What is the treatment for a comminuted metatarsal fracture?

Treatment for Comminuted Metatarsal Fractures

Surgical intervention with appropriate internal fixation is strongly recommended as the primary treatment for comminuted metatarsal fractures to optimize outcomes related to morbidity, mortality, and quality of life. 1

Initial Assessment and Classification

• Evaluate fracture pattern, location, and displacement using radiographs
• Consider CT scans for better assessment of fracture extent and preoperative planning 1
• Assess soft tissue damage, neurovascular status, and patient factors (age, activity level, comorbidities)

Treatment Options

Non-Surgical Management

• Reserved for minimally displaced, stable fractures
• Cast immobilization or specialized footwear
• Forefoot offloading shoes or half-shoes may be used to relieve pressure on the forefoot 2
• Non-weight bearing or partial weight bearing for 4-6 weeks

Surgical Management

• Indicated for:
  • Displaced fractures
  • Comminuted fractures
  • Fractures with articular involvement
  • Multiple metatarsal fractures
  • Open fractures

Surgical Techniques

1. Plate Fixation

   • Recommended for comminuted fractures or when lateral metatarsal bowing needs to be restored 3
   • High union rates and good functional outcomes
   • May require plate removal in approximately one-third of cases 3

2. Intramedullary Fixation

   • Less suitable for comminuted fractures 3
   • Better for simple fractures

3. Kirschner Wire Fixation

   • Useful for Lisfranc injuries with second metatarsal base comminuted fractures 4
   • Can avoid arthrodesis in certain cases

4. Bone Grafting

   • Autogenous cancellous bone graft may be necessary for defect nonunions 5
   • Facilitates complete healing and restoration of the bone column

5. Free Fibular Osteocutaneous Flap

   • For severe comminution with significant bone and soft tissue loss
   • Can help avoid proximal amputation 6
   • Allows for reconstruction of more than one ray if needed

Postoperative Care

• Immediate or early protected weight bearing based on fracture stability
• Regular radiographic follow-up at 2,6, and 12 weeks to assess healing 1
• Multimodal pain management approach
• Consider referral to bone health clinic for osteoporosis evaluation if appropriate 1

Rehabilitation

• Progressive weight bearing as healing progresses
• Range of motion exercises for the foot and ankle
• Strengthening exercises
• Custom orthoses or accommodative footwear may be needed

Potential Complications

• Delayed union or nonunion
• Malunion
• Hardware irritation requiring removal
• Post-traumatic arthritis
• Chronic pain
• Transfer metatarsalgia

Special Considerations

• In cases of significant comminution with bone defects, bone grafting should be considered early to prevent nonunion 5
• For severe injuries with bone and soft tissue loss, reconstructive options should be considered to avoid amputation 6
• Patients with diabetes or peripheral vascular disease require special attention to wound healing and infection prevention 2

The evidence strongly supports surgical management for comminuted metatarsal fractures to achieve optimal functional outcomes and reduce complications. The specific surgical technique should be selected based on fracture pattern, location, and patient factors, with plate fixation being particularly effective for comminuted fractures 3.