necessary.
Prognosis. — In simple uncomplicated cases the prognosis is good. If the accident results in the loss of the great toe there may be a limp, more or less noticeable in the patient's gait.
Key Takeaways
- Fractures of metatarsal bones are usually due to direct blows or crushes.
- Immobilization with a plaster sole is crucial for proper healing.
- Severe crushing injuries may require amputation.
Practical Tips
- Always immobilize the foot properly after a fracture to prevent further damage and promote healing.
- Keep the injured foot elevated and apply ice intermittently to reduce swelling and pain.
- Gradually resume weight-bearing activities only when advised by a medical professional to avoid complications.
Warnings & Risks
- Crush injuries can lead to severe soft tissue damage, which may require amputation if not treated properly.
- Do not use antiseptics like bichlorid of mercury on open wounds as they can cause more harm than good during healing.
- Avoid bearing weight too soon after a fracture, especially if multiple metatarsals are involved.
Modern Application
While the techniques described in this chapter were developed over a century ago, the principles of immobilization and gradual weight-bearing still apply today. Understanding these historical methods can provide valuable insights for modern survival preparedness, particularly in situations where immediate medical care is not available.
Frequently Asked Questions
Q: What are common causes of fractures in metatarsal bones?
Metatarsal fractures are commonly caused by direct blows or crushes. Soldiers and laborers are at higher risk due to the nature of their work, where heavy objects may be dropped on the foot or toes can get caught in moving machinery.
Q: How long does it typically take for a metatarsal fracture to heal?
Simple uncomplicated fractures of the metatarsals usually take three to four weeks to heal. However, severe cases may require longer healing times and could even necessitate amputation if there is significant soft tissue damage.
Q: What should I do if I suspect a metatarsal fracture?
If you suspect a metatarsal fracture, immobilize the foot as soon as possible to prevent further injury. Elevate the foot and apply ice intermittently to reduce swelling. Seek medical attention promptly for proper diagnosis and treatment.