What is the recommended treatment for a severely displaced oblique fracture of the mid diaphysis of the fifth metatarsal with significant distraction and surrounding soft tissue swelling?

Treatment of Severely Displaced Oblique Fracture of the Mid Diaphysis of the Fifth Metatarsal

Open reduction and internal fixation (ORIF) is the recommended treatment for severely displaced oblique fracture of the mid diaphysis of the fifth metatarsal with 3.2 mm distraction and surrounding soft tissue swelling. 1

Rationale for Surgical Management

• Surgical intervention is indicated when fifth metatarsal shaft fracture displacement exceeds 3-4 mm or angulation is greater than 10 degrees 2
• The presence of 3.2 mm distraction in this case clearly meets the threshold for surgical intervention 1, 2
• Surgical management aims to restore anatomical structure of the forefoot including length, axis, rotation, and joint position 1
• Soft tissue swelling indicates acute injury requiring prompt management to prevent further complications 3

Surgical Approach Options

Plate Fixation (Preferred Method)

• For markedly shortened and multifragment shaft fractures, open reduction and plate fixation is the method of choice 1
• Interlocking plates with screw diameter of 2.0-2.4 mm are preferred to minimize soft tissue irritation 1
• Anatomic reconstruction should be performed under longitudinal traction using small reduction clamps 1

Alternative Fixation Methods

• For long spiral fifth metatarsal shaft fractures, screw fixation may be considered 1
• For transverse fractures, percutaneous antegrade or retrograde medullary wiring with two Kirschner wires is an option 1
• In cases with minimal displacement, percutaneous K-wire fixation may be sufficient 2

Surgical Technique Considerations

• Lateral approach is typically used, with incision centrally above the easily palpable metatarsal shaft 1
• For oblique fractures, interfragmentary lag screws can be used for fracture compression if fragments are large enough 1
• Careful attention to soft tissue handling is essential given the existing swelling 3

Postoperative Management

• Initial rest, elevation of the injured leg, and local cooling are indicated 1
• Mobilization with partial weight bearing (20 kg) in foot orthosis or cast shoe for 6 weeks 1
• Progressive weight bearing protocol: 25% at week 3,50% at week 4,75% at week 5, and 100% at week 6 4
• Range-of-motion exercises and strengthening should begin after the initial 2-week non-weight-bearing period 4

Expected Outcomes

• Surgical treatment of displaced fifth metatarsal shaft fractures has good to excellent prognosis with high union rates 1
• Mean healing time for surgically managed fifth metatarsal diaphyseal fractures is approximately 7.73 weeks 5
• Complication rates are low (approximately 6.25%) with surgical management 5
• Nonunion rates with surgical treatment (1.56%) are significantly lower than with nonoperative treatment for displaced fractures 5

Potential Complications to Monitor

• Delayed union or nonunion (rare with proper surgical fixation) 5
• Superficial infection (approximately 1.56% of cases) 5
• Hardware-related irritation potentially requiring removal 5
• Malunion affecting metatarsal parabola and weight distribution across the forefoot 5

Contraindications to Surgery

• Critical life-threatening general condition preventing surgery 1
• Contaminated or infected soft tissues 1
• Lack of patient consent 1

The evidence strongly supports surgical management for this severely displaced oblique fracture of the fifth metatarsal with 3.2 mm distraction, as it exceeds the established threshold for displacement requiring surgical intervention. ORIF with plate fixation is likely to provide the best outcomes in terms of anatomic reduction, fracture healing, and restoration of normal foot biomechanics.