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Abstract: Metatarsal fractures are most often caused by a heavy object striking the dorsum of the foot or by crushing the dorsum of the foot, and are often accompanied by soft tissue contusions and swelling. The patient in this case suffered a metatarsal fracture due to a car crushing the dorsum of the foot, and many tension blisters developed on the dorsum of the foot after the injury. Immediate surgery was not possible and blister aspiration was required. After 1 week of aggressive treatment, the patient’s swelling was effectively relieved and she underwent surgical treatment with fracture incision and internal fixation. Six months after the surgery, the fracture healed and her walking returned to normal.
Basic information】Female, 39 years old
Type of disease】Metatarsal fracture
Hospital】The First Hospital of Harbin Medical University
Date of consultation】December 2021
Treatment plan】Surgical treatment (fracture incision and internal fixation surgery) + subcutaneous drug treatment (low molecular weight heparin sodium injection) + intravenous drug treatment (mannitol injection) + oral drug treatment (horse chestnut seed extract tablets, calcium carbonate D3 granules, vitamin D drops) + blister aspiration
Treatment period】Inpatient treatment for 14 days, regular outpatient follow up
Treatment effect】The fracture healed and normal activities were possible.
I. Initial consultation
The patient, Ms. Zhang, came to the hospital because of pain in her foot after being hit by a car. The patient reported that after being hit by a car, the wheels of the car ran directly over the back of her foot, and she even heard the sound of breaking bones at that time. Upon arrival at the emergency room, skin contusions in the shape of strips with soft tissue swelling and subcutaneous bruising were evident on the dorsum of the patient’s foot, and there was significant collapse and deformity of the foot. Further X-rays of the foot showed multiple comminuted fractures of the affected foot, significant displacement of the metatarsal fracture, and collapse of the arch of the foot, and the patient was diagnosed with a metatarsal fracture. After the initial interview, the patient was admitted to the hospital on an emergency basis and prepared for surgery.
II. Treatment history
After the patient was admitted to the hospital, the swelling of the foot showed a progressive increase, and on the second day, multiple tension blisters appeared on the dorsum of the foot. The patient was given intravenous mannitol injection, oral horse chestnut seed extract tablets, and elevated braking of the affected limb to reduce swelling. During the period of swelling reduction, 3D reconstruction of CT scan of the foot was completed to clarify the type of fracture, and preoperative tests such as cardiac and chest radiographs, routine blood count, liver and kidney function, and coagulation items were completed. Since the patient was immobile, subcutaneous injection of low molecular weight heparin sodium injection was given to prevent deep vein thrombosis. On the 6th day after admission, the fluid in the blister was extracted, and on the 7th day after admission, the patient underwent internal fixation of the fracture by incision and reduction.
III. Treatment results
On the second postoperative day, the patient’s incision was swollen, and on the third postoperative day, the swelling began to relieve, and the pain at the incision gradually began to relieve, and no skin necrosis or incisional disintegration was found. At 7 days after surgery, the patient had no blood or ooze from the surgical incision, no signs of infection, and had a good recovery, so he was discharged from the hospital to recuperate.
Two weeks after surgery, the patient’s incision healed well and the stitches were removed. At this time, there was no obvious pain at the fracture site, the foot deformity was corrected, the arch of the foot was restored, the ankle joint could be moved slightly normally, and there was no obvious numbness in the skin of the foot, and the patient used the healthy limb to go down to the ground. At 3 months after surgery, the patient was able to do some weight-bearing activities. Six months after surgery, the patient could move normally and the fracture had healed.
IV. Notes
We are glad that the patient’s symptoms have improved after treatment. However, the patient was not completely recovered at the time of discharge, so the following points still need to be noted.
1. The patient’s surplus was X-rayed again 3 months, 6 months and 1 year after the surgery to observe the fracture healing. The internal fixation can be removed about 1 to 1.5 years after surgery, after the fracture has healed.
2. before the fracture heals, the affected limb cannot bear weight, but muscle contraction exercises can be performed in bed, or the healthy limb can be used to get down temporarily.
3. While the patient is bedridden, he/she needs to take regular oral calcium carbonate D3 granules and vitamin D drops to prevent disuse osteoporosis. At the same time, patients should pay attention to the meat and vegetables in the diet to increase calcium and protein intake.
4. When the affected limb starts to bear weight, the patient needs to use arch cushion high support insoles until the fracture heals.
V. Personal insight
Because metatarsal fractures are mostly caused by heavy blows that crush the dorsum of the foot, they are often accompanied by severe soft tissue contusions. The patient in this case had multiple metatarsal fractures due to wheel crushing on the dorsum of the foot, and the swelling and bruising appeared immediately after the injury, and the swelling suddenly increased on the second day with a large number of tense blisters. At this time, treatment should focus on symptomatic treatment to reduce swelling, and fracture surgery should only be performed after swelling has subsided and soft tissue conditions have improved. In addition, when the fracture initially heals and starts to go down, padding the arch of the foot can help restore the height of the arch and avoid the formation of flat feet that produce chronic pain.