A 21-year-old soldier comes to the medical clinic due to right foot pain. She is in her second month of basic training and has had pain for the last 3 weeks. The patient has no history of acute trauma. The pain initially occurred only with activity but is now present even at rest. Medical history is unremarkable, and she takes no medications. Vital signs are normal. Examination shows swelling and warmth in the foot and point tenderness over the second metatarsal. Plain films of the foot show a hairline fracture of the shaft of the second metatarsal. Which of the following is the most appropriate next step in management?

Question

A 21-year-old soldier comes to the medical clinic due to right foot pain.  She is in her second month of basic training and has had pain for the last 3 weeks.  The patient has no history of acute trauma.  The pain initially occurred only with activity but is now present even at rest.  Medical history is unremarkable, and she takes no medications.  Vital signs are normal.  Examination shows swelling and warmth in the foot and point tenderness over the second metatarsal.  Plain films of the foot show a hairline fracture of the shaft of the second metatarsal.  Which of the following is the most appropriate next step in management?

Quizplus · Accepted Answer

11ec25c8_d97a_995b_bc81_9fa8921e3e8f_MD0003_00 This patient has a nondisplaced stress fracture of the second metatarsal. Stress fractures are caused by repeated tension or compression without adequate rest and most commonly occur in athletes and military recruits who suddenly increase their activity. The second metatarsal, which is subjected to significant extremes of loading during gait, is the most commonly involved metatarsal. Typical findings include subacute, activity-related pain and point tenderness over the fracture. The diagnosis is primarily based on clinical findings. X-rays may initially be normal but can show a hairline lucency or local periosteal thickening. MRI, CT, and scintigraphic bone scans are more sensitive, especially for early fracture, but are not usually needed (Choices A and B). Fractures of the second, third, and fourth metatarsals are managed conservatively as the surrounding metatarsals act as splints and nonunion is uncommon. Initial interventions include rest and simple analgesics (eg, acetaminophen). Some experts advise against nonsteroidal anti-inflammatory drugs due to a possible delay in healing times. Patients who continue to have pain despite activity restrictions may additionally be managed with a wide, hard-sole podiatric shoe. (Choices C and E) Stress fractures of the fifth metatarsal shaft are at increased risk for nonunion and are usually managed with casting or internal fixation. However, stress fractures of the middle (ie, second, third, and fourth) metatarsals usually heal well and do not require casting or surgery unless there is severe pain, displacement, or other complicating factors. Educational objective: Stress fractures of the metatarsals are associated with a sudden increase in activity and are common in athletes and military recruits; the second metatarsal is most commonly injured. Initial treatment includes rest and simple analgesics. Stress fractures of the fifth metatarsal are at increased risk for nonunion and warrant more aggressive treatment. References: Surgical versus conservative treatment for high-risk stress fractures of the lower leg (anterior tibial cortex, navicular and fifth metatarsal base): a systematic review. (http://www.ncbi.nlm.nih.gov/pubmed/25138980)

A 21-Year-Old Soldier Comes to the Medical Clinic Due to Right