Metatarsal Fractures

Nondisplaced fractures of the midshaft and distal portions of the metatarsals are treated with immobilization. Short-leg casting and immobilizer boots can lead to adequate healing in 6 to 8 weeks in most cases. Postoperative shoe use without formal immobilization can also lead to adequate healing of metatarsal fractures, although the risk of adverse outcome is higher. Displaced, angulated, and rotated fractures may require operative fixation.

Fractures of the proximal portion of the metatarsal (first through fourth metatarsals) should be approached with great care. Nondisplaced fractures may be associated with injury to the intermetatarsal ligaments, leading to widening of these joints; surgical consultation is recommended in these cases. If there is no apparent injury to the tarsometatarsal (Lisfranc) joint, cast immobilization typically leads to adequate fracture healing.

Fractures of the base of the fifth metatarsal deserve special discussion. A watershed area of blood flow in the proximal portion of the fifth metatarsal puts it at particular risk for malunion and nonunion. Avulsion fractures off the most proximal portion of the bone have an opportunity to heal with conservative management. Fractures that occur in the watershed area, so-called Jones fractures, have a high chance for malunion and nonunion that should be discussed with the patient. Jones fractures occur in the proximal one third of the metatarsal and do not involve the tarsometatarsal joint. Screw fixation of Jones fractures often leads to more acceptable outcomes.

http://emedicine.medscape.com/article/1260953-overview http://orthoinfo.aaos.org/topic.cfm?topic=A00072 Clavicle fracture http://orthoinfo.aaos.org/topic.cfm?topic=a00033 www.eorthopod.com/node/10838 AC sprain.

EVIDENCE-BASED SUMMARY

• Early mobilization with an external support device after ankle sprain leads to better short-term outcomes (reduction of pain and return to work/ sport activities) compared to early immobilization; long-term outcomes are similar (Eiff et al., 1994; Karlsson et al., 1996; Kerkhoffs et al., 2004) (SOR: A).

• Use of an external ankle brace after ankle sprain reduces the risk of recurrent sprain. Evidence also supports balance and proprioception training for reducing risk of recurrent sprain (Bahr et al., 1997; Surve et al., 1994) (SOR: B).

• An eccentric training program is effective in treating chronic Achilles tendinopathy (Alfredson et al., 1998) (SOR: B).

• Surgery for acute Achilles tendon ruptures reduces the risk of repeat rupture compared to nonsurgical treatment but produces a significantly higher risk of other complications, including wound infection (Khan et al., 2004) (SOR: A).

• Corticosteroid injection can reduce plantar fasciitis pain in the short term (Hunt and Sevier, 2004) (SOR: B).

• For acute Jones fractures in recreationally active patients, early intramedullary screw fixation results in lower failure rates and shorter times to both clinical union and return to sports than non-weight-bearing short-leg casting (Vu et al., 2006) (SOR: B).

References

Web Resources

www.eorthopod.com/node/10847 SC sprain. http://emedicine.medscape.com/article/92974-overview http://orthoinfo.aaos.org/topic.cfm?topic=A00032 Shoulder impingement. www.emedicinehealth.com/rotator_cuff_injury/article_em.htm http://orthoinfo.aaos.org/topic.cfm?topic=A00406

Rotator cuff tear. http://orthoinfo.aaos.org/topic.cfm?topic=A00529 Shoulder instability.

Elbow

http://emedicine.medscape.com/article/1231903-overview http://orthoinfo.aaos.org/topic.cfm?topic=A00068

Lateral tendinopathy http://emedicine.medscape.com/article/327860-overview www.mayoclinic.com/health/golfers-elbow/DS00713 Medial tendinopathy

Wrist and Hand

www.mayoclinic.com/health/carpal-tunnel-syndrome/DS00326

Carpal tunnel syndrome. www.mayoclinic.com/health/de-quervains-tenosynovitis/DS00692 www.handuniversity.com/topics.asp?Topic_ID=45

DeQuervain's tenosynovitis. www.mayoclinic.com/health/trigger-finger/DS00155

Trigger finger. http://orthoinfo.aaos.org/topic.cfm?topic=a00412

Distal radius fracture. http://orthoinfo.aaos.org/topic.cfm?topic=A00012 www.handuniversity.com/topics.asp?Topic_ID=30 Scaphoid fracture.

Knee

http://orthoinfo.aaos.org/topic.cfm?topic=A00212

Degenerative osteoarthritis. http://orthoinfo.aaos.org/topic.cfm?topic=A00197 Joint infection.

www.mayoclinic.com/health/patellar-tendinitis/DS00625

Patellar tendinitis. www.webmd.com/a-to-z-guides/patellofemoral-pain-syndrome-topic-overview

Patellofemoral pain. http://orthoinfo.aaos.org/topic.cfm?topic=a00358 Meniscus tear.

www.webmd.com/a-to-z-guides/anterior-cruciate-ligament-acl-injuries-topic-overview

http://orthoinfo.aaos.org/topic.cfm?topic=A00297 Ligament injury. Ankle and Foot

www.emedicinehealth.com/ankle_sprain/article_em.htm http://orthoinfo.aaos.org/topic.cfm?topic=a00150 Ankle sprain.

www.mayoclinic.com/health/achilles-tendinitis/DS00737

Achilles tendinitis. www.emedicinehealth.com/achilles_tendon_rupture/ article_em.htm

www.mayoclinic.com/health/achilles-tendon-rupture/DS00160 Achilles tendon rupture. www.mayoclinic.com/health/plantar-fasciitis/DS00508

Plantar fasciitis. http://emedicine.medscape.com/article/399372-overview

Metatarsal fracture. Splinting and Casting

http://intermed.med.uottawa.ca/procedures/cast/#02

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