History Taking: RTA Case with 5th Metatarsal Fracture

1. Presenting Complaint

• Pain on the lateral aspect of the foot/ankle following a road traffic accident
• Inability or difficulty bearing weight
• Swelling and bruising over the outer foot

2. History of Presenting Illness (HPI)

Mechanism of Injury

• Was the foot on the brake/clutch pedal at time of impact?
• Was there a direct crush (motorcycle fall, wheel over foot)?
• Did the foot roll inward on impact?
• Was there a twisting component?

Pain

• Location: Lateral border of foot, base of the 5th metatarsal, or along the shaft?
• Onset: Immediate after injury
• Character: Sharp, throbbing
• Severity: VAS/NRS score (0-10)
• Radiation: Up the leg or into the toes?
• Aggravating factors: Weight bearing, movement
• Relieving factors: Rest, elevation, analgesia
• Associated "snap" or "pop" heard at the time?

Weight-Bearing Status

• Can the patient walk at all? (Ottawa Foot Rules: inability to weight-bear = X-ray indicated)
• Did they walk after the injury?

3. Associated Injuries (Especially Important in RTA)

• Ankle injuries (ligament tears, malleolar fractures - inversion is the same mechanism)
• Other metatarsal fractures (Lisfranc pattern if multiple metatarsals involved)
• Calcaneus and talus fractures
• Knee and leg injuries (dashboard injury pattern)
• Pelvic/spinal injuries in high-speed RTA
• Open wounds or abrasions over the fracture site (open fracture risk)
• Neurovascular symptoms: Numbness or tingling in the toes?

4. Past Medical History

• Previous injury to the same foot (prior fractures, non-union risk if prior zone 2/3)
• Diabetes mellitus (impaired bone healing, neuropathy)
• Osteoporosis or metabolic bone disease (lower-energy fractures possible)
• Peripheral vascular disease (affects healing)
• Inflammatory arthritis (rheumatoid, gout)
• Neuropathy (may mask pain, increases non-union risk)
• Corticosteroid use (bone fragility)

5. Drug History

• NSAIDs (can impair fracture healing - Cox-2 inhibitors with particular concern)
• Steroids (bone quality)
• Bisphosphonates (atypical fracture pattern risk)
• Anticoagulants (haematoma, surgical planning)
• Diabetic medications
• Allergies (especially to latex, anaesthetic agents if surgery likely)

6. Social History

• Occupation: Manual labour vs. sedentary (affects weight-bearing advice and time off work; average 22 days off work post-injury)
• Dominant side / Affected foot: Right vs. left
• Driving status: Especially relevant if right foot - affects fitness to drive
• Sports/physical activity level: Athlete vs. non-athlete (directly impacts management - athletes with Zone 2 fractures are often offered surgical fixation)
• Smoking: Significantly impairs fracture healing and increases non-union risk
• Alcohol use: Nutritional status, compliance with treatment
• Living situation: Stairs at home? Anyone to help with mobility?
• BMI / Body weight: Increased load on fracture site with weight bearing

7. Functional History

• Pre-injury mobility: Was the patient walking normally before the accident?
• Pre-injury foot problems: Any previous foot pain, deformity, or flat feet (pes planus) or high arch (cavovarus - associated with Zone 3 stress fractures)?

8. System Review (Relevant)

• Fever (rule out open fracture/infection)
• Bladder/bowel changes (if high-energy RTA with spinal concern)
• Chest pain/SOB (rib fractures, pneumothorax in polytrauma)

Key Classification to Know (Lawrence & Botte Zones)

Examiner Tip: Ottawa Foot Rules (for X-ray decision)

• Bone tenderness at the base of the 5th metatarsal, OR
• Bone tenderness at the navicular, OR
• Inability to bear weight immediately or in the ED (4 steps)

• Miller's Review of Orthopaedics, 9th Ed, Ch. 12 (5th Metatarsal Base Fractures)
• Campbell's Operative Orthopaedics, 15th Ed, Ch. 93 (Metatarsals)
• Tintinalli's Emergency Medicine, Comprehensive Study (Foot and Toe Injuries)
• StatPearls - 5th Metatarsal Fracture (Smidt et al., 2023)