FRACTURE OF THE BASE OF THE FIFTH METATARSAL BONE BY INDIRECT VIOLENCE.
BY ROBERT JONES, F.R.C.S.,
OF LIVERPOOL,SURGEON TO THE ROYAL SOUTHERN HOSPITAL, LIVERPOOL.

SOME months ago, whilst dancing, I trod on the outer sideof my foot, my heel at the moment being off the ground. Something gave way midway down my foot, and I at once suspected arupture of the peroneus longus tendon. By the help of a friend
I managed to walk to my cab, a distance of over 300 or 400 yards.
The following morning I carefully examined my foot and discovered that my tendon was intact. There was a slight swellingover the base of the fifth metatarsal bone. I endeavored to obtaincrepitus and failed. A finger on the spot gave exquisite pain.
Body pressure on the toes, even the slightest, was painful; butwhen the pressure was deviated to the outer side the pain wasstill greater. Extension of the ankle and flexion of the toes wereimmediately felt at the base of the fifth metatarsal.
I hobbled down-stairs to my colleague, Dr. David Morgan,
and asked him to X-ray my foot. This was done, and the fifth
metatarsal was found fractured about three-fourths of an inch
from its base. (Fig. i.)

I could recall many cases which had come to me withsimilar symptoms arising from the transmission of bodyweight to a foot during the position of equino varus. In mostcases I had in robust fashion vainly searched for crepitus;
in all, the disability lasted several weeks.
I had scarcely recovered, when I saw a young man of thirty
years with Dr. Floyd, of Birkenhead. He had been away fishing,and stepping from stone to stone he placed the whole of his bodyweight upon an inverted foot. He felt, as he said, something
Vol. XXXV, No. 6, 1902.

697

698

ROBERT JONES.

crack in his afikle, and he limped towards his house. The symptoms were identical with my own, and the radiograph showed aprecisely similar picture. (Fig. 2.)
A week later, a man of fifty-four years was sent to me fromSouthport on account of an injury which befell him ten days
earlier. He had run to catch his train, twisted the outside of hisankle, and almost fell. He struggled on, however, caught histrain, and for some days transacted his business. He had considerable pain, and could scarcely walk by placing pressure on hisheel and inner foot alternately. There were swelling and ecchymosis over the metatarsal base, most of which had shown itself
some days after the accident. There was pain over the metatarsalbase; no crepitus. By this time I could indulge in a positive
diagnosis; and I confirmed its accuracy by an X-ray plate.
(Fig. 3.)
A fortnight later a powerful looking man of fifty years called
upon me. He told me that he had been walking up an inclined
plank which yielded, and his foot twisted inward. The injury
was painful, but he worked all day, and called on me the following morning. The symptoms closely resembled those I have previously described. I could feel no crepitus, but Dr. Morgan did
when manipulating the foot for radiography. The lesion wasagain found to be just beyond the metatarsal base. (Fig. 4.)
During the same period, Dr. Holland has twice radiographed
the same fracture. In one case a lady of fifty years slipped off a
step and fell, but no adequate history has been supplied. The
fracture, however, is in the same place. (Fig. 5.)
The other patient is one of Mr. Newbolt's, and occurred at
the age of sixteen. This patient was submitted to direct violenceof a very severe kind, sustaining many injuries to the foot. The
only point in common between this and the other cases is that thefifth metatarsal fracture is almost identical. (Fig. 6.)

Now, it is obvious that this fracture is very common,otherwise one would not be able to meet so many cases in soshort a time. There is, however, as far as I can find, no-reference to it in surgical literature.
For many years I have heard the symptoms of this accident related to me, and, although I often suspected a fracture,
it was quite impossible to demonstrate it. The symptoms arec)lCD

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FRACTURE OF THE METATARSAL BONE.

699

pain when the patient endeavors to put pressure on toes or
inner side of foot, when he fixes the toes, or attempts to invert.
The swelling is generally localized over the fractures, and painis sharp. There is generally no crepitus, no deformity, noyielding on manipulation. The history of the accident is important because it is sufficiently constant to form a factor inthe diagnosis. It is a cross-breaking strain directed anteriorly
to the metatarsal base and caused by body pressure on aninverted-foot while the heel is raised. The fracture is therefore an indirect one. I emphasize this because H. Morris
states, " Fractures of the metatarsals are always the result of
direct violence." Hamilton, who does not record an instanceof this fracture, states, " The metatarsal can scarcely be broken
except by a direct blow." Scudder, in his new work, states.
"This fracture is caused by direct violence," and Gould andWarren refer only to severe crushing injuries as a cause ofmetatarsal fracture.
If we briefly look at the anatomy of the bone, more lightwill be thrown upon the mechanism of its fracture. The
prominent base of the fifth metatarsal is closely bound to thecuboid and to the fourth metatarsal by strong ligaments on
every side. So powerful are these ligaments that dislocationof the base is the rarest of accidents. It is obviously easier tobreak the bone than to dislocate it. When the heel, therefore,
is off the ground, the body weight expends itself upon the fifthmetatarsal, rotating it slightly inward. The opposition to thisforce takes place at its base, where the strongly attached ligaments resist its displacement. A fracture occurs, therefore,
exactly where one would expect it to occur, and where ourskiagrams illustrate.
Crepitus is not felt, probably because the line of fractureruns towards the interosseous ligament and the fragments are
therefore fixed, or because impaction may occur. As reference
to the skiagrams will show, all the lines of fracture cannot betraced quite through the bone, but there can be but little doubtthat the fracture is complete. The difficulty in tracing the700

ROBERT JONES.

fracture line, added to the fact that, like a wedge, it is wider
to the outer side, is suggestive of impaction.
There are doubtless mechanical laws which render it easy
to localize its site, as is the case in a Colles's or a Pott's fracture, or even in the interesting one of the outer end of theclavicle, governed as it is by the conoid and trapezoid ligaments.

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