Management of Distal 1st Metatarsal Fractures
For distal 1st metatarsal fractures, conservative treatment with protected weight bearing in a cast shoe or walking boot for 4-6 weeks is recommended for non-displaced fractures, while displaced fractures typically require surgical fixation. 1
Assessment of Fracture
When evaluating a distal 1st metatarsal fracture, the following factors determine management:
- Displacement (>3-4 mm)
- Angulation (>10° in any plane)
- Joint involvement
- Comminution
- Soft tissue injury
Treatment Algorithm
Non-displaced Fractures
- Initial treatment: Protected weight bearing
- Immobilization: Cast shoe or controlled ankle motion (CAM) walker boot
- Duration: 4-6 weeks
- Follow-up: Radiographic evaluation at 3 weeks and at cessation of immobilization 2
Displaced Fractures (>3-4 mm or >10° angulation)
- Recommendation: Surgical fixation 1, 3
- Technique options:
- Closed reduction with percutaneous pinning
- Open reduction and internal fixation (ORIF) with plate fixation (especially for intra-articular or comminuted fractures)
Specific Considerations for 1st Metatarsal
The 1st metatarsal requires special attention due to its critical role in:
- Weight bearing
- Push-off during gait
- Stability of the medial column of the foot
Unlike central metatarsals (2nd-4th), the 1st metatarsal has less tolerance for displacement or angulation due to its biomechanical importance 3. Even minor malunion can lead to significant pain and disability.
Immobilization Options
Research shows both rigid immobilization and CAM walker boots can be effective:
- CAM walker boot: May lead to faster radiographic healing (average 7.2 weeks) compared to hard-soled shoes (8.6 weeks) 4
- Hard-soled shoe: Similar clinical and functional outcomes to CAM walker boot, despite slightly longer healing time 4
Duration of Treatment
- Protected weight bearing: 4-6 weeks
- Return to normal activities: 8-10 weeks on average 4
- Follow-up imaging: At 4 weeks and as needed until clinical and radiographic healing
Complications to Monitor
- Malunion: Can cause metatarsalgia, transfer lesions, and gait abnormalities
- Delayed union or non-union: More common with inadequate immobilization
- Post-traumatic arthritis: Particularly with intra-articular fractures
- Stiffness: May require physical therapy after immobilization period
Rehabilitation
After the immobilization period:
- Progressive weight bearing as tolerated
- Range of motion exercises
- Strengthening exercises
- Gradual return to previous activity level
Pitfalls to Avoid
- Inadequate immobilization leading to displacement
- Overlooking intra-articular extension of fractures
- Missing associated Lisfranc injuries
- Returning to full activities too early
For optimal outcomes, management should focus on maintaining proper alignment of the 1st metatarsal to prevent long-term disability and pain from malunion 1, 3.