Physical Examination for Suspected Metatarsal Fracture
When evaluating a patient for suspected metatarsal fracture, perform systematic palpation of each metatarsal bone from head to base, assess for point tenderness, swelling, ecchymosis, and deformity, and evaluate weight-bearing ability—then apply the Ottawa foot rules to determine imaging necessity 1, 2, 3.
Key Physical Examination Components
Essential Examination Steps
Palpation technique:
- Systematically palpate each metatarsal head individually from first through fifth 4
- Palpate along the entire shaft of each metatarsal bone
- Assess the base of the fifth metatarsal specifically, as this is a high-risk area 5
- Examine the first metatarsal carefully given its critical weight-bearing role 2
Clinical findings to document:
- Point tenderness over the affected metatarsal (present in 100% of cases) 3
- Swelling (present in 96% of cases) 3
- Ecchymosis (present in 15% of cases) 3
- Deformity (rare, only 2% of cases) 3
- Pain with weight-bearing (varies based on fracture severity and patient tolerance) 2
Critical Additional Assessments
Evaluate for associated injuries:
- Lisfranc ligament assessment: Apply pressure across the midfoot and look for tenderness at the tarsometatarsal joint, as metatarsal fractures can be associated with Lisfranc injuries 2, 6, 7
- Check neurovascular status: assess dorsalis pedis and posterior tibial pulses, capillary refill, and sensation 6
- Examine for open wounds or skin compromise 6
Weight-bearing assessment:
- Observe the patient's ability to bear weight and take four steps
- This is critical for applying Ottawa foot rules 1
Ottawa Foot Rules Application
Use Ottawa rules to determine imaging necessity (99% sensitivity for foot fractures) 1:
Radiographs are indicated if:
- Bone tenderness at the navicular or base of the fifth metatarsal
- Inability to bear weight both immediately after injury and in the emergency department (unable to take four steps)
- Addition of swelling as a criterion increases sensitivity and specificity 1
Important Exclusions to Ottawa Rules
Do NOT apply Ottawa rules in these situations 1:
- Neurologically compromised patients (including diabetic neuropathy)
- Altered sensorium
- Polytrauma patients
- Penetrating trauma
- Pregnancy
- Open wounds
10 days post-trauma
- Return visit for continued pain
- Underlying bone disease
- Age <18 years (in some protocols)
In these excluded scenarios, proceed directly to radiography regardless of examination findings 1.
Special Considerations
Forefoot Trauma (Metatarsal Heads and Toes)
The Ottawa rules do not directly address distal forefoot trauma 1. For suspected metatarsal head or toe fractures:
- Palpate each metatarsal head individually 4
- If fracture is suspected based on point tenderness and mechanism, obtain radiographs 1
High-Energy Mechanisms
For crush injuries or high-energy trauma 7:
- Carefully assess soft tissue damage
- Examine for compartment syndrome signs (pain out of proportion, pain with passive stretch)
- Check for multiple metatarsal involvement
- Maintain high suspicion for Lisfranc injury
Stress Fractures
For insidious onset pain without acute trauma 2, 8:
- Palpate along metatarsal shafts for focal tenderness
- Assess for recent increase in activity level
- Note that initial radiographs may be negative; bone scan or MRI may be needed later
Common Pitfalls to Avoid
- Missing Lisfranc injuries: Always assess the midfoot when evaluating metatarsal fractures, as these injuries are frequently overlooked 2, 7
- Applying Ottawa rules inappropriately: Remember the multiple exclusion criteria, particularly neurologic compromise 1
- Inadequate fifth metatarsal base examination: This area has poor blood supply and varied healing rates; carefully distinguish between tuberosity avulsions (zone 1), Jones fractures (zone 2), and stress fractures (zone 3) 6, 5
- Overlooking first metatarsal injuries: These require more aggressive management due to weight-bearing importance 2, 6