Metatarsal fractures are the most prevalent foot fractures among foot injuries [1] with an incidence rate of up to 88% [2]. Non-displaced fractures of the shaft of the metatarsal are often treated and heal with 4–6 weeks of immobilization, with majority of fractures healing in around eight weeks after occurrence of fracture [1]. If a fracture site does not heal within this normal time frame, it may face a risk of non-union, delayed union, or posttraumatic abnormalities [2].

In cases of delayed union, a noninvasive, safe, and effective therapy agent with no obvious side effects-pulsed electromagnetic therapy (PMEF), is widely used to facilitate fracture healing [3]. According to a study, the average recovery period for delayed metatarsal union following PMEF administration was four months [4]. Besides PMEF, acupuncture, a traditional Chinese treatment modality is widely utilized to treat a variety of musculoskeletal conditions, including promoting fracture healing [5]. Furthermore, PMEF and acupuncture are commonly used in conjunction to treat various other musculoskeletal conditions, including plantar fasciitis [6], low back pain [7] and muscle fatigue syndrome [8]. No study, to the best of our knowledge, has used a combination of PMEF and acupuncture to treat delayed union of fractures. The aim of this study is to present the case of a patient who was treated with a combination of PMEF and acupuncture therapy for treating delayed union of non-displaced fractures of the 2nd, 3rd, and 4th metatarsal shafts following a high energy trauma (a road traffic accident).

1. Medical history

The patient was a 30-year-old male with no past medical history or chronic illness, who had suffered non-displaced 2nd, 3rd, and 4th metatarsal shaft fractures in a road traffic accident that occurred in July 2023. Despite immobilization of the foot for eight weeks; X-rays revealed that the fractures had failed to heal, and the patient continued to experience swelling and pain at the fracture site. Apart from immobilization of the fracture site, he received no additional treatment. He then approached us for more management on September 19, 2023.

1) Radiography

The most recent X-ray at the time of admission was around eight weeks following his injury on 15th September 2023. The X-ray showed that the fracture had not healed (Fig. 1). Based on the X-ray, the patient was diagnosed with delayed union of the 2nd, 3rd, and 4th metatarsal shaft fractures.

Figure 1. An X-ray taken eight weeks after injury revealed lack of union at the fracture site.

2. Treatment

The patient was administered combination PMEF and acupuncture treatment for fifteen minutes, twice a week, for twelve sessions, to facilitate the healing of the fracture. He did not receive any other concurrent treatment including pain medication to aid in the healing of his fracture and pain.

1) Acupuncture

The following acupuncture points were prescribed to be administered ipsilaterally to the patient’s affected side with the patient positioned in supine position: LR2, LR3, ST45, ST44, GB43, and GB41. The acupuncturist inserted sterile and disposable needles (0.18 × 25 mm) at the above acupoints. All needles were inserted at 15 mm. The needles were manually manipulated until the patient experienced a “deqi” sensation, which is a dull, aching feeling. Power 100 Acupuncture Needles, manufactured from Tai-Chi were used for the acupunctures.

2) Pulsed electromagnetic therapy

TGS MP9 Pulsed Magnetic Field Therapy Unit, manufactured from I. D. Stewart Pty. Ltd. were used the administer PMEF, with base frequency of 50 Hz and pulse rate of 5.

3. Assessments

The patient’s discomfort level was assessed using the visual analogue scale (VAS), and the range of motion (ROM) in his second, third, and fourth toes was measured. In addition to examining his ability to walk and bear weight, an X-ray examination was performed to track the progress of his fracture healing.

1) Visual analogue scale

Subjective discomfort in the patient’s foot was measured using the VAS. The VAS score ranges from 0 to 10, with 0 representing no pain and 10 representing the maximum suffering.

2) Range of motion

Toe mobility was assessed by measuring the ROM of flexion and extension of the second, third, and fourth toes.

3) Weight bearing status

Weight bearing status (WB) was employed to determine the patient’s walking capacity. WB ranges from non-weight bearing or partial weight bearing to full weight bearing, as well as determines the necessity for any walking aids/devices for ambulation. Less weight bearing and the requirement of walking aids/devices imply poor walking abilities, and vice versa.

4) X-ray investigation

Follow up X-ray were performed on 28th September 2023 and 18th October 2023.

4. Response to treatment

On the day of admission, the foot of the patient was painful and swollen. He was only able to flex and extend his 2nd, 3rd, and 4th toes to about half ROM and was limited by pain (6 out of 10 on VAS). When walking with the help of an ankle-foot arthrosis (AFO) with partial weight bearing, he had adequate stability. The swelling in his foot subsided after four sessions of treatment. X-ray revealed minor union formation over the 2nd and 3rd shafts of the metatarsal, but not on the 4th (Fig. 2). The ROM and VAS scores for the patient’s 2nd, 3rd, and 4th toes, as well as his ambulation state remained unchanged. After additional eight sessions of treatment, the swelling decreased significantly. The patient could fully flex and extend his second, third, and fourth toes and the pain had further reduced (2 out of 10 on VAS). X-rays revealed union over the 2nd, 3rd, and 4th shafts of the metatarsal (Fig. 3). The patient was able to accomplish complete weight bearing without pain and without using an AFO. He was physically followed up for two additional weeks followed by phone follow up for one month. He reported no recurrence of the symptoms or disabilities with his foot.

Figure 2. An X-ray taken after four sessions of treatment revealed minor union over the 2nd and 3rd shafts.

Figure 3. An X-ray taken after twelve sessions of treatment revealed complete union at the fracture site.

5. Study ethics

Written informed consent was obtained from the patient for the publication of his medical history in this case report.

The common risk factors for delayed fracture union, such as advanced age, medical comorbidities, long-term nonsteroidal anti-inflammatory use for various genetic disorders and metabolic disease, and nutritional deficiency were not present in the current case [9]. However, a high energy trauma can cause delayed union or an absence of union in a fracture in young people as well [9]. If left untreated, these patients can develop the complications indicated earlier (non-union, delayed union, or posttraumatic abnormalities).

PMEF is a non-invasive therapy that has been proven to be effective in various conditions such as promoting bone healing, treating osteoarthritis, reducing inflammatory diseases, alleviating musculoskeletal pain, enhancing ulcer healing, and reducing spasticity [10]. Furthermore, a recently conducted systematic review reported no negative side effects associated with PMEF [10]. US Food and Drug Administration has recognized PMEF to be a safe and effective treatment for treating delayed unions of fractures. Given that PMEF facilitates fracture healing, PMEF could activate signaling cascades that promote osteogenesis and angiogenesis in an organized spatiotemporal manner, thereby improving the bone tissue’s self-repair capability [11]. According to recent animal experiments, acupuncture can initiate a complex chain of events which include: controlling the expression levels of cell growth factor, triggering Wnt/β-catenin and other signaling pathways, enhancing local blood circulation, altering the composition of mineral elements in bones, controlling the endocrine system, encouraging osteoblast activation and proliferation, and influencing bone cell apoptosis. Therefore, acupuncture enhances the healing of fractures as well [12].

In this case study, we have highlighted the clinical benefits of the combined use of magnetic therapy and acupuncture for a patient with delayed union of metatarsal fractures after a high energy impact trauma. However, this report has certain limitations. First, since only a single subject was considered, the degree of evidence was poor. Second, no control group was recruited, making it difficult to link the patient’s outcomes to the supplied treatments. Additional clinical trials with larger sample sizes and suitable control groups are needed to establish the precise effects of combination therapy of PMEF and acupuncture in treating delayed fracture unions.

Conceptualization: TCH. Data curation: All authors. Formal analysis: CTT. Investigation: All authors. Methodology: TCH. Project administration: All authors. Resources: All authors. Software: CTT. Supervision: All authors. Validation: All authors. Visualization: All authors. Writing – original draft: TCH. Writing – review & editing: All authors.

The authors have no conflicts of interest to declare.

None.

This research did not involve any human or animal experiments.