What is the recommended treatment for a 5th metatarsal fracture?

Treatment of 5th Metatarsal Fractures

For 5th metatarsal fractures, a CAM walker boot with weight-bearing as tolerated is the recommended first-line treatment for non-displaced or minimally displaced fractures, as it provides faster bone healing compared to hard-soled shoes. 1

Classification and Treatment Algorithm

Treatment depends on the fracture type, location, and displacement:

1. Tuberosity Avulsion Fractures (Zone 1)

• Non-displaced (<2mm):

  • Initial treatment: CAM walker boot with weight-bearing as tolerated 1, 2
  • Duration: 6-8 weeks
  • Follow-up: Clinical and radiographic assessment at 2,6, and 12 weeks 1
  • Return to activities: Typically 8-10 weeks 1

• Displaced (>2mm) or involving >30% of cubometatarsal joint:

  • Surgical fixation indicated 1, 3

2. Jones Fractures (Zone 2)

Treatment based on Torg classification:

• Type I (acute fracture): Non-operative treatment with CAM walker boot and non-weight bearing for 6-8 weeks 3, 4
• Type II (delayed union):
  • Non-athletes: Non-operative treatment possible
  • Athletes: Surgical fixation recommended for faster return to sports 1
• Type III (non-union with medullary sclerosis): Surgical fixation regardless of activity level 1, 3

3. Diaphyseal/Shaft Fractures

• Non-displaced or minimally displaced (<3-4mm): CAM walker boot for 4-6 weeks 3, 4
• Displaced (>3-4mm) or angulated (>10°): Surgical fixation with K-wires, plate, or screws 3

Evidence Supporting CAM Walker Boot

Research demonstrates that CAM walker boots are superior to other conservative treatments:

• Significantly faster bone healing (7.2 weeks) compared to hard-soled shoes (8.6 weeks) 2
• More effectively offloads the fifth metatarsal during common gait activities than postoperative sandals or standard athletic shoes 5
• Lower peak pressure and contact pressure at the fifth metatarsal during walking and heel-walking 5

Follow-up Protocol

• Regular follow-up at 2,6, and 12 weeks with clinical and radiographic assessment 1
• Progressive weight-bearing based on clinical and radiographic healing
• Typical bone healing occurs within 7-8 weeks 1, 2
• Return to prior activity levels:
  • Conservative treatment: 8-10 weeks 1, 2
  • Surgical treatment: 10-14 weeks 1

Important Considerations

• Avoid conventional footwear without proper offloading as this may delay healing 1
• Athletic patients may benefit from early surgical fixation for faster return to sports 1
• Diabetic patients with neuropathy may require different offloading approaches including total contact casts or non-removable knee-high walkers 1
• Pediatric patients require special attention to growth plate protection 1

Common Pitfalls to Avoid

1. Inadequate immobilization: Using regular shoes instead of proper offloading devices can delay healing
2. Premature weight-bearing: Especially for Jones fractures, which have higher risk of non-union
3. Missed diagnosis: Always obtain standard three radiographic views (anteroposterior, lateral, and mortise) 1
4. Failure to recognize surgical indications: Displaced fractures or those involving >30% of the cubometatarsal joint require surgical intervention 1, 3

Early functional treatment with appropriate immobilization in a CAM walker boot allows for earlier weight-bearing, faster healing, and shorter sick leave periods compared to other conservative methods 2, 6.