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09/18/2003    Philbert Kuo, DPM

Metatarsal Fracture

Query: Metatarsal Fracture


Today I was asked to see a curbside consult
on a teenager that had jumped over a fence and
fractured the 2nd, 3rd and 4th metatarsals. The
injury was 8 weeks ago and he was treated at a
military hospital with non-weightbearing for 4
weeks and apparently a Cam walker boot for 4
weeks. Now he is wearing a surgical shoe.


X-rays taken today reveal that the diaphyseal
fractures are still healing in the 2nd and 3rd
metatarsals and are in good alignment. The 4th
metatarsal is the problem one though. The
fracture is diaphyseal as well, however, the
shaft of the distal fragment has moved
proximally and sits
parallel right next to the shaft of the proximal
bone. Why this was not opened and reduced is
beyond me. The physicians have told the parents
that the bone will heal.


The patient is walking on the foot and it does
not hurt him. He has some discomfort when
bending the toes.His foot is not significantly
edematous. He is wondering when he can play
soccer. I would appreciate any treatment
recommendations. Wait and treat symptomatically
or ORIF?


Philbert Kuo, DPM
Chesapeake, VA
philbear@pol.net


Other messages in this thread:


01/16/2017    Don Peacock DPM, MS

Increase in Metatarsal Fractures Doomed Minimalist Shoes: CA Podiatrist

I would like to weigh in on the comments by
both Dr. Shavelson and Dr. Kirby. Both of these
men are biomechanics experts and I am not. I am
a person that has exercised for years and have
done my fair share of running. After numerous
and continuous exercise injuries I became
smarter about how to workout. I did this by
following many of the recommendations fostered
in the paleo community. One of their
recommendations is barefoot walking and I have
followed this protocol for 6 years and I am
injury free.

The human body is not made for running on the
surfaces that most people run on and it is not
genetically made for running in shoes for
repetitive bouts of daily pounding regardless
of shoe or surface. The human body is made for
walking long distances and for occasional
sprints. Our ancestors used their logic to
track down game and to gather food. They did
not run down their prey. They did occasionally
sprint to keep from being prey and ran short
distances in tracking wounded prey. The also
engaged in unstructured play that included
sprint like movements.

From a genetic standpoint, the argument for or
against running in any shoe on a daily basis
and pounding the pavement has at it's
fundamental concept a bad logic. People that
exercise should walk barefoot/minimalist shoes
and move at a slow pace for extended periods,
occasionally sprint barefoot, and lift heavy
things barefoot just like our ancestors did.

We have the same genetic makeup today. I am
aware that some societies did in fact run long
distances for the purposes of hunting. These
societies were very few in number. Research has
proven many ill effects of chronic cardio
especially running. Slow down, walk barefoot
and get in both great shape and be healthy.
Runners who go to your office seeking treatment
are by definition not healthy. We should
encourage health not abuse of the body.

Don Peacock DPM, MS, Whiteville, NC

10/14/2011    Gino Scartozzi, DPM

Plating System for 5th Metatarsal Fracture

I am wondering why this patient would make an
ideal surgical patient? Here are some of the
underlying issues as revealed by the clinician
that can compromise the post-operative recovery
of this patient: diabetes with a neuropathic
state (with no revelation of glycemic control),
who smokes and has an inability to modify his
work activities in any post-operative recovery
period. No doubt, this is the "Holy Trinity" of
underlying etiologies that can have the makings
of a malpractice case. I apologize, no blasphemy
was intended by me as I write this on a Sunday
evening!


The fracture that is presented is of the fifth
metatarsal distal metaphyseal-diaphyseal region.
It is noted with the lateral-oblique projection
and dorsal-plantar projection, the fifth
metatarsal capital fragment is dorsiflexed. The
extent of the dorsiflexion of the fifth
metatarsal capital fragment cannot be determined
since a lateral projection is not available in
this case discussion. These fractures, although
they may look "horrible" on x-ray, heal well and
uneventfully.


Post-fracture treatment with orthoses should be
considered after casting with this patient. The
implementation of a bone stimulator should also
be considered with this patient, along with the
recommendation that the patient stop smoking, if
possible. These fractures heal well even in many
geriatric patients that I have encountered over
the years of practice.


This fracture and treatment differs from a Jones
fracture at the proximal diaphyseal-metaphyseal
region of the fifth metatarsal. The treatment
for a Jones Fracture, in most cases, requires
open reduction-internal fixation with non-
weightbearing for approximately 6 weeks.
Concomitant use of a bone stimulator would be
strongly advised.


Gino Scartozzi, DPM, New Hyde Park, NY,
Gsdpm@aol.com


01/27/2006    Barry Mullen, DPM

Intra-Articular Metatarsal Fracture

Query: Intra-Articular Metatarsal Fracture


A mid 50's, healthy male sustained a non-
displaced intra-articular fracture of the 2nd
metatarsal base. The fracture's intra-articular
involvement was not appreciated at the time of
the initial presentation and was initially
treated via cast immobilization only. The
patient was somewhat non-compliant in the
suggested non-weight-bearing for 8 weights. Now,
at weeks 10 post injury, there is hypertrophic
bone callus formation, irregularity of the 2nd
met base articular surface, incomplete fracture
healing with modest to severe persistent pain
experienced by the patient both at the fracture
site and within the 2nd MCJ during his rehab
attempt. Clinically, he is regressing. MRI's
show increased signal intensity in T2 throughout
both sides of the fracture site.


In light of his current 2nd MCJ joint pain,
regressive post trauma rehab course, we now
contemplate having to fuse the 2nd MCJ. The
patient's foot type is a cavus foot type. Even
though the proximal fragment appears to remain
viable, the incongruity of the 2nd MCJ is of
major long-term concern to us. We feel the
fracture is moving towards a hypertrophic non-
union. Since the joint is compromised and is so
critical to how the Lisfranc's apparatus
functions, we have serious doubts that just
ORIF'ing the 2nd met base alone will be
insufficient, let alone whether this is even
accomplishable at 10 weeks post injury because
of all the fibrosis and hypertrophic bone that
has formed.


What is the collective experience of our
colleagues of performing an isolated 2nd MCJ
fusion? Since metatarsals 1 and 4,5 with their
respective tarsal articulations act
independently from one another, should the 3rd
met-cuneiform joint also be fused, or, does one
need to fuse the entire Lisfranc's complex? Any
literature supporting your expert opinions would
also be greatly appreciated.


Barry Mullen, DPM, Hackettstown, NJ,
YAZY630@aol.com


02/02/2005    Daniel J. Tucker, DPM

Return to Full Weight-Bearing Post 5th Metatarsal Fracture (Gregg Corrigan, DPM)

RE: Return to Full Weight-Bearing Post 5th
Metatarsal Fracture (Gregg Corrigan, DPM)


We can't only treat the x-rays, we have to treat
the patients as well.
Midshaft metatarsal fractures are often quite
unstable and require
ORIF. For those cases where closed reduction is
effective, a period of 4 to 6 weeks of non-
weight bearing followed by a 2 to 4 week period
of
protected weight bearing is my usual protocol.
Certainly for an obese
patient with this type of fracture, adding a
bone stimulator might very
well accelerate the heal time. If the x-rays
show progression in
healing, and the patient's symptoms are
improving, use the patient's comfort level as a
guide to advance weight-bearing status. I'm
curious however, to know how you determine
that "clinically motion stopped at the fracture
site at two weeks"?


Daniel J. Tucker, DPM
Rockville Centre, NY


01/01/2005    Gregg Corrigan DPM

Return to Full Weight-Bearing Post 5th Metatarsal Fracture

Query: Return to Full Weight-Bearing Post 5th
Metatarsal Fracture


A 60 yo, 180 LB female presented to the office
6 weeks ago status post inversion injury to the
left foot. X-rays revealed spiral oblique
fracture midshaft 5th metatarsal. Closed
reduction resulted in excellent alignment and
minimal gapping of the fractured bone ends. She
was placed in a CAM walker, crutches and weight
on the left heel only for transfer. She used a
bone stimulator once daily as per manufacturer’s
directions. X-rays were taken q 2 weeks. The 6-
week x-rays show about 50% consolidation within
the fracture site from proximal to distal after
initial 2 mm. osteoclasis bone resorption with
no "cocoon-type" bone callus. The distal 50%
still shows gapping from the initial bone
resorption. Clinically, motion at the fracture
site stopped after 2 weeks. Is there any way to
know when to return the patient to full weight-
bearing other than complete consolidation of the
fracture site as noted on x-ray?


Gregg Corrigan DPM
Davenport, IA


06/10/2004    Greg Still, DPM

Repair of 5th Metatarsal Fracture (Non-union)

Query: Repair of 5th Metatarsal Fracture (Non-
union)


I'd very much appreciate any suggestions on how
to code the following:
- Resection of non-union and hypertrophic bone
at the 5th metatarsal base; Application of
allograft; and Screw fixation.


Would it be reasonable to code it as CPT 28322
(repair, nonunion or malunion; metatarsal, with
or without bone graft [includes obtaining
graft])? How about CPT 28322-22?


Greg Still, DPM
Estes Park, CO


Codingline response: The CPT code you selected,
CPT 28322, is the proper code for the procedure
you outlined. The code describes a repair of a
non-union which is what you did. That code also
includes the obtaining and use of an autograft
graft (you chose to use an allograft - no
additional reimbursement). The use/choice of
fixation is included in the procedure allowance.


To use the "-22" modifier would require
additional work performed beyond what
is "normal" for this procedure. From your
description, there appears to be no additional
or unusual work performed beyond the code's
description.


Tony Poggio, DPM
Alameda, CA


09/19/2003    Multiple Respondents

Metatarsal Fracture (Philbert Kuo, DPM)

RE: Metatarsal Fracture (Philbert Kuo, DPM)
From: Multiple Respondents


In my opinion the easiest way to handle a
metatarsal fracture that is as clearly displaced
and malaligned as you described is rather
simple. Show the teenager’s parents his/her X-
rays. Point out the potential biomechanical
deficit that will result if the fracture is left
alone and let them decide. Recommend and
encourage them to go for a 2nd or 3rd opinion,
but hold your ground, especially in your
progress notes. This way if they decide not to
treat and come back to bite you later, you will
have iron clad documentation.


If they decide to undergo treatment, there is
no time like the present.


Thomas A. Graziano, DPM
Clifton, NJ


If it is grossly displaced, it should be
repaired. Whether a plate and screws, or k-wire
and circlage are appropriate, fixing it will
allow proper healing. The teenager will
obviously develop other problems (stress
fractures, plantar lesions, bursitis) without
restoration of a normal metatarsal parabola. I
would discuss the risks and benefits, and then
tell them what you would do if it was your
child!


Allen Sater DPM
Jupiter FL
Bunionpain@aol.com


Although the healing in children is
different than in adults (in that a fracture
without any good cortical/cancellous alignment
will still heal and remodel to a good looking
result, unlike in adults), it is a bit trickier
in this age of patient. If you think it is in
poor alignment or bayonetted to the point that
it will result in a poor parabola and undue
stress that may lead to sub-met pressures and
possibly other fractures after undue stress, do
the ORIF. If there is a void to fill, you can
consider bone from the medial malleolus or
calcaneus or allomatrix and plate it.


Let us know how it goes.


David Secord, DPM
Corpus Christi, TX
David5603@POL.net


I think you are obligated to perform an ORIF
now... Waiting until the patient develops a
painful malunion with an abnormal metatarsal
parabola won't help matters much.


Daniel J. Tucker, DPM
Rockville Centre, NY


03/06/2002    Mike Wilkinson, DPM

5th Metatarsal Fractures (Laurence Rogers, DPM)

RE: 5th Metatarsal Fractures (Laurence Rogers,
DPM)
From: Mike Wilkinson, DPM

I have had good luck with electrical bone growth
stimulation on 5th met base fractures (even
Jones fractures). There are several keys to
success. Good training and motivation of the
patient's compliance in the use of the EBI unit
10 hours per day (8 hours sleep plus 2 is easier
than one thinks). The more immobilization and
NWB'g the higher success rate (this must be
balanced against the risk of disuse atrophy but
early NWB (first 6 weeks) is worth it. I
suggest you get a hold of your EBI
representative and get sample of strong letters
of medical necessity. I have gained approval in
as little as two months from the date of
fracture and never close to nine months. Once
you've done a few stimulators you can leverage a
freebee if you have an indigent patient or
insurance denial. Many of us including myself
are not credentialed for bone grafting. When we
do this ORIF repair we may need to! graft and
bring in an orthopod, losing control of the
patient. The decision for surgery vs. bone stim
is an art that incorporates the patient's age,
activity, bone stock, compliance, and the size
and degree of malalignment of the fracture gap.
If the patient is a smoker, they may not heal
the surgery, another good reason to try a bone
stimulator. Give bone stim a try sometime.
There is even an application CPT code 20974
available, not to mention x-ray and E/M revenue.

Mike Wilkinson, DPM
Casper, WY
Wilkftdoc@aol.com

03/05/2002    Elliot Udell, DPM

5th Metatarsal Fractures (Laurence Rogers, DPM)

RE: 5th Metatarsal Fractures (Laurence Rogers,
DPM)
From: Elliot Udell, DPM


We have seen some gratifying results with the
use of bone stimulators on these patients. The
problem however with dispensing bone stimulators
to patients with 5th met fractures is that many
insurance companies will not pay for them unless
you can really prove delayed healing and
patients tend not to want to pay out of pocket
for such a modality. Some insurance companies
will not consider a bone stimulator unless the
fracture does not show signs of healing for at
least nine months. Others are more lenient.

Elliot Udell, DPM
Hicksville, NY
elliotu@aol.com

02/27/2002    Laurence C. Rogers, DPM

5th Metatarsal Fractures

RE: 5th Metatarsal Fractures
From: Laurence C. Rogers, DPM

Recently I have had a rash of female patients
who have sub-acute fractures of their 5th
metatarsal base. X-rays show trabecular
disturbances of the tuberosity or the base of
the 5th metatarsal that produce of the
tuberosity, compared to the contralateral foot
or produces prolonged and intractable pain.

It would be understandable if these women had a
history of adduction of the foot with
simultaneous external rotation of the trunk over
the 5th metabase, or blunt trauma of a rigid
plantarflexed 1st metatarsal; but, these women
have none of these etiologies. In fact, one
young
20y.o.W/F has osteopetrosis.

B-K removable casts helped for a short while,
but once the pain seems to go away and the
patient removes the cast then the pain returns.
Orthotics don't seem to help; using the theory
that a polypropylene plate with no posting will
transfer the weight evenly across the foot and
`off-load' the 5th metabase. I have seen
gratifying results with internal fixation for a
true Jones fracture, but I can't get myself to
perform internal fixation when x-rays only show
disturbances in the trabecular pattern with
associated pain on palpation of the area with
osseous disturbance.

My most recent patient, a 20 y.o. women with
osteopetrosis, was sent for an MRI. The
interpretation was a stress fracture that is
healing. Back to square-one. I would appreciate
some suggestions.

Laurence C. Rogers, DPM
Rochester, IN

02/27/2002    Laurence C. Rogers, DPM

5th Metatarsal Fractures

RE: 5th Metatarsal Fractures
From: Laurence C. Rogers, DPM

Recently I have had a rash of female patients
who have sub-acute fractures of their 5th
metatarsal base. X-rays show trabecular
disturbances of the tuberosity or the base of
the 5th metatarsal that produce of the
tuberosity, compared to the contralateral foot
or produces prolonged and intractable pain.

It would be understandable if these women had a
history of adduction of the foot with
simultaneous external rotation of the trunk over
the 5th metabase, or blunt trauma of a rigid
plantarflexed 1st metatarsal; but, these women
have none of these etiologies. In fact, one
young 20 y.o. W/F has osteoporosis.

B-K removable casts helped for a short while,
but once the pain seems to go away and the
patient removes the cast then the pain returns.
Orthotics don't seem to help; using the theory
that a polypropylene plate with no posting will
transfer the weight evenly across the foot and
`off-load'
the 5th metabase. I have seen gratifying
results with internal fixation for a true Jones
fracture, but I can't get myself to perform
internal fixation when x-rays only show
disturbances in the trabecular pattern with
associated pain on palpation of the area with
osseous disturbance.

My most recent patient, a 20 y.o. women with
osteoporosis, was sent for an MRI. The
interpretation was a stress fracture that is
healing. Back to square-one. I would appreciate
some suggestions.

Laurence C. Rogers, DPM
Rochester, IN
Neurogenx?122


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