Clinical Note Review

Transcription

• Patient came for follow-up, "4 days, no other complaints"

• Swelling / fullness Right foot lateral compartment
• Tenderness over 5th metatarsal base
• ROM: Painful
• No external injury

• Shows Right 5th metatarsal base - undisplaced (fracture, implied)

• Below Knee Slab x 1 week

1. Tab. PCM 500 mg 1-1-1 (TDS) x 3 days
2. Tab. Serratiopeptidase 10 mg 1-0-1 (BD) x 3 days
3. Tab. Pantoprazole 40 mg 1-0-1 (BD)
4. Tab. Ibuprofen/Combiflam 400 mg 1-0-1 (BD)
5. R/W (Review With) pin → OPD review on Thursday 6/8/26 (or next Thursday)

Clinical Review

Diagnosis

Management Assessment

Points to Note / Suggestions

1. Slab duration - 1 week is likely just the initial review interval, not total immobilization. At follow-up, the slab should be converted to a below-knee cast or walking boot for a total of 4-6 weeks from injury for Zone 1 fractures.
2. Weight-bearing status not clearly documented - for undisplaced Zone 1 fractures, weight-bearing as tolerated in a slab/boot is generally acceptable and should be advised.
3. Crutches - not mentioned; advisable for comfort especially if non-weight-bearing.
4. NSAIDs + PCM + Combiflam - Combiflam already contains both ibuprofen and paracetamol. If Combiflam is prescribed, separate PCM 500mg is potentially redundant and could lead to paracetamol double-dosing. Clarify whether both are intended.
5. Serratiopeptidase 10mg - the standard adult dose is 10 mg TDS (not BD); however BD dosing is also used. Minor point.
6. BP 120/80 - normal, no concerns.
7. Injury date context - complaint appears to be from an earlier visit; the OPD review note is dated 2/8/26, and follow-up scheduled for 6/8/26 (Thursday) - a 4-day interval which is appropriate for a fresh fracture review.

Summary

Persistent Pain at 2 Weeks - 5th Metatarsal Base Fracture

Why Pain Persists: The Slab Was Removed Too Early

• Conservative immobilization: 4-6 weeks minimum
• Full clinical healing (return to normal activity): 6-8 weeks

What to Do Now

1. Re-assess with X-Ray

• Callus formation - is healing progressing?
• Any displacement that may have occurred
• Rule out a Zone 2 (Jones fracture) which is in a watershed vascular zone with high risk of nonunion and delayed healing

2. Re-immobilize

• Re-apply below-knee slab or walking boot for another 3-4 weeks (to complete a total of 5-6 weeks from the date of injury)
• The patient should ideally be partial/non-weight-bearing or use a walking boot that offloads the fracture site

3. Crutches

4. Medications

• Analgesic - PCM 500mg TDS as needed
• Calcium + Vitamin D3 supplementation (if not already given) - supports bone healing
• Avoid prolonged NSAIDs (>2 weeks) as they may impair fracture healing

5. Physiotherapy

• Gentle ROM exercises
• Peroneal muscle strengthening
• Proprioception training

Red Flags - When to Escalate

• X-ray shows fracture displacement or non-union at 6-8 weeks
• Pain is increasing rather than decreasing
• X-ray suggests this is a Zone 2 (Jones fracture) - these have a high nonunion rate and often require intramedullary screw fixation, especially in active patients (per Campbell's Operative Orthopaedics 15th Ed, 2026)

Summary Table

Severe / Serious Conditions That May Cause Persistent Pain After 5th Metatarsal Base Fracture

First - Understand the Zone (Critical)

1. Misclassification - This May Be a Jones Fracture (Zone 2)

• The original X-ray was read as "undisplaced 5th metatarsal base fracture" but if the fracture line actually extends into the metaphyseal-diaphyseal junction (Zone 2), it is a true Jones fracture
• Jones fractures occupy a vascular watershed zone with poor blood supply - they carry a 15-25% nonunion rate with conservative management alone
• At 2 weeks with continued pain after slab removal, a Zone 2 fracture should be actively excluded
• Action: Repeat oblique X-ray or MRI to confirm zone classification

2. Nonunion / Delayed Union

• Nonunion = fracture fails to heal after sufficient time (typically >3 months with no radiographic progression)
• Delayed union = slower than expected healing, still possible but taking longer
• Risk factors in this patient:
  • Premature slab removal at 2 weeks
  • Early weight-bearing without protection
  • Possible Zone 2/3 fracture
  • Undetected metabolic issues (diabetes, osteoporosis, Vitamin D deficiency)
• X-ray finding: sclerosis at fracture ends, persistent fracture line, no callus bridging
• Treatment if confirmed: Intramedullary screw fixation ± bone grafting (per Miller's Review of Orthopaedics 9th Ed)

3. Fracture Displacement (Secondary)

• An originally undisplaced fracture can displace secondarily if the patient bears full weight prematurely without adequate immobilization
• Displaced fractures involving the 5th metatarsal-cuboid articular surface require ORIF (open reduction internal fixation)
• Tenting of the skin is an indication for emergency fixation
• Action: Urgent repeat X-ray

4. Refracture

• Returning to activity before radiographic union is confirmed sharply increases refracture risk
• Zone 3 stress fractures carry a 33% refracture risk with nonoperative treatment
• Clinically presents as sudden worsening of pain or new pop during weight-bearing

5. Complex Regional Pain Syndrome (CRPS) / Reflex Sympathetic Dystrophy

• A neuro-vascular pain disorder triggered by trauma/fracture
• Presents with burning, disproportionate pain, allodynia (pain to light touch), swelling, skin color/temperature changes, and hypersensitivity
• More common after inadequately managed or prolonged immobilized injuries
• Diagnosis: Clinical (Budapest criteria); bone scan or MRI may help
• Treatment: Early mobilization, physiotherapy, nerve blocks, medications (amitriptyline, gabapentin)

6. Underlying Metabolic Bone Disease

7. Cavovarus Foot Deformity (Underlying Biomechanical Cause)

• A high-arched (cavus) foot with varus alignment places excess lateral loading on the 5th metatarsal
• This can cause persistent pain, stress fractures, and recurrent fractures
• Per Miller's Review: "Presence of a varus foot deformity is not uncommon in the patient with a Zone 3 fracture, and concomitant lateral closed-wedge calcaneal osteotomy should be considered to prevent recurrence"
• Action: Assess foot arch; may need custom orthotics or corrective surgery

8. Peroneus Brevis Tendon Injury

• The same inversion mechanism that fractures the 5th metatarsal base can cause a longitudinal split tear of the peroneus brevis tendon
• This is frequently missed on plain X-ray
• Causes persistent lateral foot/ankle pain even after fracture heals
• Diagnosis: MRI of ankle
• Treatment: Physiotherapy, or surgical repair if severe

9. Lisfranc Injury (Missed Associated Injury)

• A more severe inversion injury can cause tarsometatarsal (Lisfranc) ligament disruption alongside the 5th metatarsal fracture
• If missed and untreated, leads to chronic midfoot pain and progressive flat foot deformity
• Action: Check X-ray for widening of 1st-2nd metatarsal base gap (>2mm suspicious)

Summary - Priority Action Plan

Pain at 2 weeks + premature slab removal
         ↓
1. Repeat X-ray (AP + oblique) → Confirm zone, check displacement, callus
2. If Zone 2/3 confirmed → Orthopedic surgeon referral for screw fixation
3. Bloods: FBS/HbA1c, Calcium, Vit D, PTH
4. MRI if X-ray normal but pain persists → Rule out peroneus brevis tear, CRPS, occult fracture
5. Re-immobilize immediately (walking boot/slab) until imaging reviewed

Assessment: This Is Consistent With Normal Healing

• Week 0: Injury, undisplaced 5th metatarsal base fracture
• Week 1-2: Below-knee slab
• Week 2: Slab removed, pain on mobilization (expected, too early functionally)
• Week ~3: Pain now bearable, walking with normal gait — improving

What This Means Practically

1. No red flags present — no worsening pain, no new deformity, no inability to bear weight, no night pain described. Bearable pain with normal gait is the expected pattern of a fracture transitioning from protected to full function.
2. Continue current course: gentle activity as tolerated, avoid high-impact loading (running, jumping, twisting) until ~6 weeks.
3. No need to reimmobilize unless pain suddenly worsens or gait changes.

Watch For (Red Flags Requiring Re-evaluation)

• Pain worsening rather than plateauing/improving
• New swelling, warmth, or redness (infection or CRPS)
• Sudden sharp pain or inability to bear weight (possible refracture/displacement)
• Pain lasting unchanged beyond 6-8 weeks (possible nonunion, especially if this turns out to be a Jones-zone fracture rather than a simple avulsion)

Recommended Follow-Up

• Clinical review with the treating doctor around 6 weeks from injury to confirm resolution and consider a repeat X-ray if pain hasn't fully resolved by then.
• Continue Calcium + Vitamin D if not already on it, and avoid prolonged NSAID use now that acute inflammation has settled.
• Gradual return to full activity (sports, prolonged standing) only after she is pain-free.