What is the treatment protocol for a 2nd metatarsal fracture?

Treatment Protocol for 2nd Metatarsal Fracture

The treatment of a 2nd metatarsal fracture primarily involves immobilization with a short leg walking cast or boot for 4-6 weeks, with progressive weight bearing as tolerated based on fracture stability and pain levels. 1, 2

Initial Assessment

• Proper radiographic evaluation with three standard views (anteroposterior, lateral, and mortise) is necessary for accurate diagnosis 3
• Weight-bearing radiographs, when possible, provide important information about fracture stability 3, 4
• Assess for obvious deformity, swelling, bruising, severe pain with movement, or inability to move the foot 5

Treatment Algorithm

Non-displaced 2nd Metatarsal Fractures

• Initial treatment: Protected weight bearing in a cast shoe or short leg walking boot for 4-6 weeks 6, 1
• No manipulation is required for non-displaced fractures 2
• Regular radiographic assessment to ensure proper healing and alignment 3

Displaced 2nd Metatarsal Fractures

• Closed reduction should be attempted for displaced fractures 6
• If reduction is successful but unstable, percutaneous pinning is suitable for maintaining alignment 6
• Fractures with joint involvement or multiple fragments may require open reduction and plate fixation 6
• Splinting of the fractured foot is useful to reduce pain, reduce risk for further injury, and facilitate transport to a medical facility 5

Immobilization Guidelines

• Rigid immobilization is preferred over removable splints for displaced fractures 5
• For stable fractures, a short leg walking cast or boot is recommended for 4-6 weeks 1, 2
• If an open wound is associated with the fracture, cover it with a clean dressing to lower the risk for contamination and infection 5

Weight-bearing Recommendations

• Initial protected weight bearing or non-weight bearing depending on fracture stability 1
• Progressive weight bearing as tolerated after initial immobilization period 4
• Return to full weight bearing typically after 4-6 weeks when clinical and radiographic healing is evident 2

Special Considerations

• If a fractured extremity appears blue, purple, or pale, immediate medical attention is required as this may indicate poor perfusion 5
• For patients with diabetes and neuropathy, special attention should be paid to offloading the foot to prevent complications 3
• Monitor preadolescent patients for signs of hypothermia if cooling is applied to associated soft tissue injuries 5

Rehabilitation Protocol

• Early introduction of physical training and muscle strengthening followed by long-term balance training is recommended after immobilization period 3
• Avoid prolonged immobilization to prevent stiffness and muscle atrophy 3
• Progressive mobility as tolerated after initial immobilization 1

Common Pitfalls and Complications

• Delayed diagnosis is common with 2nd metatarsal base fractures, which can lead to chronic midfoot pain 7
• Initial radiographs may not always show the fracture; consider additional imaging if pain persists 7
• Potential complications include arthritis, infection, malunion, or nonunion 2
• Recovery period can be prolonged, with mean recovery time of 14 months reported in some cases 7

Follow-up Care

• Regular radiographic assessment to ensure proper healing and alignment 3
• If symptoms persist beyond expected healing time, consider additional imaging to rule out nonunion 7
• Some patients may require surgical bone grafting if nonunion occurs 7