March fracture

March fracture

Introduction

Fatigue/stress fracture of the distal ⅓rd  of one of the metatarsals occurring because of recurrent stress.

  • M/C 2nd > 3rd metatarsal
  • Common in college athletes and the military (25% of all stress fractures)

History

First described in 1855, termed after the foot pain and swelling experienced by Prussian soldiers on long marches.


Aetiology

  • Soldiers during sustained periods of marching.
  • Runners (M/C in metatarsal neck)
  • Dancers (M/C in proximal shaft)
  • Ballet dancers (M/C at base of 2nd metatarsal and at Lisfranc joints)
  • Associated conditions:
    • Osteoporosis
    • Osteomalacia
    • Cavus feet

Clinical features

  • Gradual onset
  • Cramp-like pain in affected forefoot when boot/shoes are taken off
  • Moderate local oedema (dorsal aspect)
  • Pain on moving each toe in turn, that of the involved metatarsal
    • Palpation from dorsal surface, a point of tenderness is found directly over the lesion.

Diagnosis

Imaging

march-fracture-fatigue-fracture-a-b-frontal-radiographs-of-the-right-foot-in-a
March fracture (fatigue fracture). (a, b) Frontal radiographs of the right foot in a college gymnast show the early (a) and late (b) radiographic findings of a second metatarsal fatigue fracture (arrow). The fracture completely healed with rest. (c, d) Coronal T2- weighted fat-saturated (c) and sagittal T1-weighted (d) MR images obtained at the same time as a show marked mass effect (arrows) around the second metatarsal. This finding could have been misinterpreted as a neoplasm or infectious process without the radiographs and proper patient history. | Musculoskeletal Colloquialisms: How Did We Come Up with These Names?1 – Scientific Figure on ResearchGate. Available from: https://www.researchgate.net/figure/March-fracture-fatigue-fracture-a-b-Frontal-radiographs-of-the-right-foot-in-a_fig18_8452212 [accessed 12 Jun, 2019]

Differential diagnosis

  • Acute metatarsal fracture
  • Hallux rigidus “stiff big toe”
    • Degenerative arthritis and stiffness due to bone spurs that affects the MTP joint at the base of the hallux (big toe)
  • Jones fracture
    • Fracture of the proximal diaphysis of the 5th metatarsal, distal to the tuberosity, without joint involvement.
  • Sesamoid stress fracture
  • Acute sesamoid fracture
  • Proximal fifth metatarsal avulsion fracture

Management

  • First-line treatment: Immobilization (6-12 weeks) with cast
  • Stress fracture with a cavus foot: Plantar fascia release
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