What is the management of a metatarsal fracture?

From the Guidelines

The management of a metatarsal fracture should prioritize conservative treatment with simple immobilization for non-displaced, non-articular, or minimally displaced fractures. This approach is supported by the American College of Foot and Ankle Surgeons, as noted in a study published in the American Family Physician 1. The diagnosis of a metatarsal fracture is based on a history of trauma, focal pain on palpation, and confirmation with radiographic studies.

Key Considerations

• The fracture type, location, and displacement are crucial in determining the management approach
• Conservative treatment, including rest, ice, compression, and elevation (RICE protocol), is recommended for the first 48-72 hours
• Weight-bearing restrictions, using crutches or a walking boot for 4-6 weeks, are essential to promote healing
• A stiff-soled shoe or walking boot can help immobilize the foot and reduce pressure on the fracture site
• Pain management with acetaminophen or NSAIDs, such as ibuprofen, may be necessary for 1-2 weeks as needed

Surgical Intervention

• Displaced fractures (>3-4mm displacement or >10° angulation) may require surgical intervention with internal fixation
• Fifth metatarsal fractures, particularly Jones fractures, have a high risk of non-union and may require surgical fixation even when non-displaced

Rehabilitation and Follow-up

• Rehabilitation should begin after adequate healing, typically at 6-8 weeks, focusing on range of motion exercises, strengthening, and gradual return to activities
• Healing time varies from 6-12 weeks depending on fracture location and severity
• Complications to monitor include malunion, delayed union, and post-traumatic arthritis, particularly with intra-articular fractures

From the Research

Management of Metatarsal Fractures

• The treatment goals of metatarsal fractures are to maintain the metatarsal parabola, sagittal position of the metatarsal heads, and a congruent metatarsophalangeal joint 2.
• Most metatarsal fractures can be treated nonoperatively, but displaced fractures require surgical intervention to preserve normal gait biomechanics 2.
• The management of metatarsal fractures depends on the location and type of fracture, as well as the patient's overall health and activity level.

Nonoperative Management

• Nondisplaced fractures of the metatarsal shaft usually require only a soft dressing followed by a firm, supportive shoe and progressive weight bearing 3.
• Stress fractures of the first to fourth metatarsal shafts typically heal well with rest alone and usually do not require immobilization 3.
• Avulsion fractures of the proximal fifth metatarsal tuberosity can usually be managed with a soft dressing 3.

Operative Management

• Displaced fractures require surgical intervention to preserve normal gait biomechanics 2.
• Proximal fifth metatarsal fractures that are distal to the tuberosity have a poorer prognosis and may require surgical treatment 3.
• Fractures in zone III (at the distal end of the joint) should primarily be treated surgically 4.

Specific Fracture Locations

• Fractures of the first metatarsal require referral or specific treatment based on severity 3.
• Fractures of the fifth metatarsal base can be treated with early functional therapy for zone I and II fractures, while zone III fractures should be treated surgically 4.
• Jones fractures have a higher risk of nonunion and require at least six to eight weeks in a short leg non-weight-bearing cast 5.