Title: Functional Treatment of Acute Metatarsal Fractures: A Prospective Randomised Comparison of Management in a Cast Versus Elasticated Support Bandage
Authors: Zenios M, Kim WY, Sampath J, Muddu BN
Source: Injury 36(7): 832-835, 2005
PODIATRIC RELEVANCE:
Lesser metatarsal fractures comprise a large percentage of common foot fractures. The main goal of treatment is to return the patient to normal daily function. This article examines the association of early functional mobilization with improved clinical outcomes by comparing treatment with below-knee weightbearing casts to elasticated support bandages.
METHODS:
This was a prospective, randomized controlled trial of 50 patients. Patients were randomized into one of two groups using a sealed envelope method. Twenty-five patients (Group I) received a below-knee weightbearing cast made of lightweight synthetic material. Twenty-five patients (Group II) received an elasticated tubular bandage. Both groups received crutches for support and were advised to mobilize as tolerated from the time of injury. Patients in both groups were given oral analgesic medication and given instructions to maintain a diary, recording daily analgesic intake and mobilization records. All patients were evaluated after 1 week, 4 weeks, and 12 weeks. Outcome measures utilized at each visit included Visual Analogue Scale (VAS) pain scores, analgesic requirements as indicated in the patient log sheets, midfoot circumference of both the injured and non-injured foot, time taken to walk independent of crutches. AOFAS midfoot rating scale scores were also measured at the 12 week visit, and standard radiographs of the affected foot were taken at 12 weeks to assess for radiographic union.
Exclusion criteria included the following: Jones fracture, open fractures, stress fractures, fractures of the first metatarsal, polytrauma with major organ disruption and/or life-threatening injuries, multiple metatarsal fractures (more than 2 fractures), associated concurrent fractures or dislocations in the ipsilateral lower limb, patients older than 75 years, nonambulatory patients, pathological fractures, patients unable to provide informed consent due to mental incapacity and pediatric injuries.
RESULTS:
Significantly lower pain scores were recorded at 1 week in patients treated without a plaster cast (Group II). Group II also complained of less pain at 4 and 12 weeks, though the differences decreased with time and were not statistically significant. There was no significant difference between the two groups in midfoot circumference as compared to the contralateral foot or in the need for analgesics at 1, 4 and 12 weeks. Radiographs of all patients in Group I showed complete union at 12 weeks as compared to 87% percent of patients in Group II. There was no significant difference between the two groups in the time taken to walk independently of crutches from the time of injury. However, Group II scored significantly better on the AOFAS midfoot score at 12 weeks. One patient in Group I developed deep venous thrombosis 2 weeks after cast application and was eliminated from the study.
COMMENTS:
The goal in treating any foot fracture is early functional mobilization and a return to normal, pain free activity. At the same time it is important to achieve osseous union of the injury. This article attempts to demonstrate that the common practice of plaster casting for metatarsal fractures leads to increased pain and a prolonged course to mobilization. Though the group treated with elasticated bandage support revealed better pain scores, the group treated with plaster casting had a higher radiographic union, neither parameter showed statistical significance. There was also no difference between the two groups in the time to independent mobility. The results of this study reveal that treatment of metatarsal fractures with elasticated bandage support may be a cost effective alternative to plaster casting, while at the same time providing similar clinical outcomes. Finally, while the patient who developed a DVT was eliminated from the study, the case does highlight the greater chance for this complication in patients immobilized in a plaster cast. Further research should be conducted to determine efficacy of elasticated support in the treatment of metatarsal fractures.
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Disclaimer:
Scientific Abstract Monthly postings are submitted by podiatric surgical residents. The ideas presented are not the opinions of the American College of Foot and Ankle Surgeons (ACFAS), nor are they presented as facts. ACFAS presents this information without any warranty of any kind, expressed or implied, and is not liable for its accuracy nor for any loss or damage caused by the user's reliance on information obtained in these areas.