Multifragmentary diaphyseal and proximal extraarticular fractures of the 1st to 4th metatarsal

These injuries are multifragmentary fractures of the shaft and proximal metaphysis of metatarsals 1–4.

They are classified as follows: 

• Multifragmentary diaphyseal fractures (AO/OTA 87.1–4.2C)

• Proximal extraarticular multifragmentary fractures (AO/OTA 87.1–4.1A(b))

1–4 indicates which metatarsal is injured.

The following clinical presentation is typical:

• The patient describes an acute trauma with immediate pain and difficulty in weight-bearing
• The foot progressively exhibits swelling and ecchymosis
• The damaged area is very painful to palpation and weight-bearing
• Deformities may not be appreciated; sensation can be disrupted, particularly plantarly
• Crepitation may be appreciated with palpation of the affected area (this will be very painful for the patient)
• Level of soft tissue swelling increases proportionally with the number of fractured metatarsals
• Open fractures will have draining wounds
• Vascular compromise is uncommon

Conventional radiographs of the foot (AP and lateral oblique views) are sufficient for diagnosis and treatment.

CT scans are invaluable for clarification of the fracture pattern and assessment of additional fractures of the fore-, mid-, and hindfoot.

Fractures may be created with multiple mechanisms:

• Axial
• Bending
• Torsion
• Combined trauma

They may involve either high- or low-energy mechanisms.

High-energy mechanism injuries are often associated with midfoot instability (Lisfranc instability).

Compartment syndrome and Lisfranc injuries should always be suspected.