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

Abstract

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...

Investigation of Risk Factors and Characteristics of Dance Injuries

“…4 Several authors 3,4,[13][14][15] have reported that classical ballet injuries have the highest occurrence of dance injuries. Knowledge on the causes of injury in dancers is important to the understanding of how such injuries occur and the adoption of preventive measures aimed at maintaining the health of the dancers.…”

Proximal base stress fracture of the second metatarsal in a Highland dancer

“…Radiographs may be normal for the first 2–3 weeks after stress fracture development 1. MRI had been suggested necessary to differentiate a stress fracture from synovitis of the Lisfranc joint6; however, they both require the same conservative management. Currently, MRI is not considered essential in the diagnosis of a metatarsal stress fracture.…”

“…Currently, MRI is not considered essential in the diagnosis of a metatarsal stress fracture. CT may also play a part when identifying the exact location of the stress fracture1 and for assessment of healing and diagnosing non-union 6…”

Stress Fractures about the Foot and Ankle in Athletes

“…They are common injuries in runners, military recruits, ballet dancers, and basketball players, and most patients will report a recent increase in training. [1][2][3][4][5][6][7][8]10,13,20,22,[41][42][43][44][45][46][47][48][49][50][51][52][53][54][55][56][57][58] Forefoot pain with weight bearing, inability to toe walk, point tenderness, and swelling are present on exam. [1][2][3][4][5][6][7][8]10,13,20,22,[41][42][43][44][45][46][47][48]…”

“…41,43 The insidious onset of vague midfoot pain is often overlooked or misdiagnosed. 41,43,49,[51][52][53]56 The second and third metatarsals are most affected.…”