What is the treatment for a 2nd proximal metatarsal avulsion fracture?

Treatment of 2nd Proximal Metatarsal Avulsion Fracture

Conservative treatment with functional immobilization in a walking boot is the recommended approach for a 2nd proximal metatarsal avulsion fracture, allowing for weight-bearing as tolerated. 1, 2

Initial Management

• Proper radiographic evaluation with three standard views (anteroposterior, lateral, and mortise) is necessary to confirm diagnosis and assess displacement 2
• Initial pain management should include simple analgesics such as paracetamol on a regular basis, with cautious use of opioids if needed 1
• Early fracture fixation provides the most effective pain relief, but most proximal 2nd metatarsal avulsion fractures can be managed non-operatively 2

Treatment Protocol

• For non-displaced or minimally displaced fractures:
  • Initial immobilization with a walking boot for 2-3 weeks 3
  • Weight-bearing as tolerated in the walking boot 4
  • Progressive mobilization and walking therapy after initial immobilization 5
• For displaced fractures (>2mm):
  • Consider surgical fixation if significant displacement cannot be corrected by closed reduction 5
  • CT imaging may be beneficial to evaluate the true extent of osseous injury and guide surgical planning 2

Rehabilitation

• After 2-3 weeks in the walking boot, transition to a rigid-sole shoe for an additional 3-4 weeks 3
• Early introduction of physical training and muscle strengthening followed by balance training is recommended 2
• Regular radiographic assessment at 5-6 weeks to ensure proper healing and alignment 5, 2

Prognosis and Complications

• Proximal 2nd metatarsal fractures are considered high-risk stress fractures according to the American College of Radiology 1
• Complete radiographic union typically occurs within 6-8 weeks 6
• Prolonged immobilization may lead to stiffness and muscle atrophy, requiring appropriate rehabilitation 2
• MRI may be useful for prognostic information if there are concerns about healing, as it can predict time to return to full activity 1

Special Considerations

• For athletic individuals, a more aggressive approach with earlier return to activity may be considered after adequate healing is demonstrated 7
• For patients with diabetes or neuropathy, special attention should be paid to offloading the foot to prevent complications 2
• Avoid non-steroidal anti-inflammatory drugs in elderly patients or those with renal dysfunction 1

Follow-up

• Clinical and radiographic assessment at 2-3 weeks, 6 weeks, and 12 weeks post-injury 5
• Return to full activities typically occurs between 6-12 weeks depending on healing progress and patient's functional demands 4, 6
• Consider MRI for persistent symptoms to rule out incomplete healing or progression to stress fracture 1