March fracture
Encyclopedia
March fracture, also known as fatigue fracture or stress fracture of metatarsal bone, is the fracture
of the distal third of one of the metatarsals occurring because of recurrent stress. It is more common in soldier
s, but also occurs in hikers, organists, and even those, like hospital doctors, whose duties entail much standing. March fractures most commonly occur in the second and third metatarsal bones of the foot. It is a common cause of foot pain, especially when people suddenly increase their activities.
can occur at many sites in the body; "march fracture" simply refers to a stress fracture specifically of the metatarsals, thus named because the injury is sometimes sustained by soldiers during sustained periods of marching. Although march fractures can occur to the 5th metatarsal, fractures of this bone are more likely to be trauma-related fractures to the diaphysis
, termed Jones fracture
s. In runners, march fracture occurs most often in the metatarsal neck, while in dancers it occurs in the proximal shaft. In ballet dancers, fracture mostly occurs at the base of the second metatarsal and at Lisfranc joints. This fracture always occurs following a prolonged stress or weight bearing, and the history of direct trauma is very rare. Consideration should always be given to osteoporosis
and osteomalacia
. Cavus feet are a risk factor for march fracture.
appears on the dorsal aspect. On moving each toe in turn, that of the involved metatarsal causes pain, and when the bone is palpated from the dorsal
surface, a point of tenderness
is found directly over the lesion. Radiography
at this stage is negative, but the condition is diagnosed correctly by military surgeon
s without the aid of x-ray
s. In civil life, it is seldom diagnosed correctly for a week or two, when, because of lack of immobilization, there is an excessive deposit of callus
(which may be palpable) around the fracture.
is seldom helpful, but a CT scan and an MRI study may help in diagnosis.
Bone scans are positive early on. Dual energy X-ray absorptiometry
is also helpful to rule out comorbid osteoporosis.
release may be appropriate.
Fracture
A fracture is the separation of an object or material into two, or more, pieces under the action of stress.The word fracture is often applied to bones of living creatures , or to crystals or crystalline materials, such as gemstones or metal...
of the distal third of one of the metatarsals occurring because of recurrent stress. It is more common in soldier
Soldier
A soldier is a member of the land component of national armed forces; whereas a soldier hired for service in a foreign army would be termed a mercenary...
s, but also occurs in hikers, organists, and even those, like hospital doctors, whose duties entail much standing. March fractures most commonly occur in the second and third metatarsal bones of the foot. It is a common cause of foot pain, especially when people suddenly increase their activities.
Occurrence
Stress fractureStress fracture
A stress fracture is one type of incomplete fracture in bones. It is caused by "unusual or repeated stress" and also heavy continuous weight on the ankle or leg...
can occur at many sites in the body; "march fracture" simply refers to a stress fracture specifically of the metatarsals, thus named because the injury is sometimes sustained by soldiers during sustained periods of marching. Although march fractures can occur to the 5th metatarsal, fractures of this bone are more likely to be trauma-related fractures to the diaphysis
Diaphysis
The diaphysis is the main or mid section of a long bone. It is made up of cortical bone and usually contains bone marrow and adipose tissue ....
, termed Jones fracture
Jones fracture
A Jones fracture is a fracture of the diaphysis of the fifth metatarsal of the foot. The fifth metatarsal is at the base of the small toe. The proximal end, where the Jones fracture occurs, is in the midportion of the foot. Patients who sustain a Jones fracture have pain over this area, swelling,...
s. In runners, march fracture occurs most often in the metatarsal neck, while in dancers it occurs in the proximal shaft. In ballet dancers, fracture mostly occurs at the base of the second metatarsal and at Lisfranc joints. This fracture always occurs following a prolonged stress or weight bearing, and the history of direct trauma is very rare. Consideration should always be given to osteoporosis
Osteoporosis
Osteoporosis is a disease of bones that leads to an increased risk of fracture. In osteoporosis the bone mineral density is reduced, bone microarchitecture is deteriorating, and the amount and variety of proteins in bone is altered...
and osteomalacia
Osteomalacia
Osteomalacia is the softening of the bones caused by defective bone mineralization secondary to inadequate amounts of available phosphorus and calcium, or because of overactive resorption of calcium from the bone as a result of hyperparathyroidism...
. Cavus feet are a risk factor for march fracture.
Clinical features
The onset is undramatic. When the boot or shoes are taken off, there is a cramp-like pain in the affected forefoot, and moderate local edemaEdema
Edema or oedema ; both words from the Greek , oídēma "swelling"), formerly known as dropsy or hydropsy, is an abnormal accumulation of fluid beneath the skin or in one or more cavities of the body that produces swelling...
appears on the dorsal aspect. On moving each toe in turn, that of the involved metatarsal causes pain, and when the bone is palpated from the dorsal
Dorsum (biology)
In anatomy, the dorsum is the upper side of animals that typically run, fly, or swim in a horizontal position, and the back side of animals that walk upright. In vertebrates the dorsum contains the backbone. The term dorsal refers to anatomical structures that are either situated toward or grow...
surface, a point of tenderness
Tenderness
Tenderness can mean:* a tendency to express warm, compassionate, or affectionate feelings* delicate or intimate physical contact* tenderness – pain or discomfort when an affected area is touched-Other:...
is found directly over the lesion. Radiography
Radiography
Radiography is the use of X-rays to view a non-uniformly composed material such as the human body. By using the physical properties of the ray an image can be developed which displays areas of different density and composition....
at this stage is negative, but the condition is diagnosed correctly by military surgeon
Surgeon
In medicine, a surgeon is a specialist in surgery. Surgery is a broad category of invasive medical treatment that involves the cutting of a body, whether human or animal, for a specific reason such as the removal of diseased tissue or to repair a tear or breakage...
s without the aid of x-ray
X-ray
X-radiation is a form of electromagnetic radiation. X-rays have a wavelength in the range of 0.01 to 10 nanometers, corresponding to frequencies in the range 30 petahertz to 30 exahertz and energies in the range 120 eV to 120 keV. They are shorter in wavelength than UV rays and longer than gamma...
s. In civil life, it is seldom diagnosed correctly for a week or two, when, because of lack of immobilization, there is an excessive deposit of callus
Callus
A callus is an especially toughened area of skin which has become relatively thick and hard in response to repeated friction, pressure, or other irritation. Rubbing that is too frequent or forceful will cause blisters rather than allow calluses to form. Since repeated contact is required, calluses...
(which may be palpable) around the fracture.
Diagnostic studies
X-rayX-ray
X-radiation is a form of electromagnetic radiation. X-rays have a wavelength in the range of 0.01 to 10 nanometers, corresponding to frequencies in the range 30 petahertz to 30 exahertz and energies in the range 120 eV to 120 keV. They are shorter in wavelength than UV rays and longer than gamma...
is seldom helpful, but a CT scan and an MRI study may help in diagnosis.
Bone scans are positive early on. Dual energy X-ray absorptiometry
Dual energy X-ray absorptiometry
Dual-emission X-ray absorptiometry is a means of measuring bone mineral density . Two X-ray beams with differing energy levels are aimed at the patient's bones. When soft tissue absorption is subtracted out, the BMD can be determined from the absorption of each beam by bone...
is also helpful to rule out comorbid osteoporosis.
Differential diagnosis
- Acute metatarsal fracture
- Hallux rigidusHallux rigidusDegenerative arthritis and stiffness due to bone spurs that affects the MTP joint at the base of the hallux is called Hallux rigidus or stiff big toe.- Symptoms :...
- Jones fractureJones fractureA Jones fracture is a fracture of the diaphysis of the fifth metatarsal of the foot. The fifth metatarsal is at the base of the small toe. The proximal end, where the Jones fracture occurs, is in the midportion of the foot. Patients who sustain a Jones fracture have pain over this area, swelling,...
- Sesamoid stress fracture
- Acute sesamoid fracture
- Proximal fifth metatarsal avulsion fracture
Treatment
The first line treatment should be reduction of movements for 6 to 12 weeks. Wooden-soled shoes or a cast should be given for this purpose. In rare cases in which stress fracture occurs with a cavus foot, plantar fasciaPlantar fascia
The plantar fascia is the thick connective tissue which supports the arch on the bottom of the foot. It runs from the tuberosity of the calcaneus forward to the heads of the metatarsal bones .The often painful condition plantar fasciitis is an inflammatory condition of the plantar...
release may be appropriate.