CHAPTER 65 • FOOT INJURIES 387- Fractures just distal to the tuberosity, at the meta-
physeal–diaphyseal junction bear the eponym
Jones’ fracture. They are caused by forceful adduc-
tion of a plantar-flexed ankle. These fractures
demonstrate higher rates of nonunion than tuberos-
ity fractures. Nonoperative treatment consists of
nonweightbearing in a short leg cast for 6–8 weeks.
If more rapid return to activity is desired for high-
level or recreational athletes, operative treatment
with an intramedullary screw may be advised.
Nonunions or delayed unions are also treated with
intramedullary fixation and bone graft. - The third fracture pattern of the proximal fifth
metatarsal is the diaphyseal stress fracture. Criteria
for stress fracture are a history of prodromal symp-
toms at the lateral aspect of the foot, radiographic
evidence of stress phenomena in the bone, and no
history of treatment for fracture of the fifth
metatarsal. Initial treatment of acute diaphyseal
stress fractures of the fifth metatarsal consists of
nonweightbearing ambulation in a short leg cast
for 6–8 weeks. Stress fractures that go on to
become delayed unions or nonunions may require
operative intervention (Rosenberg and Sferra,
2000).
HALLUXRIGIDUS
- Hallux rigidus a common disorder, seen in about 1 in
45 individuals over the age of 50. It is characterized
by limitation of motion of the first metatarsopha-
langeal joint, particularly in dorsiflexion. Hallux
rigidus has been attributed to many causes, including
trauma, inflammatory or metabolic conditions, and
congenital disorders.
•Patients present complaining of limitation of motion and
pain at the metatarsophalangeal joint with ambulation or
athletic activity. A palpable exostosis may be present at
the dorsal MTPJ and the patient may have symptoms
from footwear impinging on the exostosis or cheil. - Standing AP, lateral, and oblique views reveal nar-
rowing of the joint space and a dorsal osteophyte. - Initial treatment is nonoperative, consisting of
NSAIDs, activity modification to avoid high impact
activity. A steel or fiberglass shank in the sole of the
shoe can relieve symptoms by limiting dorsiflexion.
Rocker bottom shoes and custom insoles may have
similar effect. Failure of nonoperative treatment is an
indication for surgery. Surgical treatment can consist
of cheilectomy, arthrodesis, or Keller arthroplasty
(Fleming, 2000).
SESAMOIDS
- Injuries of the sesamoids can cause significant pain
and disability for athletes.- Stress fracture of sesamoids is associated with
insidious pain and may progress to osteonecrosis. - The condition must be differentiated radiographi-
cally from bipartite sesamoid. Bone scan can be
helpful if there is doubt. - Initial treatment is with a short leg walking cast.
Excision of the sesamoid may be indicated with
failure of closed treatment (Biedert and Hintemann,
2003).
- Stress fracture of sesamoids is associated with
- Sesamoiditis
- Inflammation of the sesamoid complex includes
tendinitis of the flexor hallucis longus, synovitis,
and chondromalacia of the sesamoids.
2.Presents as insidious onset pain localized to the ball
of the foot. Physical examination reveals tenderness
to palpation of the sesamoids. Routine radiographs
are normal. - Metatarsal bars or sesamoid cut-outs can provide
relief by shifting weight proximally, off the
sesamoids. If necessary, rest can be enforced with
the use of a short-leg walking cast. Anti-inflamma-
tories are a useful adjunct. Recalcitrant cases may
benefit from a single intra-articular injection of
corticosteroid, followed by cast immobilization for
2–4 weeks. Failure of conservative treatment war-
rants consideration of sesamoidectomy.
•Acute fracture - Acute fracture of the sesamoid can occur by com-
pression as in direct blow or a fall from a height, or in
tension with violent dorsiflexion of the first metatar-
sophalangeal joint. Presents with history of identifi-
able trauma to the region, swelling, ecchymosis, and
tenderness to palpation at the plantar MTP joint. - In addition to standard AP, oblique, and lateral
radiographs, an axial view of the sesamoids should
be obtained. Acute fractures can be distinguished
from other conditions, such as bipartite sesamoids
or osteonecrosis by their radiographic appearance.
Acute fractures demonstrate sharp, irregular edges
in contrast to the smooth, sclerotic edges of the
bipartite sesamoid. Osteonecrosis of the sesamoid
is characterized by fragmentation into multiple
pieces, often with evidence of remodeling or new
bone formation. - Treatment for nondisplaced fractures is similar to
treatment of sesamoiditis, ranging from hard-soled
shoe or metatarsal bar to a short leg walking cast.
Treatment of displaced fractures or nondisplaced
fractures that fail closed treatment is surgical exci-
sion (Grace, 2000).
1 STMETATARSALPHALANGEALJOINTDISLOCATION
•Traumatic dislocations of the first metatarsopha-
langeal joint are relatively rare, and represent the