fractured 4th metatarsal

by Caroline
(Liverpool)

I fell of a step nearly 3 weeks ago landed awkward foot went behind my back and my whole body weight landed on it. Broke my 4th metatarsal in left foot still can't bear any weight on it and still got severe pain. Got cast boot on but it's hurting me and very heavy. Still swollen as well. Would a fibreglass cast be a better option as I'm also weak on my other foot due to badly torn ligaments a few times and I am more prone to brittle bone since I had my ovaries removed I'm on hrt. I am 41 year old lady.

RESPONSE

Hi Caroline,

We may be splitting hairs here but I assume when you say cast boot, you are talking about a boot worn when there is a cast applied to the foot and leg, except, in your case you are not wearing a cast.

If this is the case, I personally find that to be one of the worst ways for a person to ambulate with a broken foot. It was not really designed to be worn by itself. In many instances when I see patients for follow up after they have been to an emergency room or to a walk in clinic in my area, they come in wearing a cast boot and in most cases they are not happy with the cast boot.

If for no other reason the boot is usually too large for the foot and it moves all over the place and is just plain uncomfortable to ambulate with.

If your fracture is not too severe, then a better substitute for a cast boot would be a surgical shoe which is a rigid soled shoe that we put patients in after surgery. It will fit more snugly to the foot, reduce motion in the foot and better stabilize a broken metatarsal.

The problem to be aware of with both a cast boot and surgical shoe is that most patients, after a while, start to complain of pain elsewhere, usually the lower back. The reason for this is because the shoe and boot have no shock absorption capabilities and obviously alter your gait cycle.

Another suggestion if you are wearing a cast boot or surgical shoe is to try and wear a shoe on the other foot that is of the same heel height as the boot or surgical shoe. A sneaker is usually your best bet. This keeps your limbs "even" and reduces the discomfort.

Ok, so now I have told you that I do not like the cast boot and that may be the source of your pain by itself, or your pain may be more than that, specifically, the degree of fracture of the fourth metatarsal. When treating fractures the decision on how to treat it is based on the severity of the break. A simple metatarsal fracture where there is just one "crack" in the bone (as opposed to multiple fracture sites) can usually be treated with a surgical shoe. The key here is the gap or distance between the two ends of the broken bone.

If your doctor assumes the gap is small enough that immobilization with a boot or shoe is enough for the gap to "bridge" then that is all that needs to be done. If, however, the gap it too large, then walking on the bone with a cast boot or surgical shoe is not the answer and you run the risk of the fracture not closing.

Lets complicate matters even more. Since you have hormonal changes associated with your hysterectomy and it is acknowledged that you have osteoporosis (brittle bones) then extra precaution needs to be taken. Osteoporosis is demineralization of bone which makes it harder for broken bones to heal.

Hopefully, you are not a smoker as that too will work against bone healing.

Lastly, the area of the fourth metatarsal bone that is actually broken can also play a role in predicting the ability of the bone to heal with just immobilization. Discuss that aspect with your doctor.

So, we are now three weeks post trauma and you are still having a lot of pain walking. In "normal" situations, patients notice a reduction in pain as the weeks pass. I am not saying that you should be totally pain free at this point, but it would be expected that you would be experiencing less pain now than three weeks ago.

My dilemma is whether or not your pain at this point in time is the result of a poor choice in the cast boot or is there an issue with the type of fracture you sustained, or the inability of your body to heal the fracture. I have no idea which it is because I am on the other side of the internet.

Hopefully, the doctor treating your fracture is an orthopedist or foot specialist and perhaps not a general doctor.

Because you are still experiencing pain I think your problem needs to be readdressed.

Normally, one way to treat a simple fracture of a metatarsal is to put the patient on crutches and not allow them to bear weight on the fractured foot. This is probably not an option for you as you state you have weakness on your other foot.

My thought then would be to put you in a fiberglass cast with a walker added to the bottom of the cast where your body weight would hit the middle of the arch and there would be no direct weight on the broken metatarsal bone itself. This would be predicated on one condition; a new x-ray was taken to make sure that there has not been any worsening of the fracture and the assumption that this is a simple fracture with minimal gapping.

Marc Mitnick DPM
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