March Fracture, Including Others Than Those of the Foot

With the advent of the Second World War there has been a decided increase in the incidence of march fracture. One may expect to encounter this lesion wherever armed forces are on the march or are undergoing extensive physical training. This is particularly true if the troops are recent recruits and if there is a weight-bearing overload due to heavy packs. As pointed out by Camp and McCullough (7), march fracture is an example of pseudofracture and may occur in a diseased bone or in a bone subjected to excessive strain. In addition to the metatarsal, the bones involved are likely to be the tibia, femur, pelvis, ribs, radius, and ulna; less frequently these fractures may occur in other parts of the skeletal system. In so far as the foot is concerned, march fracture may be defined as a painful edematous swelling of the forefoot, insidious in onset and associated with an often unsuspected fracture of a metatarsal. Breithaupt (4), a Prussian military surgeon, first called attention to this entity in 1855. He noticed the painful swelling of the feet in soldiers returning from long marches and considered it an inflammatory reaction in the tendon sheaths due to trauma, a condition which he termed “Fussgeschwulst.” Pauzat (23), in 1887, called it pied forcé and described it as a severe periosteal proliferation. Stechow (32) first demonstrated the true character of the lesion in 1897 by roentgen studies. It was first noticed in civilians by Deutschländer (9), who reported 6 cases in women in 1921. Swart (34) has recently cited a case of fracture of the second metatarsal occurring in the seventh month of pregnancy. Etiology Various theories and factors must be given consideration in connection with the etiology of march fractures. An architectural weakness of the foot definitely predisposes to the lesion; flat feet and poor circulation may also be contributing factors (30). The wearing of ill-fitting shoes seems to be an important point. Jansen (14) and Deutschländer (9) stress spasm of the interosseous muscles. Dodd (10), however, considers spasm as secondary and trauma as primary in importance. We believe that a plausible explanation is the excessive degree of muscle strain that takes place. After the muscles are severely exhausted, there is a period of relaxation which permits additional strain on the bones, eventually resulting in fracture. Brandt (3) states that march fracture is based on the torsion mechanics of the foot whereby there is an acute sinking of a previously well formed foot. He has well described the traumatic feature as “rhythmically repeated sub-threshold mechanical insults” to bone rather than a single traumatic incident. Any occupation requiring long-continued walking or standing may lead to march fracture. The majority of cases, however, occur in fresh troops with a high percentage of rookies who have led a more or less sedentary life. As would be expected, the earlier and more detailed reports of the condition came from the highly militarized nations of Continental Europe.