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Managing
Difficult to Heal Fractures
By Jay
Lieberman, DPM Case One Patient 9 years s/p ORIF 4th metatarsal base fracture re-fractures 4th metatarsal This 36 year old female presented to our office nine years status post open reduction and plating of a fracture along the base of the fourth metatarsal right foot. Another physician had performed the initial repair. The injury occurred when the patient took a mis-step while walking on a broken sidewalk. The fracture failed to heal with casting, and she subsequently underwent pinning of the metatarsal. The fracture failed to heal again, and she underwent plating. The patient continued to have lingering pain in the foot, but was able to return to activities of daily living. She presumed that the residual symptomatology was related to the plate and came to our office to discuss removal. Initial x-rays demonstrated a hypertrophic non-union at the mid shaft of the fourth metatarsal.
Interestingly, the fracture appeared at the distal most aspect of the plate. We obtained the old postoperative x-rays to determine whether the current bone defect corresponded to the original fracture site or not. The x-rays suggested that the original fracture was a slightly more proximal than the current presentation. The patient was brought to the operating room and the following procedures were performed:
At six weeks postop, the patient was already demonstrating proximal incorporation of the graft.
The MiniFixator was maintained in place for ten weeks. Once removed, the patient was casted and an EBI Bone Healing System� was used to augment the healing process.
At fourteen weeks, she was allowed to weight bear with a surgical shoe. The patient went on to satisfactory healing of the fracture. Case Two Non-Union Jones Fracture Delayed unions are often seen in Jones fractures. This transverse fracture is commonly located 1.5 to 3.0 cm distal to the fifth metatarsal tuberosity. This site has poor vascularity and considerable biomechanical stresses, which increase the likelihood for delayed union. The x-rays below, are of a 35-year-old male who sustained a Grade II inversion injury to the right ankle one year prior to presentation. Initially, he did not seek treatment for the problem. Lingering pain about the base of the fifth metatarsal brought him in to an orthopedic office. A Jones fracture was discovered. The patient was immobilized for six weeks. He then resumed normal activity. For the next nine months, he was asymptomatic. During this time, the patient engaged in various activities, including basketball. One week prior to presentation in our office, he described a mild "tweak" in the right foot. This resulted in severe pain and swelling. X-rays taken in our office demonstrated an incompletely healed Jones fracture. In all likelihood, the original injury never completely healed. The mild jerking (tweak) was enough to re-fracture the partially healed injury.
In light of the long delay, we proceeded with aggressive management of the problem. A takedown was performed. Osteo inductive de-mineralized bone matrix (Intergro� DBM) was placed around the fracture site, and a bone screw was inserted.
A bone stimulator was, again, used to augment healing...this time, the EBI OrthoPak� 2 Bone Growth Stimulator. The fracture went on to heal uneventfully.
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