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Non-union in a neck of fifth metatarsal fracture: A case report

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Trauma Case Reports
journal homepage: www.elsevier.com/locate/tcr
Case Report
Non-union in a neck of fth metatarsal fracture: A case report
David T. Bui
, Aaron J. Pym, David Lunz, JeS. Ling
Prince of Wales Hospital, Sydney 2031, Australia
ARTICLE INFO
Keywords:
Fracture
Non-union
Metatarsal
Neck
Augment
Introduction
Unlike more common 5th metatarsal fractures such as those aecting the base (Zone 1 avulsion-types, Zone 2 Jones-types, or Zone
3 Stress-types) [1] or shaft (spiral dancer's fracture, or stress-types) [2], neck of fth metatarsal fractures are extremely rare [3]. In
a forty-nine subject series on the incidence of 5th metatarsal fractures, only 2% (1/49) aected the metatarsal neck [4]. Distal fth
metatarsal fractures are generally treated non-operatively with good outcomes [2,5]. However, a case of non-union in a neck of 5th
metatarsal fracture is yet to be reported in the literature.
As such, there is a lack of guidance relating to the treatment of this rare type of injury. We present the case of a 27 year old woman
who sustained a neck of 5th metatarsal fracture leading to non-union, which was treated successfully with debridement, autologous
bone graft and recombinant human platelet derived growth factor (rhPDGF) and beta-tricalcium phosphate (BTP) granules, combined
with internal xation.
Literature review
A search of SCOPUS, Medline, and PubMed search engines using the keywords fth OR 5thAND metatarsal*AND fracture*
AND neckAND non-union* OR non-union*was performed on 27th of July 2017. Searches were not limited by dates. Any article
reporting a case or case series of 5th metatarsal neck fracture non-union including either the presentation, management or com-
plications were included for review. Studies were excluded if they were published in a language other than English, or duplicate
publication. 15 results were identied by search, with 9 unique studies, however amongst these no case of non-union in a fth
metatarsal neck fracture was identied in the accompanying abstract or full-text publication.
Case report
The patient gave explicit and written consent to the publication of the present report.
A 27 year old project ocer presented to the oce of the senior author 8 weeks after sustaining a transverse fracture to the neck
https://doi.org/10.1016/j.tcr.2018.11.010
Accepted 22 November 2018
Corresponding author.
E-mail address: david.bui@unsw.edu.au (D.T. Bui).
Trauma Case Reports 18 (2018) 37–41
Available online 27 November 2018
2352-6440/ © 2018 Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/BY-NC-ND/4.0/).
of the 5th metatarsal of her left foot. This occurred after an inversion injury of the hindfoot whilst dancing. The patient was a t and
healthy non-smoker with no previous history of injury to this foot. Her past medical history was signicant for post-traumatic stress
disorder, which was well controlled on a selective serotonin reuptake inhibitor (SSRI), and mild asthma managed with a standard
reliever and preventer.
Management of the fracture at that point had been non-weight-bearing in a sti-soled postoperative shoe and crutches for 1 week,
followed by full-weight-bearing thereafter. At this rst visit (8 weeks post injury) the patient reported considerable foot pain and had
diculty mobilising. On examination there was signicant tenderness to palpation directly over the fracture site. Radiographs
performed 2 weeks prior to this presentation demonstrated a clear fracture line with minimal evidence of healing (Fig. 1). She was
transferred into a fracture boot to better stabilise the fracture, however, on follow up 5 weeks after this appointment, now 13 weeks
post injury, she described persistent pain with clear evidence of non-union on plain radiographs and CT scan (Figs. 2, 3, 4). With clear
evidence of a symptomatic, established non-union, the patient was consented for surgery.
The patient was positioned in the lateral position and a direct lateral approach was made to the foot centred over the 5th
metatarsophalangeal joint. The non-union was identied and debrided back to bleeding cancellous surfaces. A 1 cm incision was
made over the lateral border of the calcaneum taking care to avoid the sural nerve and cancellous bone was harvested as autologous
bone graft. The autologous bone graft was then mixed with Augment © Wright Medical Group N.V. , which consists of platelet
derived growth factor (PDGF) and beta-tricalcium phosphate granules. A generous amount of this mixture was then packed into the
fracture site, followed by internal xation along the lateral border of the bone with a 1.5 mm Medartis hand module T plate with 3
screws in each fragment in compression mode (Fig. 5). The wound was then closed in layers and she was discharged in a fracture boot
non-weight-bearing for 6 weeks. At 6 weeks post-operatively, there were clinical and radiological signs of healing, and she was
transitioned to partial weight-bearing in the boot, starting with 25% of her weight in week 7, increasing her weight-bearing by 25%
per week till she was fully weight-bearing by 10 weeks. At 4 months post-operatively, there was radiographic evidence of complete
union on radiographs (Fig. 6), and there was no tenderness over the fracture site, however, she reported more global symptoms
consistent with Chronic Regional Pain Syndrome (CRPS) and required a multi-modal treatment plan including input from a chronic
pain clinic. At 12-months post-operatively, her CRPS had improved and she had returned to full activity including exercise.
Discussion
Fractures of the base and shaft of the 5th metatarsal are common, however, isolated fractures of the neck of the 5th metatarsal are
extremely rare. [3]. Furthermore, a non-union of this rare fracture has not been reported in the literature.
Fig. 1. Radiograph 6 weeks post-injury.
D.T. Bui et al. Trauma Case Reports 18 (2018) 37–41
38
Non-union is dened as the cessation of the reparative processes of healing without bone union, diagnosed on the basis of both
radiographic and clinical ndings. In particular, there is an emphasis on a failure of progression of healing on serial radiographs
[6,7]. A number of risk factors have been implicated which can be divided into patient factors (age, gender, medical comorbidities
e.g. anaemia, diabetes), environmental factors (smoking, medications e.g. steroids) and injury factors (high or low energy trauma,
vascular supply of fracture, presence of infection) [8,9]. In this case report, the patient was of good health with no patient,
Fig. 2. Radiograph non-union 13 weeks post-injury.
Fig. 3. CT Axial non-union 13 weeks post-injury.
Fig. 4. CT sagittal non-union 13 weeks post-injury.
D.T. Bui et al. Trauma Case Reports 18 (2018) 37–41
39
environmental or injury risk factors for non-union. However, treatment factors such as a failure to adequately immobilise a fracture,
can also lead to non-union. In this particular case, the patient had been weightbearing from 1 week after the time of injury, an
approach that has been advocated in the literature for distal shaft and neck fractures [1]. This early weightbearing protocol is
appropriate for most base and shaft fractures of the 5th metatarsal, but may not provide adequate immobilisation for fractures of the
neck of the 5th metatarsal, which is an area subject to dierent stresses. It is possible that an initial period of immobilistaion and
nonweightbearing in either a cast or fracture boot may have resulted in fracture union, obviating the need for surgery.
Treatment options for established non-union can be either non-operative or operative. The evidence supporting many non-op-
erative modalities is relatively weak in non-long bones and foot and ankle surgery, such as in electrical stimulation [10], ultrasound
[11] and extracorporal shockwave therapy [12].
Operative management of non-union can involve the use of biological enhancements and mechanical processes. The gold
standardin biological techniques is autologous bone graft, however there are many other options including allograft implantation,
Fig. 5. Preliminary intraoperative xation.
Fig. 6. Radiograph 4 months post-operative demonstrating complete healing.
D.T. Bui et al. Trauma Case Reports 18 (2018) 37–41
40
bone graft substitutes, use of growth factors including bone morphogenic proteins (BMP) and platelet derived growth factor (PDGF),
osteoconductive scaolds and osteoprogenitor stemcells. These can be combined with mechanical methods such as debridement,
distraction and xation strategies [13].
In the case we have presented, we have used Augment mixed with calcaneal autograft, combined with rigid internal xation and a
period of non-weight-bearing in the post-operative period, to address the issues of biology and mechanical stability or lack thereof.
Augment (© Wright Medical Group N.V. ), is a completely synthetic, liquid injectable bone graft substitute composed of re-
combinant human platelet-derived growth factor BB (rhPDGF-BB) and beta-tricalcium phosphate (BTP) granules. RhPDGF-BB, also
known as becaplermin, is a potent recruiter of, and strong mitogenic factor for, cells crucial to musculoskeletal tissue repair, including
mesenchymal stem cells (MSCs), osteogenic cells and tenocytes [14]. It has been proven to be safe for human use and approved in
Australia and New Zealand, the United States, Canada and a number of other countries worldwide [15,16]. Additionally, rhPDGF-BB
has recently been found to represent a safe and ecacious treatment alternative to autologous bone graft in various foot and ankle
procedures including various ankle and hindfoot arthrodesis procedures [16].
In this case, we combined autologous bone graft from the calcaneum with Augment. The manufacturer of Augment neither
encourages nor discourages the addition of autograft bone to the preparation, however, this is routinely done at our institution as we
believe the patient's own bone is still the best scaold to promote bone healing, and the combination with Augment might oer the
optimal circumstances for osteogenesis, osteoinduction and osteoconduction. Given the success of healing in this case, the authors
propose the use of Augment as a potential adjunctive treatment for non-union of the 5th metatarsal neck, and this may be applicable
to non-unions elsewhere.
Ultimately, this case illustrates that early weightbearing, may lead to non-union in neck of 5th metatarsal fractures, in contrast to
most base and shaft fractures of the 5th metatarsal, where early weightbearing is entirely appropriate. As such, an initial period of
non-weightbearing in a cast or fracture boot may be best initial management for this rare fracture. If faced with the problem of non-
union in this fracture, we have shown that a combination of debridement, biologic enhancement with autologous bone graft mixed
with a commercial preparation of PDGF, and rigid stabilisation, can achieve successful union.
References
[1] E.W. Zwitser, R.S. Breederveld, Fractures of the fth metatarsal; diagnosis and treatment, Injury 41 (6) (2010) 555562.
[2] M.J. O'Malley, W.G. Hamilton, J. Munyak, Fractures of the distal shaft of the fth metatarsal. Dancer's fracture, Am. J. Sports Med. 24 (2) (1996) 240243.
[3] K.B. Landorf, Fifth metatarsal fractures are not all the same: proximal diaphyseal fractures are prone to delayed healing, Foot 8 (1) (1998) 3845.
[4] G. Arangio, The Jones fracture - transverse proximal diaphyseal fractures of the fth metatarsal: frequency by radiology, Foot 1 (4) (1992) 201204.
[5] Foot Pain in a Gymnast, Visual Diagnosis in Emergency and Critical Care Medicine, Second edition, (2011), p. 91.
[6] D.J. Hak, et al., Delayed union and nonunions: epidemiology, clinical issues, and nancial aspects, Injury 45 (Suppl. 2) (2014) S3S7.
[7] P. Megas, Classication of non-union, Injury 36 (Suppl. 4) (2005) S30S37.
[8] M. Panteli, et al., Biological and molecular prole of fracture non-union tissue: current insights, J. Cell. Mol. Med. 19 (4) (2015) 685713.
[9] C. Copuroglu, G.M. Calori, P.V. Giannoudis, Fracture non-union: who is at risk? Injury 44 (11) (2013) 13791382.
[10] B. Mollon, et al., Electrical stimulation for long-bone fracture-healing: a meta-analysis of randomized controlled trials, J. Bone Joint Surg. Am. 90 (11) (2008)
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[11] J.W. Busse, et al., Low intensity pulsed ultrasonography for fractures: systematic review of randomised controlled trials, BMJ 338 (2009) b351.
[12] B. Petrisor, S. Lisson, S. Sprague, Extracorporeal shockwave therapy: a systematic review of its use in fracture management, Indian J. Orthop. 43 (2009).
[13] R. Dimitriou, et al., Bone regeneration current concepts and future directions, BMC Med. 9 (66) (2011).
[14] G.E. Friedlaender, et al., The role of recombinant human platelet-derived growth factor-BB (rhPDGF-BB) in orthopaedic bone repair and regeneration, Curr.
Pharm. Des. 19 (19) (2013) 33843390.
[15] L.A. Solchaga, et al., Safety of recombinant human platelet-derived growth factor-BB in augment((R)) bone graft, J. Tissue Eng. 3 (1) (2012)
2041731412442668.
[16] C.W. DiGiovanni, et al., Recombinant human platelet-derived growth factor-BB and beta-tricalcium phosphate (rhPDGF-BB/β-TCP): an alternative to autogenous
bone graft, J. Bone Joint Surg. 95 (13) (2013) 11841192.
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