broken second metatarsal- slight misalignment

[mrscullini]

i broke my left second metatarsal riding my dirtbike on sunday, july 6th. there is slight misalignment by approximately 1-2 mm. this misalignment is with the foot at 45 degrees. the film taken straight down on the foot shows no misalignment.

the doctor originally said it was borderline and she was going to cast it. then she consulted with her colleague and they decided on surgery.

i need minimal mobility asap. my wife is due in approximately 3 weeks and is freaking out because i am immobile.

i've got some swelling and bruising which are both decreasing daily. it is in a jones compression and i am icing my toes. i have very minimal pain and i am not even taking otc pain meds. i am using crutches most of the time and completely unload the foot. around the house i am using a single crutch and very lightly loading the foot. still, no pain. i am going for a second opinion on monday. i would like to get it casted or in an air boot.

can i avoid surgery? can i ditch the crutches and slightly weight it after it is in a cast?

here is a pic of the film. the shot on the right is with my foot rolled 45 degrees. the shot on the left is straight down on my foot.

Flickr: mrscullini92's Photostream

any thoughts?

thanks, john

[Dr. D]

Metatarsal fractures generally heal well, even without surgery. This is most likely why your doctor said she was originally going to cast it. It's always important to get a few views of the foot when evaluating broken bones, because not all views will show the displacement. On the AP view (top to bottom view) there is a little displacement, mostly shortening. On the MO view (the 45 degree angle view) the shortening is quite evident. This is probably the reason the doctor changed her mind. This picture will give you a little bit of an idea of how the 2nd metatarsal should look (keep in mind that the length in this image will appear exaggerated on this view - the MO view).



Will your broken bone heal without surgery? Probably. But, when the 2nd metatarsal is shortened, it can cause problems down the road. The second metatarsal should be longer than the 1st and 3rd - when it is not, many people will develop pain under the 3rd (and/or 4th) metatarsal head, this can also cause the big toe to take up more than it's share of the weight, causing big toe joint problems and some people have a floating 2nd toe (the 2nd toe doesn't touch the ground). These are all just possibilities.

Yes, it is borderline. Some doctors would probably recommend surgery for the above reasons and others would put you in a cast. It's always good to get a second opinion.

[mrscullini]

thanks dr. d for such a thorough respone. kind of a coincidence, i am in truckee. i noticed you are in south lake tahoe. i have a second opinion scheduled tomorrow afternoon in reno.

knowing what you know at this point, would you opt for surgery or cast it? also, is it possible to realign by hand and then cast it?

thanks again.

[Dr. D]

"Realign by hand" is called a closed reduction and generally involves numbing the foot and then placing the toes in a traction device to attempt to realign the fracture. Most offices don't have traction devices, so most closed reduction attempts are done in the emergency room, or prior to surgery. Once the patient is under anesthesia, this allows for all the muscle groups to fully relax and the best chance at closed reduction. Closed reduction can be attempted by hand and if adequate realignment is achieved, a cast can be placed or sometimes a pin used to stabilize the fracture site. Because of the oblique nature of your fracture, there is a greater chance of it displacing again. If the fracture was transverse (the fracture line perpendicular to the metatarsal bone) then it would be stable after closed reduction.

After getting the second opinion, use all the information you have obtained to make your decision regarding the surgery. It's always handy to get extra information on forums, but you shouldn't make your decision based on it.