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Q1: What type of fractures are these and what is their aetiology?
These are known as stress fractures. They appear as a result of increased load because of altered mechanics of the foot, occurring most often in athletes, but also in patients with diminished function of the first metatarsophalangeal joint, neuropathy, metabolic disorders, and hindfoot malalignment.1 Metatarsal fractures are particularly seen in military service in young adults and are also called “march fractures.” In that case the aetiology is thought to be repeated long term rhythmic loading.2
Stress fractures are also mentioned in connection with some diseases or special clinical deformations such as rheumatoid arthritis, chronic bronchitis, deformities, and so on. Thus they do not appear only in a healthy bone as was originally thought.
Q2: Where are the other sites in the foot that stress fractures can occur?
Fractures occur most commonly in the distal second and third metatarsal shafts and in the navicular and calcaneum, but can occur in almost any bone of the foot.3
Q3: What would be the best management at this stage?
The fracture is healing well, with callus formation. As the patient still has pain, all she needs is some protection from weight bearing until the pain resolves, after which normal walking is allowed. This patient responded to our conservative line of treatment.
While stress fractures are common in military practice, they are much less so in civilian life. Bilateral ones are very unusual. The diagnosis depends on a careful history and physical examination, with selected use of imaging techniques. Any suspicious history associated with swelling and point tenderness warrants further investigation with a bone scan or magnetic resonance imaging. These are, however, not always readily available; but a repeatx ray after two to three weeks usually reveals some callus formation, even if a fracture cannot be visualised. In terms of management, non-operative treatment is usually successful, but surgery is recommended in athletes with fifth metatarsal stress fractures.1
Bilateral stress fractures of the second metatarsal bones.