Design: Retrospective chart and radiographic review.

Background: Stress fractures of the fifth metatarsal are increasingly common among elite professional footballers (soccer players). This reflects the use of lighter, less protective and more flexible sports footwear combined with the increasingly physical demands of the professional game at the highest level. Stress fractures of the fifth metatarsal can be satisfactorily treated non-operatively by cast immobilisation and a graduated return to activity. The demands placed on the modern elite professional footballer are such that a different treatment approach is required for the same injury in this subgroup of patients.

Methods: Stress fractures of the fifth metatarsal in elite professional footballers are treated by the senior author (JPH) by operative surgical fixation. We reviewed the charts and radiographs of all fifth metatarsal stress fractures that were treated operatively in elite professional footballers over a five year period. Details recorded included fracture location, method of fixation, complications, time to radiological union and time to return to independent weightbearing and competitive sporting activity.

Results: There were 32 fifth metatarsal stress fractures in 30 elite professional footballers. All fractures were clinically united at a mean 5.5 weeks and radiologically united at a mean of 10.3 weeks. The patients could weightbear immediately and could independently weightbear from 4 weeks. The mean time to return to full competitive activity was 10.3 weeks. There were no complications.

Conclusions: Operative treatment of fifth metatarsal stress fractures is an effective treatment in elite professional footballers that produces consistently good results and allows an early return to full activity.

Biomechanical foot orthoses (or foot wedges) are commonly used in clinical practice. The aim of this study was to investigate the effect of foot wedges on plantar pressure during normal gait.

Thirty normal adult subjects (11 men, 19 women; mean age = 25.2 years, range = 18–36 years) walked along a floor-mounted wooden walkway incorporating the Musgrave™ pressure plate under six testing conditions : (1) barefoot; (2) tubigrip stocking; (3) tubigrip stocking and medial forefoot wedge; (4) tubigrip stocking and lateral forefoot wedge; (5) tubigrip stocking and medial heel wedge; and (6) tubigrip stocking and lateral heel wedge. Pelite™ foot wedges were placed underfoot inside the tubigrip stocking.

Recorded footprints were divided into four quadrants (anteromedial (AMQ), anterolateral (ALQ), posteromedial (PMQ), and posterolateral (PLQ)). Statistical analysis of quadrant plantar pressures, anterior-posterior plantar pressure ratios, medial-lateral plantar pressure ratios and mean centre of pressure to mid-axis distances was performed using the paired t-test.

Forefoot wedges caused earlier forefoot loading (p< 0.05). They increased anterior-posterior plantar pressure distribution (p< 0.001): medial wedges increased AMQ plantar pressure (p< 0.001) and decreased PLQ plantar pressure (p< 0.01); lateral wedges increased ALQ plantar pressure (p< 0.001) and decreased PLQ plantar pressure (p< 0.01).

Heel wedges delayed forefoot loading (p< 0.02). They decreased anterior-posterior plantar pressure distribution (p< 0.05): medial wedges decreased ALQ plantar pressure (p< 0.01); lateral wedges decreased ALQ plantar pressure (p< 0.01) and increased PLQ plantar pressure (p< 0.001).

Foot wedges did not significantly affect medial-lateral plantar pressure distribution.

We conclude that foot wedges do affect plantar pressure in those with normal feet and normal gait. Foot wedges affected anteroposterior plantar pressure distribution but did not affect mediolateral plantar pressure distribution.

The management of type two odontoid peg fractures remains controversial. The policy in our unit is to initially manage all of these injuries non-operatively. Patients with displaced fractures (0.2mm translation, > 15° angulation) are placed in halo vests followed by fracture reduction under radiological control. Undisplaced or minimally displaced fractures are treated in either custom-made minerva orthoses or halo vests.

We report the results of 42 consecutive cases of type two odontoid peg fractures. There were 24 males and 18 females with a mean age of 53 (range 18–89) years. Twenty-one (50%) of patients were > 65 years of age. In 29 cases the fracture was undisplaced or minimally displaced and in the remaining 13 cases it was displaced (> 2mm translation, > 15° angulation) either posteriorly (extension-type)(6) or anteriorly (flexion type) (7). All displaced cases were treated in halo vests while the remainder were treated in minervas (14) or halo vests (15).

Loss of reduction occurred in nine cases necessitating adjustment in five and C1/2 posterior fusion in four. Of these cases five were displaced extension type-fractures, two required fusion. Pin site infection necessitated early removal of halo vest and conversion to minerva in three cases. In all of these cases fracture union was achieved.

Overall, union was achieved in 37 patients giving a non-union rate of 12%. The mean age of the five non-unions was 42 years with only one patient over 65 years of age. Four of these patients had C1/2 posterior fusions and the remaining patient refused surgery.

Of the 29 patients with displaced or minimally displaced fractures five (17%) required surgery for either non-union (3) or displacement (2), whereas three (23%) of the displaced group required surgery for non-union (1) or displacement (2). All of these were extension type fractures.

We conclude that a policy of non-operative management of these fractures resulted in union in a high proportion of patients of all age groups except for those with extension type fractures. This fracture pattern may warrant primary surgical intervention.