From the Guidelines
Surgical intervention for a metatarsal fracture is typically considered when there is significant displacement, angulation, or joint involvement, as these factors can lead to increased morbidity, mortality, and decreased quality of life if left untreated. When evaluating the need for surgical intervention, it is essential to consider the specific characteristics of the fracture, including the location, displacement, and angulation.
- Significant displacement (greater than 3-4mm) is a key indicator for surgical intervention, as it can lead to malunion or non-union, resulting in chronic pain and decreased mobility 1.
- Angulation exceeding 10 degrees can also necessitate surgery, as it can cause abnormal foot mechanics and lead to further complications.
- Joint involvement or instability of the fracture are additional factors that may require surgical intervention to restore proper alignment and stability.
- Open fractures, those with soft tissue compromise, or when conservative treatment has failed are also indications for surgery.
- Specific types of metatarsal fractures, such as fifth metatarsal fractures in specific zones (Jones fractures or proximal diaphyseal fractures), often require surgery due to their poor blood supply and high non-union rates, especially in athletes or active individuals.
- The surgical approach typically involves open reduction and internal fixation using screws, plates, or wires to restore proper alignment and stability, with the goal of restoring normal foot mechanics, preventing malunion or non-union, and allowing for earlier weight-bearing and return to activities compared to conservative management of displaced fractures.
From the Research
Indications for Surgical Intervention
A metatarsal fracture is considered for surgical intervention in the following cases:
- Displaced fractures with joint involvement and multiple fragments, which frequently require open reduction and plate fixation 2
- Fractures with displacement in the horizontal plane that cannot be treated conservatively 2
- Transverse fractures at the metaphyseal-diaphyseal junction of the fifth metatarsal ("Jones fractures") that require an individualized approach tailored to the level of activity and time to union 2, 3
- Avulsion fractures of the fifth metatarsal bone that are displaced more than 2 mm or have more than 30% of the joint involved 2, 3, 4
- Symptomatic posttraumatic deformities that need adequate correction, in most cases by osteotomy across the former fracture site 2
Specific Fracture Types
- Fifth metatarsal avulsion fractures: surgical treatment is indicated when the fracture is displaced more than 2mm or when more than 30% of the cubometatarsal joint is involved 3, 4
- Jones fractures: the indication for surgical treatment depends on activity level and Torg classification, with type III fractures having more complications and should be treated operatively 3
- Non or minimally displaced shaft fractures: can be treated non-operatively, but if the dislocation is more than 3-4mm or the angulation is more than 10 degrees, percutaneous K-wires, plate or screw fixation is indicated 3
Treatment Options
- Percutaneous pinning is suitable for most fractures of the lesser metatarsals 2
- Open reduction and plate fixation is frequently required for fractures with joint involvement and multiple fragments 2
- Intramedullary screw fixation and inlaid corticocancellous bone graft are established techniques for treating Jones fractures, but the choice of technique depends on the individual case 5