Treatment of Metatarsal Fractures
The treatment for metatarsal fractures primarily involves protected weight bearing in a cast shoe or walking boot for 4-6 weeks for nondisplaced fractures, while displaced fractures often require internal fixation. 1
Treatment Based on Fracture Type and Location
Nondisplaced Metatarsal Fractures
- Nondisplaced fractures and fractures of the second to fourth metatarsal with displacement in the horizontal plane can be treated conservatively with protected weight bearing in a cast shoe for 4-6 weeks 1
- For metatarsal shaft fractures, initial treatment includes a posterior splint and avoidance of weight-bearing activities, followed by a short leg walking cast or boot for four to six weeks 2
Displaced Metatarsal Fractures
- Most displaced fractures require closed reduction with internal fixation to maintain alignment 1
- Percutaneous pinning is suitable for most fractures of the lesser metatarsals 1
- Fractures with joint involvement and multiple fragments frequently require open reduction and plate fixation 1
Fifth Metatarsal Fractures (Special Considerations)
Fifth metatarsal tuberosity avulsion fractures (Zone 1) can be treated with:
Jones fractures (Zone 2 - fractures at the metaphyseal-diaphyseal junction):
- Higher risk of nonunion due to vascular watershed region 4
- Traditional treatment requires at least six to eight weeks in a short leg non-weight-bearing cast; healing time can be as long as 10 to 12 weeks 2
- Recent evidence suggests that immediate weight bearing as tolerated in a walking boot may be effective for minimally displaced Jones fractures in low-demand adults 4
- Requires an individualized approach tailored to the patient's level of activity and time to union 1
Toe Fractures
- Great toe fractures: Short leg walking boot or cast with toe plate for two to three weeks, then a rigid-sole shoe for an additional three to four weeks 2
- Lesser toe fractures: Buddy taping and a rigid-sole shoe for four to six weeks 2
Surgical Management
- Avulsion fractures of the fifth metatarsal bone require open reduction and tension-band wiring or screw fixation if displaced more than 2 mm or with more than 30% of the joint involved 1
- Symptomatic posttraumatic deformities need adequate correction, in most cases by osteotomy across the former fracture site 1
Special Considerations for Patients with Diabetes
- Proper fitting of orthotic devices is essential to prevent pressure sores and complications such as ulceration at the fracture site 5
- Special attention to offloading is required to prevent ulceration, with focus on proper wound care and management 5
- For diabetic patients with neuropathic plantar metatarsal head ulcers where non-surgical offloading fails, consider:
Follow-up and Return to Activity
- Average time to return to prior level of activities is approximately 8-10 weeks, depending on treatment method 3
- Early functional treatment with an orthopedic boot can allow full weightbearing after approximately 9 days, with average time of sick-leave around 19 days 7
Common Pitfalls and Caveats
- Failure to recognize displaced fractures that require reduction and fixation can lead to malunion and chronic pain 1
- Jones fractures have a higher risk of nonunion and require more aggressive management than other metatarsal fractures 2, 4
- Inadequate offloading in diabetic patients can lead to ulceration and significant complications 5