Management of Non-Displaced 5th Metatarsal Fracture
The initial management for a non-displaced fracture of the 5th metatarsal should be conservative treatment with protected weight-bearing in a rigid-sole shoe for 4-6 weeks, allowing early mobilization and weight-bearing as tolerated. 1, 2
Assessment and Diagnosis
- Diagnosis is typically confirmed with standing (weight-bearing) radiographs including:
- Anteroposterior (AP)
- Medial oblique
- Lateral projections 1
- The Ottawa rules can help determine if imaging is necessary, with specific attention to:
- Point bone tenderness at the base of the fifth metatarsal
- Inability to bear weight or walk 4 steps immediately after injury 3
Treatment Protocol
Immobilization Options
Rigid-sole shoe (Preferred):
CAM-Walker boot (Alternative):
- May provide faster radiographic healing (7.2 vs 8.6 weeks)
- Similar functional outcomes to rigid-sole shoe
- More restrictive for patients 5
Weight-bearing Status
- Progressive weight-bearing as tolerated with assistive devices initially if needed
- Full weight-bearing is encouraged as soon as pain allows 4
Pain Management
- Multimodal approach:
- NSAIDs (first-line)
- Acetaminophen
- Avoid opioids due to potential risks 1
Expected Healing Timeline
- Average time to radiographic healing: 7-8 weeks 4, 6, 5
- Return to prior activity levels: 8-10 weeks 5
- Pain-free walking: 4-8 weeks (depending on immobilization method) 4
Follow-up Protocol
- Clinical and radiographic follow-up at:
- 2 weeks: Ensure maintained alignment
- 4-6 weeks: Assess healing progress 1
- Monitor for complications:
- Delayed union (uncommon but possible)
- Persistent pain
- Malunion 1
Special Considerations
When to Consider Surgical Management
- Displacement >2-3mm
- Angulation >10 degrees
- Involvement of >30% of the cubometatarsal joint
- Failed conservative management with persistent symptoms after 6 weeks 7
Pitfalls and Caveats
- Avoid prolonged immobilization, which can lead to stiffness and delayed recovery
- Different types of 5th metatarsal fractures require different approaches:
- Avulsion fractures (Zone 1): Excellent results with conservative management
- Jones fractures (Zone 2): Higher risk of delayed union, may require more aggressive management
- Diaphyseal stress fractures (Zone 3): May require surgical intervention in active individuals 7
- Ensure proper differentiation between fracture types, as Jones fractures have higher non-union rates and may require more careful monitoring
The evidence strongly supports that non-displaced 5th metatarsal fractures can be effectively managed with conservative treatment, with rigid-sole shoes offering the best balance of healing and patient comfort while allowing earlier return to normal activities 4, 5.