What is the treatment for a minimally displaced metatarsal fracture?

Treatment of Minimally Displaced Metatarsal Fractures

Minimally displaced metatarsal fractures should be treated conservatively with protected weight bearing in a walking boot or cast shoe for 4-6 weeks. 1

Initial Management

The treatment approach for minimally displaced metatarsal fractures follows a conservative pathway:

1. Immobilization Options:

   • CAM-Walker Boot: Provides good support while allowing some mobility
   • Hard-soled shoe: Alternative option with similar functional outcomes
   • Cast shoe: Appropriate for stable fractures

2. Weight Bearing Status:

   • Protected weight bearing as tolerated is appropriate for most minimally displaced metatarsal fractures
   • Recent evidence shows that immediate weight bearing as tolerated (WBAT) in a walking boot demonstrates good healing rates 2

Treatment Duration and Follow-up

• Immobilization period: 4-6 weeks total 1, 3
• Radiographic follow-up: Typically at 2-4 weeks to confirm alignment is maintained
• Clinical monitoring: Assess for pain reduction and improved weight bearing capacity

Evidence Comparison

Research shows comparable outcomes between different conservative treatment options:

• A comparative study of CAM-walker boots versus hard-soled shoes found:
  • Similar pain scores and functional outcomes at 8 and 12 weeks
  • Slightly faster bone healing with CAM-walker boots (7.2 weeks vs 8.6 weeks)
  • Similar time to return to prior activity levels (8.3 vs 9.7 weeks) 4

Special Considerations

Anatomic Location Variations

1. Second to Fourth Metatarsal Fractures:

   • Conservative management with protected weight bearing for 4-6 weeks 1
   • Displacement in horizontal plane can be managed non-operatively

2. Fifth Metatarsal Base Fractures (Zone 1):

   • Can be treated with either hard-soled shoe or CAM-walker boot 4
   • Weight bearing as tolerated is appropriate

3. Great Toe Fractures:

   • Short leg walking boot or cast with toe plate for 2-3 weeks
   • Transition to rigid-sole shoe for additional 3-4 weeks 3

When to Consider Surgical Management

While this question focuses on minimally displaced fractures, it's important to recognize when surgical intervention might be needed:

• Displacement >2mm
• Articular involvement >30%
• Multiple fragments requiring anatomic reduction
• Fractures with joint involvement
• Failure of conservative management 1

Pitfalls and Caveats

1. Inadequate Follow-up:

   • Ensure radiographic follow-up to confirm maintenance of alignment
   • Loss of reduction may require transition to surgical management

2. Misdiagnosis of Fracture Type:

   • Jones fractures (transverse fractures at metaphyseal-diaphyseal junction of fifth metatarsal) have higher nonunion rates and may require different management 3
   • Ensure accurate classification of metatarsal fractures

3. Prolonged Immobilization:

   • Extended immobilization beyond necessary timeframes can lead to stiffness and delayed return to function
   • Progressive mobility should be encouraged as healing progresses

4. Failure to Address Pain:

   • Adequate pain management is essential for compliance with weight bearing restrictions
   • NSAIDs and appropriate analgesics should be considered

By following these guidelines, minimally displaced metatarsal fractures can be effectively managed with good functional outcomes and return to prior activity levels.