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TREATMENT TO FIFTH METATARSAL FRACTURE IN FOOTBALL: CASE REPORT FEATURE / GOMEZ-BERNAL, ET AL Fracture of the fifth metatarsal bone is a common injury in professional soccer players. An 18-year-old player suffered a fracture of the fifth metatarsal bone of the left foot during a match. A biomechanical study was performed and three plantar orthoses with different prescriptions for everyday shoes, running shoes, and football boots were designed and fabricated by subjecting the virtual 3D profile of the orthoses to the baropodometric loads of the patient using the Finite Element Method (FEM) calculation. FEM is a mathematical model is the use of calculations, models and simulations to predict and understand how an object might behave under various physical conditions. Engineers use FEM to find characteristic and vulnerabilities in their design prototypes. The use of plantar orthoses showed positive results that reduced the perception of VAS pain from 9/10 to 1/10. At the same time, a reduction of plantar pressure at the location of the lesion was observed with the use of the orthosis, allowing a rapid return to play thanks to this novel treatment. The return to sport after suffering a stress injury to the fifth metatarsal can be difficult and time-consuming for a football player. Bone healing problems or fractures are some of the problems that can jeopardize a player’s career. The time of absence and the prognosis of the injury will be marked mainly by the location of the fracture and the treatment applied (1-4). Different classifications describe proximal fractures in the fifth metatarsal, according to the location. The classification proposed by Dameron is the most widely used (Figure 1) (5). Zone 1 includes fractures generated at the base by avulsion. The mechanism of injury is usually a forced inversion of the foot, which generates excess traction of the short lateral strut and plantar fascia. Zone 2 corresponds to fractures generated in the area immediately adjacent to the base, up to approximately one-third of the total length of the fifth metatarsal. Fractures in this area are known as jones. Zone 3 comprises the area immediately adjacent to the jones fracture distally. It is in this area that stress fractures are generated, coinciding with the least irritated metatarsal area.
38
Cuboid
4th metatarsal
93%
4%
3%
Zone II
5th metatarsal
Zone III
Zone I Figure 1. Fracture classification by location according to Dameron. The vascularisation of the fifth metatarsal plays a fundamental role in the localization of fractures and their consolation. The proximal third is nourished at the blood level thanks to the styloid process and its base which provides a great contribution due to the different insertions of the tendon and ligamentous structures that cover the area. However, the diaphysis is characterised by the absence of this type of insertion, so there is less blood supply. In particular, the diaphysis is irrigated by a nutrient artery, which provides blood supply to the area, along with a slight contribution from the periosteal blood vessels. There is no continuity with the anastomosis of the base irrigation and dialysis, generating an avascular zone responsible for the consolidation problems (6,7) (Figure 2). To understand the relevance of this type of fracture and the characteristics of the fifth metatarsal bone, Low et al (8) studied fractures of this bone in soccer and pointed out that consolidation problems occur in 1% after surgical treatment and 20% after conservative treatment.
Figure 2. Diagram of vascularisation of the fifth metatarsal.
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In our clinical case, we present an 18-yearold professional soccer player, with a weight of 72 kg and a height of 173 cm. He had never been treated with a plantar orthosis as prevention in his biomechanics of the footprint by his own choice. The patient suffered an injury to the lateral area of his left foot during a soccer game as a result of a foot strike during a play. Immediately after the incident, the patient left the field with the help of medical assistance. He was advised not to put any weight on that foot at any time. At the end of the game, the patient was taken directly to the hospital for a CT scan and a diagnosis of the injury. After the first physical examination, the player presented a visual analog pain scale (VAS) score of 9. Upon examining the etiology and area of pain, a bony injury to the fifth metatarsal bone was suspected. The hospital radiologist and the club’s chief of medical services issued a diagnosis of a crack of the fifth metatarsal in the proximal third, corresponding to the area where Jones fractures occur (Figure 3). With the diagnosis established and due to the technical team’s need to have the player integrated into the team for the competition, the decision was made to treat
Figure 3. CT in plantar view of the initial fissure (A) and after 4 weeks of evolution (B).