Overuse ballet injury of the base of the second metatarsal

Stress fractures are defined as spontaneous fractures of normal bone that are the result of repetitive stresses that are themselves harmless. 1 Although the metatarsal shaft is the most common location of a stress fracture in the general population, the base of the second metatarsal is by far the most common site in ballet dancers. Few series published in the orthopaedic literature report a quick recovery of this fracture after conservative treatment, and cases of nonunion have not been previously reported. 2,3,5 We report a nonunion at the base of the second metatarsal, secondary to a stress fracture, in a 24-year-old professional ballet dancer with successful outcome after surgical repair. CASE REPORTA 24-year-old male ballet dancer was evaluated in our institution. He reported pain on the dorsum of the foot at the base of the second metatarsal that was exacerbated by the demipointe position. The pain started 2 months earlier with no traumatic cause. Physical examination revealed tenderness at the second tarsometatarsal joint. Plain radiographs were within normal limits, showing cortical thickening of the second metatarsal shaft, which is often seen in ballet dancers ( Figure 1).A bone scan with technetium 99m showed increased uptake localized to the area of the second tarsometatarsal joint (Figure 2). The MRI demonstrated a stress fracture line at the proximal metaphysial-diaphysial junction and bone marrow edema (Figure 3). Treatment consisted of cessation of all balletic activities for 6 weeks and then progressive return to dance activities. After 6 months, the patient described only transient relief, and we confirmed continued tenderness and pain at the base of the second metatarsal. After clinical examination, the patient underwent standard plain radiographs, which were negative. Computed tomography showed a fracture line, with sclerotic and hypertrophic changes, as well as obliteration of the medullary canal ( Figure 4). This was interpreted as a nonunion. 8 Because of the chronicity of the symptoms, surgical intervention was carried out 10 months after clinical onset. A dorsal approach over the second metatarsal was performed, and it was possible to identify the fracture line with distraction maneuvers as well as mobility of the fragments. The sclerotic bone was removed with a curette, and an autogenous corticocancellous inlay bone graft was placed at the nonunion site. Both fragments were fixed with a 5-hole 3.5-narrow low-contact dynamic compression plate using 4 cortical screws. After surgery, a short-leg nonweightbearing cast was applied for a period of 4 weeks. Active range of motion exercises were started 1 month postoperatively, with weightbearing as tolerated 2 weeks later. After 3 months, the patient progressively returned to full-time dancing without symptoms. A year postoperatively, he had no recurrence of symptoms, and radiographs showed a complete healing of the nonunion ( Figure 5). We did not consider plate removal because it was well tolerated by the patient.This previously unreported str...

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“…2,4,5 Although different causes have been proposed to explain this infrequent fracture, they are probably only part of a multifactorial etiology.…”

Section: Discussionmentioning

confidence: 99%

Stress Fracture Nonunion at the Base of the Second Metatarsal in a Ballet Dancer

et al. 2004

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“…MRI can differentiate among bone stress reaction, synovitis, and stress fracture. T1-weighted images demonstrate decreased medullary signal with bone stress reaction 12 and fracture delineation for stress fractures. MRI short tau inversion recovery (STIR) sequencing can demonstrate marrow edema, cortical disruption, and soft-tissue changes with stress fractures.…”

Section: Clinical Diagnosismentioning

confidence: 98%

“…There are few published studies on the results of treatment of stress fractures involving the second and third metatarsal shafts, but the results of treatment of stress fractures of the second metatarsal base in dancers have been described. Harrington et al, 12 in 1993, (Level IV) and O'Malley et al, 25 in 1996, (Level IV) used either immobilization in a short-leg cast or a wooden-soled shoe with rest from dance activity for 6 to 8 weeks. Harrington et al 12 reported pain-free return to dancing in seven of eight patients in their series, with one complaining of occasional ache.…”

Section: Treatmentmentioning

confidence: 99%

Current Concepts Review: Stress Fractures of the Foot

Gehrmann¹,

Renard²

2006

Foot Ankle Int.

121

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“…Clinically, it is very difficult to differentiate these fractures from chronic injury or synovitis of the Lisfranc joint. MRI is the gold standard for diagnosis; oedema of the metatarsal head is noted in case of stress fractures and can be readily differentiated from synovitis of the Lisfranc joint 58 92 93…”

Section: Site-specific Stress Fracturesmentioning

confidence: 99%