Second metatarsal stress fracture

Case contributed by Dr Paul Heyworth

Presentation

Chronic pain right 2nd metatarsal.

Patient Data

Age: 40
Gender: Male

Stress fracture of the distal third of the right 2nd metatarsal diaphysis with associated periosteal reaction and fracture line medially. Anatomical alignment preserved. MTPJ spacing preserved.

Lucency at the adjacent third metatarsal is favored to represent a nutrient foramen.

Case Discussion

Plain radiographs have poor sensitivity in detecting stress fractures, as positive findings may take months to appear. During the first few weeks after the onset of symptoms, x-rays of the affected area may look normal.

Positive findings include sclerosis, periosteal reaction/elevation, cortical thickening and a fracture line. Although insensitive, subtle loss of cortical density has been described as the grey cortex sign of early-stage stress injury. New periosteal bone formation may take up to 2 weeks to be detectable.

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