Does a spiral fracture of the metatarsal require surgery or can it be treated with a cast?

Management of Spiral Fracture of the Metatarsal

A spiral fracture of the metatarsal can be effectively treated with conservative management using a rigid sole shoe or walking boot, without the need for surgery in most cases.

Assessment and Diagnosis

• Spiral fractures of the metatarsal are typically diagnosed through clinical examination and radiographic imaging
• Radiographs (anteroposterior, lateral, and mortise views) are the initial imaging modality of choice 1
• CT may be useful for complex fractures or when radiographs are inconclusive 1
• MRI may be considered for suspected occult fractures with persistent pain after negative radiographs 2

Treatment Options

Conservative Management (Recommended for Most Cases)

1. Non-surgical approach is recommended for most spiral metatarsal fractures, even with displacement 3, 4

   • Research shows excellent long-term functional outcomes with non-operative management 3
   • A study of 142 displaced oblique spiral fractures of the fifth metatarsal showed excellent outcomes with non-operative treatment over a 3.5-year follow-up period 3

2. Immobilization options:

   • Rigid sole shoe: Provides better outcomes compared to a walking boot
     • Shorter time to pain-free walking (4.6 vs 8.4 weeks)
     • Earlier return to normal footwear (6 vs 7.3 weeks)
     • Less restrictive for patients 4
   • Walking boot or cast shoe for 4-6 weeks with protected weight bearing 5
   • For more unstable fractures: short-leg non-weight bearing cast for 6-8 weeks 6

3. Weight bearing status:

   • Early weight bearing with a rigid sole shoe is recommended 4
   • Protected weight bearing for 4-6 weeks for more unstable fractures 5

4. Pain management:

   • NSAIDs such as ibuprofen 400-600mg three times daily 2
   • Acetaminophen if NSAIDs are contraindicated

Surgical Management (Limited Indications)

Surgical intervention should be considered in the following scenarios:

• Comminuted or severely displaced fractures
• Fractures involving >30% of the articular surface
• Painful nonunions
• Type III fractures (sclerotic margins with recurrent fracture) 6

Surgical options include:

• Open reduction and internal fixation with screws or plates
• Percutaneous pinning for certain displaced fractures 5

Expected Outcomes and Follow-up

• Average time to bony union: 8.3 weeks 4
• Time to pain-free walking: 4.6-8.4 weeks (depending on treatment method) 4
• Return to normal footwear: 6-7.3 weeks 4
• Excellent long-term functional outcomes with non-operative management 3

Potential Complications

• Delayed union (uncommon): Seen in approximately 2% of cases 3, 4
• Nonunion (rare): May require surgical intervention if painful 3
• Refracture: Rare but possible, especially with early return to high-impact activities 7

Special Considerations

• During the COVID-19 pandemic, guidelines have emphasized maximizing the use of removable casts and splints to minimize hospital visits 1
• For dancers and athletes with spiral "dancer's fracture" of the fifth metatarsal, non-operative treatment is still recommended with expected return to performance in approximately 19 weeks 7

Conclusion

Based on the most recent and highest quality evidence, spiral fractures of the metatarsal can be successfully managed non-operatively with excellent functional outcomes, even when displaced. A rigid sole shoe with early weight bearing appears to provide the best balance of healing and functional recovery.