Toe and Forefoot Fractures-OrthoInfo - AAOS
Copyright 2016 American Academy of Orthopaedic Surgeons
Toe and Forefoot Fractures
Fractures of the toes and forefoot are quite common. Fractures can result from a direct    blow to the foot—such as accidentally kicking something hard or dropping a heavy object    on your toes. They can also result from the overuse and repetitive stress that comes    with participating in high-impact sports like running and basketball.
Although fracturing a bone in your toe or forefoot can be quite painful—it rarely    requires surgery. In most cases, a fracture will heal with rest and a change in activities.
Anatomy
The forefoot has 5 metatarsal bones and 14 phalanges (toe bones). There are 3 phalanges    in each toe—except for the first toe, which usually has only 2.
All the bones in the forefoot are designed to work together when you walk. A fracture,    or break, in any of these bones can be painful and impact how your foot functions.
The bones of the forefoot.
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Description
Toe and forefoot fractures often result from trauma or direct injury to the bone.    Fractures can also develop after repetitive activity, rather than a single injury.    This is called a "stress fracture."
Fractures may either be "non-displaced," where the bone is cracked but the ends of    the bone are together, or "displaced," where the end of the broken bones have partially    or completely separated.
Fractures can also be divided into "closed fractures" where the skin is not broken    and "open fractures" where the skin is broken and the wound extends down to the bone.
Open fractures are particularly serious because, once the skin is broken, bacteria    can enter the wound and cause infection in the bone. Immediate treatment is required    to prevent infection.
The most common symptoms of a fracture are pain and swelling. Other symptoms may include:
Bruising or discoloration that extends to nearby parts of the foot
Pain with walking and weight bearing
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First Aid
If you think you have a fracture, it is important to see your doctor as soon as possible.    A fracture that is not treated can lead to chronic foot pain and arthritis and affect    your ability to walk.
While you are waiting to see your doctor, you should do the following:
Apply ice to help reduce swelling.
Elevate your foot as much as possible.
Limit weight bearing.
Doctor Examination
Physical Examination
When you see your doctor, he or she will take a history to find out how your foot       was injured and ask about your symptoms. Your doctor will then examine your foot and       may compare it to the foot on the opposite side.
Your foot may become swollen and discolored after a fracture.
During the exam, he or she will look for:
Swelling
Tenderness over the fracture site
Bruising or discoloration—your foot may be red or ecchymotic ("black and blue")
Deformity
Skin abrasions or open wounds
Loss of sensation—an indication of nerve injury
Imaging Studies
Your doctor will also order imaging studies to help diagnose the fracture.
X-rays. X-rays provide images of dense structures, such as bone. An x-ray can usually be       done in your doctor's office.
Most fractures can be seen on a routine plain x-ray. A stress fracture, however, may       start as a tiny crack in the bone and may not be visible on a first x-ray.
In many cases, a stress fracture cannot be seen until several weeks later when it       has actually started to heal and a type of healing bone called "callus" appears around       the fracture site.
(Left) In this x-ray, a recent stress fracture in the third metatarsal is barely visible          (arrow). (Right) Several weeks later, there is callus formation at the site and the fracture can          be seen more clearly.
Magnetic Resonance Imaging (MRI) scans. If your doctor suspects a stress fracture but cannot see it on a plain x-ray, he       or she may recommend an MRI scan.  This type of study uses a magnetic field and radio       waves to create a computerized image of your foot.
More sensitive than an x-ray, an MRI can detect changes in the bone that may indicate       a fracture. Unlike an x-ray, there is no radiation with an MRI. The study takes 40       minutes to do, however, and has to be scheduled separately from your doctor's visit.
Treatment for a toe or forefoot fracture depends upon:
The location of the injury
The type of fracture
Fractures of the Toes
Even though toes are very small, injuries to the toes can often be quite painful.
A fracture of the toe may result from a direct injury, such as dropping a heavy object       on the front of your foot, or from accidentally kicking or running into a hard object.       A fracture may also result if you accidentally hit the side of your foot on a piece       of furniture on the ground—and your toes are twisted or pulled sideways or in an awkward       direction.
The proximal phalanx is the toe bone that is closest to the metatarsals. Because it       is the longest of the toe bones, it is the most likely to fracture.
A fractured toe may become swollen, tender and discolored. If the bone is out of place,       your toe will appear deformed.
Treatment
Most broken toes can be treated symptomatically. For several days it may be painful          to bear weight on your injured toe. As your pain subsides, however, you can begin          to bear weight as you are comfortable. During this time, it may be helpful to wear          a wider than normal shoe.
"Buddy taping" your broken toe to an adjacent toe can also sometimes help relieve          pain.
If the bone is out of place and your toe appears deformed, it may be necessary for          your doctor to manipulate or "reduce" the fracture. This procedure is most often done          in the doctor's office. You will be given a local anesthetic to numb your foot, then          your doctor will manipulate the fracture back into place and straighten your toe.
(Left) In this x-ray, a fracture in the proximal phalanx of the fifth toe (arrow) has caused             the toe to become deformed. (Right) The bones in the angled toe have been manipulated (reduced) back into place.
Metatarsal Fractures
The metatarsals are the long bones between your toes and the middle of your foot.       Each metatarsal has the following four parts:
Head—which makes a joint with the base of the toe
Neck—the narrow area between the head and the shaft
Shaft—the long part of the bone
Base—which makes a joint with the midfoot
Fractures can occur in any part of the metatarsal, but most often occur in the neck       or shaft of the bone.
(Left) The four parts of each metatarsal. (Right) X-ray shows a fracture in the shaft of the 2nd metatarsal.
Like toe fractures, metatarsal fractures can result from either a direct blow to the       forefoot or from a twisting injury.
Some metatarsal fractures are stress fractures. Stress fractures are small cracks       in the surface of the bone that may extend and become larger over time.
High-impact activities like running can lead to stress fractures in the metatarsals.
Stress fractures are typically caused by repetitive activity or pressure on the forefoot.       They are common in runners and athletes who participate in high-impact sports such       as soccer and basketball.
A stress fracture can also come from a sudden increase in physical activity or a change       in your exercise routine.
Treatment
Most metatarsal fractures can be treated with an initial period of elevation and limited          weight bearing. This is followed by gradual weight bearing, as tolerated, in a cast          or walking boot. Surgery is not often required.
However, if you have fractured several metatarsals at the same time and your foot          is deformed or unstable, surgery is necessary.
During the procedure, your doctor will make an incision in your foot, then insert          pins or plates and screws to hold the bones in place while they heal. This is called          "internal fixation."
Surgery may be delayed for several days to allow the swelling in your foot to go down.          If you have an open fracture, however, your doctor will perform surgery immediately.
Fifth Metatarsal Fractures
X-ray shows an avulsion fracture at the base of the fifth metatarsal (arrow).
The fifth metatarsal is the long bone on the outside of your foot. Injuries to this       bone may be different than fractures of the first four metatarsals.
Most commonly, the fifth metatarsal fractures through the base of the bone. This usually       occurs from an injury where the foot and ankle are twisted downward and inward.
In this type of injury, the tendon that attaches to the base of the fifth metatarsal       may stretch and pull a fragment of bone away from the base. Since the fragment is       pulled away from the rest of the bone, this type of injury is called an "avulsion       fracture."
An avulsion fracture is also sometimes called a "ballerina fracture" or "dancer's       fracture" because of the "pointe" position that ballet dancers assume when they are       up on their toes.
Another type of fifth metatarsal fracture is a horizontal or transverse fracture through       the junction of the base and shaft of the bone. This is sometimes called a "Jones       fracture." Since the blood supply to this area is poor, Jones fractures are more prone       to difficulties in healing.
Treatment
Most fifth metatarsal fractures can be treated with weight bearing as comfortable          in a walking boot. If an avulsion fracture results in a large displaced fracture fragment,          however, open reduction and internal fixation with plates and screws may be necessary.
Because of its location on the bone, a Jones fracture may take longer to heal. In          some cases, a Jones fracture may not heal at all, a condition called "nonunion."           When this happens, surgery is often required to treat the fracture.
(Left) X-ray shows a Jones fracture at the base of the fifth metatarsal (arrow). (Right) A screw has been used to hold the bone in place while it heals.