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

Treatment for 5th Metatarsal Transverse Fracture

The treatment for a 5th metatarsal transverse fracture should primarily consist of symptomatic treatment with a double elasticated bandage or orthopedic boot, as immobilization in a cast has not shown superior outcomes in terms of patient-reported measures. 1

Classification and Assessment

Before determining treatment, proper assessment is essential:

1. Radiographic evaluation: Three standard views should be obtained:

   • Anteroposterior
   • Lateral
   • Mortise views (including the base of the fifth metatarsal) 2

2. Classification of fracture type:

   • Tuberosity avulsion fractures (most common)
   • Shaft fractures
   • Jones fractures (at the metaphyseal-diaphyseal junction)
   • Stress fractures 3

Treatment Algorithm

Non-displaced or Minimally Displaced Transverse Fractures

1. First-line treatment:

   • Symptomatic treatment with double elasticated bandage 1
   • Orthopedic boot allowing early weight-bearing 4

2. Expected outcomes:

   • Return to full weight-bearing within approximately 9 days 4
   • Average time of sick leave: 19 days 4
   • Complete return to pre-injury activity levels within 33 days (compared to 46 days with cast immobilization) 5

3. Follow-up:

   • Radiographic evidence of healing typically present by 44-65 days 5
   • Regular imaging to assess healing progression at 2,6, and 12 weeks 6

Displaced Fractures

Surgical intervention is indicated when:

• Displacement is more than 3-4mm
• Angulation is more than 10 degrees
• More than 30% of the cubometatarsal joint is involved 3

Surgical options include:

• Percutaneous K-wire fixation
• Plate fixation
• Screw fixation 3

Special Considerations for Jones Fractures

Treatment depends on Torg classification and patient activity level:

• Type I (acute fracture): Non-operative treatment
• Type II (delayed union): Treatment depends on patient activity level
  • Low activity: Non-operative treatment
  • High activity: Surgical fixation
• Type III (non-union with sclerosis): Surgical treatment recommended 3, 7

Rehabilitation Protocol

1. Early phase (0-2 weeks):

   • Pain management with acetaminophen as primary treatment 6
   • Protected weight-bearing with orthopedic boot or bandage
   • Elevation and ice for swelling control

2. Middle phase (2-6 weeks):

   • Progressive weight-bearing as tolerated
   • Gentle range of motion exercises
   • Strengthening of intrinsic foot muscles

3. Late phase (6+ weeks):

   • Return to normal footwear when radiographic healing is evident
   • Progressive return to activities
   • Balance and proprioception training

Common Pitfalls and Caveats

1. Misdiagnosis: Transverse 5th metatarsal fractures can be mistaken for ankle sprains. Proper radiographic assessment is crucial when there is point tenderness over the 5th metatarsal 2.

2. Delayed healing: Jones fractures (at the metaphyseal-diaphyseal junction) are prone to delayed union or non-union due to the watershed blood supply in this region. Close monitoring is essential 7.

3. Premature return to activity: Even with symptomatic treatment, patients should be advised against returning to high-impact activities until radiographic healing is confirmed.

4. Inadequate follow-up: Regular imaging is important to ensure proper healing and to identify complications early 6.

The evidence strongly supports that symptomatic treatment with a functional approach (bandage or orthopedic boot) is as effective as cast immobilization for non-displaced transverse 5th metatarsal fractures, with the benefit of earlier return to function and improved patient satisfaction 1, 4, 5.