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Three Part Question

In [patients with closed non-displaced fractures of the central (2nd-4th metatarsals)] is [support bandaging as good as plaster fixation] for [fracture union]

Clinical Scenario

A patient presents with a simple transverse fracture of his second metatarsal, you wonder whether he could be safely discharged in a support bandage rather than a below knee backslab

Search Strategy

Medline, National Library for Health Search Engine, 1996-May 2009;

[exp CASTS, SURGICAL OR cast*.ti,ab OR exp BANDAGES OR dressing*. ti,ab OR exp FRACTURES, FIXATION OR SPLINTS OR plaster*.ti,ab OR splint*.ti,ab] AND [fract*.ti OR break*.ti or brok*.ti] AND [foot*.ti OR metatars*.ti OR forefoot*.ti] LIMIT to Publication Year 1966-Current and Abstracts and (Clinical Queries Therapy sensitivity or Therapy specificity or Therapy optimized or Prognosis sensitivity or Prognosis specificity or Prognosis optimized or Reviews sensitivity or Reviews specificity or Reviews optimized or Qualitative Studies sensitivity or Qualitative Studies specificity or Qualitative Studies optimized) and Humans and English Language

Search Outcome

217 articles found, of which only 1 was relevant to the three part question

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Zenios M 2005 UK	50 patients aged 16-75 with a closed fracture of a single metatarsal (excluding the first) randomised to either deltacast or tubigrip	prospective randomised controlled trial		Deltacast vs Tubigrip	Small sample size, especially considering only 3 of the 50 patients had a fracture of a central metatarsal, the remaining being fractures of the 5th. In addition, there was no intention-to-treat analysis, as one patient with complications was excluded from the trial after 2 weeks. Overall the study design was good, however there was no information regarding who assessed the degree of radiological union; whether they were blinded to the study and on what grounds they graded non-union. Regarding the statistically significant results, the AOFAS score has not been validated for metatarsal fractures and the difference in scores between the groups is likely due to the high incidence of pain in the plaster group; which could itself be explained by the application of a full cast irrespective of the degree of initial swelling.
			radiological union at 12 weeks (% cases)	87 vs 100 (p=0.11)
			median pain score at 1 week	5 vs 2 (pp=0.005)
			median pain score at 4 weeks	3 vs 1 (p=0.06)
			median pain score at 12 weeks	1 vs 1 (p=0.18)
			analgesia requirement at 1 week (% cases)	71 vs 56 (p=0.28)
			analgesia requirement at 4 weeks (% cases)	46 vs 20 (p=0.05)
			analgesia requirement at 12 weeks (% cases)	25 vs 8 (p=0.11)
			median foot circumference difference at 1 week	1 vs 1 (p=0.63)
			median foot circumference difference at 4 weeks	0.5 vs 1 (p=0.73)
			median foot circumference difference at 12 weeks	0 vs 0 (p=0.07)
			Time taken to walk independant of crutches (weeks)	3 vs 2 (p=0.32)
			AOFAS score at 12 weeks	80 vs 100 (p<0.001)

Comment(s)

Of the metatarsals, the 5th is the most commonly fractured, followed by the 3rd, 2nd, 1st and 4th. This review has intentionally excluded fractures of the 5th as a BestBet already exists on this subject. In addition, as the 1st metatarsal carries twice the load of any of the other metatarsals during the stance phase, its management is traditionally more proactive and has therefore been excluded from this BestBet. Typically, the presence of a single, undisplaced metatarsal fracture is considered stable due to the support of surrounding metatarsals and therefore suitable for support and early mobilisation. The only trial found on the subject suggests a favourable outcome for patients treated in a support bandage; however, only 3 of the study group had a fracture of a central metatarsal and there were multiple exclusions, including the paediatric and elderly populations. Furthermore, there is no consensus on the best form of support given the wide variations used, ranging from metatarsal ‘bars’ to firm footwear or purely tubigrip/stockinet.

Clinical Bottom Line

There is no evidence supporting the use of bandaging over plaster for the treatment of central metatarsal fractures. Local guidelines should be followed.

References

1. Zenios M, Kim WY, Sampath J, Muddu BN Functional treatment of acut metatarsal fractures: a prospective randomised comparison of management in a cast versus elasticated support bandage Injury 2005; 36:832-5