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Monday, January 2, 2017

Metatarsal Fracture with Displacement: Email Advice

Hi, Dr. Blake. 

I am a 60 year old with a fracture that does not seem to be healing even at the 7 weeks mark. A hard bench had hit my foot when I slipped from it in the gym, to cause the fracture. It's a mid shaft fracture with a bit of displacement like 3mm. Does that make sense? 
Dr Blake's comment: Thanks for the email. If you could take some photos of the images that would sure help, but 3 mm of displacement will take a while to heal, especially because it is at the mid-shaft where the bone heals slower than at the ends. 

Since I have experienced no pain with my foot in an air cast since day one, being quite active at home, and having an outing where I need to walk at least twice a week , my doctor asked me to wean off the air cast slowly starting on Dec 29.
Dr Blake's comment: I am answering this on Jan 2nd, but the advice would be the same for any weaning process. You give yourself between 2 and 6 weeks to go from boot to shoe. You start with one hour the first day out of the boot, then 2 hours the second day, etc. You can not have any more pain out of the cast than in the cast. You should be in the 0-2 pain environment and you can not deviate from this. I love to have the patients in a softer shoe, with lacing that can be adjusted, and arch supports to spread out the weight. The pace should initially be slower out of the boot. Try 10 minute ice pack 3 times a day to control the inflammation for the first 2 weeks. 

I have been trying to do that but I am concerned that I may not be doing so in the right way. I have read through your blogs but have this question. When I try to walk on this fractured right foot, I tend to be compensating by walking flat footedly. I am not putting my heel down first and pushing off from the front of the foot. In a way, I am limping.
Dr. Blake's comment: It is probably okay to flat foot this until you are out of the boot completely or, at  least, for 2 weeks. You definitely do not want to walk only on the outside of your foot, but try to gradually place all your weight down on the flat of the foot (heel should take alot of weight) like a slow march. The pushoff will come, but I think you have to be completely out of the boot for a week or so, and doing great, before I would risk an active pushoff. 

Also, my foot swells up as soon as I have walked 10-15 steps. Pain level has been 0,1 or 2.  Its just slight soreness, when I walk without the air cast.
Dr Blake's comment: The swelling is the body's protection, so pain will be your guide more on when to get off it! Understand that you have to have the boot with you at all times, in case you have to put it on. If you put it on for relief, than you have to wait 2 hours before trying to go without it. Standing is the worse for the swelling. If you are a sweller, see my video on contrast bathing and start at 1 minute warm water and 1 minute cold water for 10 cycles. That is a 50% heat to ice ratio and really gets the circulation going. If you are still swelling, you can try 1 hot, 3 cold cycles still for about 20 minutes. You need a big athletic shoe for this process because you want to wear inserts, or at least compression socks for the swelling. 

Please advise as to how I should place my foot down etc, how much swelling is okay, and whether I should ice my foot after the activity. I am taking vitamin D, calcium, and magnesium, and have just been given Prolia injection.

Dr Blake's comment: If you needed to take Prolia, then I assume you have some level of osteoporosis. This is going to take a while to heal a midshaft displaced fracture. Do not set time limits. The next period is to maintain the 0-2 pain levels and get out of the cast. Walk slow and flat footed so the heel can take some weight. See if you qualify for an Exogen bone stimulator to help the healing. Send me some images if you would. Definitely see about a Sole OTC arch support and a cushioned athletic shoe like the Brooks Ghost or the New Balance Fresh Foam 1080. I have had these go 6-9 months, so forget rules at may apply to someone else. Good luck. Rich

Thank you every so much. Waiting to hear from you ..

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Thank you very much for leaving a comment. Due to my time restraints, some comments may not be answered.I will answer questions that I feel will help the community as a whole.. I can only answer medical questions in a general form. No specific answers can be given. Please consult a podiatrist, therapist, orthopedist, or sports medicine physician in your area for specific questions.