Treating A Non-Union Of A Second Metatarsal Fracture

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Author(s): 
H. John Visser, DPM, Dan Thouvenot, DPM, and Jackson Crough, DPM

These authors detail the diagnosis and treatment of a non-union following a second metatarsal fracture in a 61-year-old patient who was unable to remain non-weightbearing.

Fracture non-unions are a challenging clinical problem. The treatment is often highly individualized and complex. Of the 6 million fractures that occur annually in the United States, 5 to 10 percent are reportedly complicated by non-union or delayed union.1

   Many different risk factors can lead to non-unions. Systemic, patient-derived and iatrogenic risks can all cause decreased healing within bones. Conditions such as smoking, diabetes mellitus, alcohol abuse and increased age are documented risk factors for non-unions.2 Local risk factors include poor blood supply at the fracture site, bone gap, infection, comminution and extensive soft tissue damage.2

   As part of the initial treatment, consider the possible causes for the non-union and then direct treatment toward reducing the risk factor. Conservative treatment options involve casting or bracing along with external bone stimulators and pharmacologic intervention. Surgical management can entail multiple different procedures but the main principles involve adequate resection, correct anatomic alignment and stable fixation.

   However, these cases can be lengthy and difficult. Serious complications including deep infection, hematoma, persistent drainage, neurovascular injury and pain persisting for more than six months are not uncommon.3 The following case discussion involves non-union within a fracture site but one can use similar treatments for failed union following arthrodesis and osteotomies as well.

What You Should Know About The Patient Presentation And Treatment

A 61-year-old Caucasian male presented with pain and swelling to his right foot for a duration of approximately six months. The patient had a history of Parkinson’s disease with dementia and neither he nor his family could recall an initial injury to the foot. He had initially seen another doctor, who placed him in a below-knee immobilizer but the family does admit he was non-adherent in using this modality./

   Upon presentation, the patient had dorsal swelling and pain. Radiographic examination of the foot revealed a comminuted fracture at the base of the second metatarsal. At this time, we placed the patient in a controlled ankle motion (CAM) boot and instructed him on the importance of being adherent. A computed tomography (CT) exam later revealed no signs of healing across the fracture site.

   At this point, we placed an external bone stimulator about the foot and the patient began to use it. He followed up every four to six weeks for serial radiographs to monitor the healing process. After seven months of attempted bone growth stimulation, callus formation had still not occurred across the fracture site.

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