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Beth Israel Deaconess Medical Center Harvard Medical School Boston, MA 02215
Pao et al. [1] report six patients with small avulsion fractures of the base of the fifth metatarsal that were not visualized on routine radiographs of the foot but that were identified on radiographs of the ankle. This fracture probably relates to the pull of the plantar aponeurosis rather than the larger more common fracture of the fifth metatarsal tuberosity occurring as a result of the pull of the peroneus brevis tendon. The fracture they describe is clearly a common one: 23% of the authors' cases were not identified on foot radiographs. Pao et al. emphasize that "If there is a clinical suspicion of a fracture at the base of the fifth metatarsal but the radiographs of the foot reveal normal findings, an additional projection...should be obtained to rule out this avulsion fracture."
This article makes important observations, but I disagree with the authors' recommendation, which would result in many additional examinations, most of which would be ordered after the initial foot radiographs have been perused or additional history is obtained. I have undoubtedly failed to diagnose hundreds of these fractures, but I am unaware of any resultant adverse outcomes. As the authors point out "Patients with tuberosity fractures are treated conservatively with weight-bearing as tolerated and the fracture heals rapidly" [1].
Obtaining routine additional foot radiographs to diagnose this subtle fracture is analogous to obtaining rib radiographs in trauma patients when the accompanying chest radiographic findings are normal [2] or obtaining additional radial head-capitellum views of the elbow in trauma patients with visible elbow effusions [3]. These additional examinations may reveal suspected fractures, but they rarely influence treatment or prognosis.
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University of Virginia Medical System Charlottesville, VA 22908
My colleagues and I appreciate Dr. Hall's interest in our article about avulsion fractures of the base of the fifth metatarsal not visualized on routine radiographs of the foot but identified on ankle films [1]. Although the main purpose of the article was to describe that this avulsion fracture may not be seen on foot radiographs, we also recommend that one additional radiograph be obtained in the symptomatic patient to diagnose this fracture.
We disagree with Hall's comment about "obtaining routine additional foot radiographs to diagnose this fracture." We are not recommending that an additional foot radiograph be obtained routinely but only in those patients with normal findings on foot radiographs but with clinical findings suggestive of a fracture at the fifth metatarsal.
We agree with Hall's comment that "most of them [additional foot radiographs] ordered after the initial foot radiographs have been perused or additional history is obtained." This will indeed happen, which is why we describe one additional view that will enable the diagnosis of this fracture. At our institution, we have a close working relationship with the emergency department and will often help them with a patient's diagnosis by recommending the appropriate radiologic examination. An awareness that this avulsion fracture may not be visible on foot radiographs may assist the radiologist in diagnosing this fracture, which will benefit both the emergency department and the patient by facilitating the diagnosis of a fracture as opposed to a misdiagnosis of a "sprained ankle."
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