What is the initial treatment for a 5th metatarsal head fracture?

Initial Treatment for 5th Metatarsal Head Fracture

The initial treatment for a 5th metatarsal head fracture is protected weight bearing in a cast shoe or controlled ankle motion (CAM) walker boot for 4-6 weeks. 1

Treatment Algorithm

Non-displaced or Minimally Displaced Fractures

• Conservative treatment is appropriate for non-displaced fractures and fractures with minimal displacement in the horizontal plane 1
• Options include:
  • Hard-soled shoe (HSS) for 4-6 weeks 2
  • Controlled ankle motion (CAM) walker boot for 4-6 weeks 2
  • Protected weight bearing during this period 1

Comparative Outcomes

• CAM walker boots show faster bone healing (average 7.2 weeks) compared to hard-soled shoes (average 8.6 weeks) 2
• Despite differences in healing time, both treatments achieve similar clinical and functional outcomes 2
• Return to prior activity levels is comparable between both treatment options (8.3 weeks for CAM walker boot vs 9.7 weeks for hard-soled shoe) 2

Displaced Fractures

• Fractures with significant displacement (>2mm) or involving >30% of the joint surface require more aggressive intervention 1
• Treatment options include:
  • Closed reduction with percutaneous pinning for most displaced fractures 1
  • Open reduction and internal fixation (ORIF) with plate fixation for fractures with joint involvement or multiple fragments 1, 3
  • Screw fixation for long spiral fractures 3

Special Considerations

Location-Specific Treatment

• For 5th metatarsal head fractures specifically (as opposed to base or shaft fractures), conservative treatment is typically sufficient unless there is significant displacement 1
• Metatarsal head fractures must be distinguished from Jones fractures (transverse fractures at the metaphyseal-diaphyseal junction), which may require more aggressive treatment 4

Follow-up and Monitoring

• Radiographic assessment at 4-6 weeks to evaluate healing 2, 5
• If no signs of healing are present at 6 weeks, consider extending immobilization or surgical intervention 4
• Virtual fracture clinic follow-up has shown excellent outcomes for management of 5th metatarsal fractures with high patient satisfaction 5

Risk of Complications

• Non-union rates are generally low for 5th metatarsal fractures (approximately 3.1%), with zone 1 (base) fractures having the lowest risk 5
• Most non-unions can be managed conservatively if asymptomatic 5
• Symptomatic non-unions may require surgical intervention 5

Pitfalls and Caveats

• Avoid excessive immobilization, which can lead to stiffness and delayed return to function 1
• Ensure proper fitting of orthotic devices to prevent pressure sores, especially in patients with diabetes 6
• Distinguish between different zones of 5th metatarsal fractures, as treatment approaches may differ 5
• For patients with diabetes, special attention should be paid to offloading to prevent ulceration at the fracture site 6