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Tuesday, December 26, 2017

Fifth Metatarsal Fracture: Email Advice

Hello Dr. Blake,

   Thank you in advance for answering me and I will be happy to donate to
your blog.

 At the beginning of May of this year (2017) I rolled my foot and broke my
5th metatarsal.
It is a slightly displaced avulsion fracture at the base.
I kept it in a soft cast non weight bearing for 4 weeks. After 4 weeks, I
felt I could walk on it while in the cast with out too much pain. After a
week I took it out of the cast and walked carefully. I wonder if this was
too soon, but I thought it was okay because I really had minimal pain.
Dr Blake's comment: This is considered appropriate as you want to stimulate mineralization and the fracture should be knitting well by then. And, you are creating and maintaining the 0-2 pain level. 

When I had a follow up xray 6 weeks after the initial xray, I was actually
surprised that there was no sign of healing and that it was still broken.
Somehow, maybe because of inflammation, I wasn't feeling the break at that
time. Over the course of the summer, I felt weakness in my ligaments and
like I had a 'dumb foot'. I have been trying to strengthen with a tensor
band and balancing. September 27th xray showed no healing in the bone.
Dr Blake's comment: Xrays reflect the amount of calcium in an individual area. Since the fracture area has high metabolism, typically there is alot of water in the area, giving the impression of poor healing. The Golden Rule is that xrays reflect the healing 2 months late, so they are poor indicators of what is happening right now. 

Now, almost 8 months later, I feel the break (tender), and the whole foot
feels sore and achy after walking on it for a half hour to an hour. It
feels great with no pain when I wake up in morning. I just had a CT scan
yesterday to see if there is any sign of healing. Will see surgeon about
results on January 8th. My questions....
Dr Blake's comment: The base of the 5th metatarsal typically bears all of our weight as we lift our heal off the ground. The fracture area can be healed, but sensitive, for 6 months after the injury. Things that help reduce the sensitivity are taping to stabilize the area, inserts with off weight bearing padding to float the broken area, icing and contrasts bathes to daily reduce inflammation, and pain free massage to move the sensitive tissue out of the area and de-sensitize the local skin nerves. I am always afraid, unless you are doing these things, an agressive surgeon will look at the CT scan and do surgery. But, of course, there is no guarantee you will need it, but these are options. Also, if we feel that he bone is slow, get a Exogen bone stimulator for twice daily home use. 
How long before I have to worry about Avascular Necrosis?
Dr Blake's comment: Were there signs of demineralization of the fragment? Since there is such good blood supply, I have never seen it in this area. 

Should I consider putting it back in the boot, or even using crutches
again? Will it make any difference at this point?
Dr Blake's comment: You have to create the 0-2 pain level environment. Some docs and PTs are good designing the padding, experimenting with taping, using PT treatments, perhaps stiff soled hiking boots, hike and bike shoes, etc. Can you send me a photo of the xray, honing down on the fracture? I personnally would not go back in a boot, unless off weight padding or inserts are not helpful. 
I received an Exogen in the mail today. I've heard it's never too late to
use it and can help 'non unions'.
Dr Blake's comment: Great!!!

Should I be concerned about ligaments that are not healing?
Dr Blake's comment: An MRI is needed to check. Definitely with a bad sprain in this area with ligament tears, orthotics and taping for one year in normal. Golden Rule it is normally better to break a bone than sprain a ligament. I know too little to really comment. 

I know surgery is an option if I am still not pain free in a few months
but I have doubts that it will heal from surgery. If such a simple break
doesn't heal naturally doesn't it seem likely that it would also have
difficulty healing from surgery?
Dr Blake's comment: If you do need surgery, it will be depend on what they do. Typically, they rebreak the bone, and put a screw across the fracture. They heal wonderfully unless you have some overall problem with healing: diabetes, smoking, obesity, vascular disease, etc. If you smoke, stop now. There are good studies showing the positive effect that has on surgery healing even if only 3 months have elapsed from stopping. If you have any question on bone health, get a Vit D3 level and bone density. 

 I have done everything I can think of to heal this...supplementation
(calcium, vit D, vitamin C, trace minerals, collagen), acupuncture,
osteopathy, physio.
Dr Blake's comment: Have not heard anything about taping (specifically for the fracture and surrounding ligaments, orthotics of some sort to off weight the bone at heel lift, icing and contrasts for anti-inflammatory, and of course, an MRI to look closer at the soft tissue. 

My main question is...can I be optimistic that I can still fully heal the
bone and ligaments 8 months after the accident?
Dr Blake's comment: I can only say from this far away that it is very rare that surgery is needed, although not impossible. Therefore, with those odds, try to work with my suggestions above, and see if they help. Good luck, and Merry Christmas. Rich

Thank you very much and Merry Christmas!

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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.