What is the management for metatarsal fractures?

Management of Metatarsal Fractures

The management of metatarsal fractures depends on the location, displacement, and stability of the fracture, with non-displaced fractures generally managed conservatively with protected weight bearing in a cast shoe for 4-6 weeks, while displaced fractures often require reduction and internal fixation. 1

Classification and Initial Assessment

• Proper radiographic evaluation with three standard views (anteroposterior, lateral, and mortise) is essential for accurate diagnosis of metatarsal fractures 2
• Weight-bearing radiographs provide important information about fracture stability when the stability is uncertain 2, 3
• Assess for obvious deformity, swelling, bruising, severe pain with movement, or inability to move the foot 3

Treatment Algorithm Based on Fracture Type

Non-displaced Metatarsal Fractures

• Non-displaced fractures of the 2nd to 4th metatarsals can be treated conservatively with protected weight bearing in a cast shoe for 4-6 weeks 1
• Regular radiographic assessment is necessary to ensure proper healing and alignment 2, 3
• A short leg walking boot or cast may be used for initial immobilization 4

Displaced Metatarsal Fractures

• Closed reduction should be attempted for displaced fractures, but internal fixation is often needed to maintain reduction 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
• If displacement is more than 3-4mm or angulation exceeds 10 degrees, surgical intervention is indicated 5

Specific Management for Fifth Metatarsal Fractures

• Fifth metatarsal tuberosity avulsion fractures:
  • If non-displaced: treated with compressive dressing initially, then transition to short leg walking boot for two weeks 4
  • If displaced more than 2mm or involving more than 30% of the cubometatarsal joint: open reduction and tension-band wiring or screw fixation 1, 5
• Jones fractures (transverse fractures at metaphyseal-diaphyseal junction):
  • Require at least 6-8 weeks in a short leg non-weight-bearing cast 4
  • Healing time can be as long as 10-12 weeks 4
  • Treatment approach should be individualized based on patient activity level and Torg classification 5

First Metatarsal Fractures

• Due to their importance in weight-bearing and gait, first metatarsal fractures should be treated aggressively 6
• Non-displaced fractures: plaster immobilization 6
• Displaced fractures: rigid internal fixation using AO techniques if open reduction is required 6

Weight-bearing Recommendations

• Initial protected weight bearing with appropriate immobilization device 1, 4
• Progressive weight bearing as tolerated after initial immobilization period 3
• For Jones fractures, non-weight-bearing status is typically maintained for 6-8 weeks 4

Rehabilitation Protocol

• Early introduction of physical training and muscle strengthening after the immobilization period 2, 3
• Long-term balance training and fall prevention exercises 2
• Avoid prolonged immobilization to prevent stiffness and muscle atrophy 2, 3
• When immobilization is discontinued, aggressive motion exercises are necessary to achieve optimal outcomes 7

Special Considerations

• For patients with diabetes and neuropathy, special attention should be paid to offloading the foot to prevent complications 2, 3
• Symptomatic treatment with elasticated bandage may be non-inferior to cast immobilization for avulsion fractures of the base of the fifth metatarsal 8
• Malunited metatarsal fractures can be a source of pain and disability, requiring correction through osteotomy in symptomatic cases 1

Follow-up Care

• Regular radiographic assessment to monitor healing progression 2, 3
• Typical follow-up schedule: 2 weeks, 4-6 weeks, and 12 weeks post-injury, with additional visits as needed based on fracture type and healing progress 4
• Patient education about potential complications and expected outcomes is essential 7