Treatment of 5th Metatarsal Neck Fractures
Most 5th metatarsal neck fractures should be treated conservatively with protected weight-bearing in a cast shoe or walking boot for 4-6 weeks, as nondisplaced and minimally displaced fractures heal reliably without surgery. 1
Initial Assessment and Imaging
Standard ankle radiographs (AP, lateral, and mortise views) should include the base of the 5th metatarsal distal to the tuberosity to adequately visualize neck fractures. 2
Treatment Algorithm Based on Displacement
Non-displaced or Minimally Displaced Fractures
- Treat conservatively with immediate full weight-bearing as tolerated in a stable orthosis or cast shoe for 4-6 weeks 3, 4
- Functional treatment with full weight-bearing produces excellent outcomes (VAS-FA score 96±4) regardless of fracture characteristics 4
- Return to work typically occurs within 17±12 days and return to sports within 53±22 days 4
Grossly Displaced Fractures
- Open reduction and internal fixation is indicated for grossly dislocated neck fractures 3
- Plate fixation with interlocking plates (2.0-2.4 mm screw diameter) is the method of choice for markedly shortened and multifragment subcapital fractures 3
- Alternative fixation methods include percutaneous antegrade or retrograde medullary wiring with two Kirschner wires for transverse or subcapital fractures 3
- Post-operative protocol: partial weight-bearing (20 kg) in foot orthosis or cast shoe for 6 weeks 3
Important Clinical Considerations
Fracture characteristics such as displacement, intra-articular involvement, and number of fragments do NOT significantly influence outcomes with functional treatment. 4 This challenges traditional surgical indications based solely on these radiographic features.
Common Pitfalls to Avoid
- Do not routinely operate on displaced neck fractures without considering functional treatment first, as even displaced fractures heal well conservatively 4
- Avoid prolonged immobilization beyond 6 weeks, as this provides no additional benefit 1, 3
- Do not confuse neck fractures with Jones fractures (metaphyseal-diaphyseal junction), which require different management 1
Pediatric Considerations
In children and adolescents, neck and shaft fractures of the 5th metatarsal do well with casting alone. 5 However, displaced intra-articular fractures should be treated with non-weight bearing casts to avoid delays in healing and angulation. 5