Treatment of Displaced, Angulated Mid-Shaft Fifth Metatarsal Fracture
For a displaced and angulated mid-shaft fifth metatarsal fracture, surgical fixation with either plate fixation or percutaneous screw fixation is recommended when displacement exceeds 3-4mm or angulation exceeds 10 degrees, as these thresholds are associated with poor outcomes and delayed healing with conservative management. 1
Treatment Algorithm Based on Displacement and Angulation
Surgical Indications (Preferred Approach for Your Case)
- Displacement >3-4mm or angulation >10 degrees requires operative intervention to restore anatomical alignment and prevent complications 1
- Surgical treatment achieves high union rates (89-100%) and excellent functional outcomes for displaced shaft fractures 2, 3
Surgical Options
Option 1: Plate Fixation (Preferred for Markedly Displaced/Comminuted Fractures)
- Open reduction and internal fixation via lateral approach over the palpable fifth metatarsal shaft 2
- Use interlocking plates with 2.0-2.4mm screw diameter to minimize soft tissue irritation 2
- Anatomic reconstruction under longitudinal traction at the fifth toe using reduction clamps and temporary K-wire fixation 2
- Consider interfragmentary lag screws for compression if fragments are large enough 2
Option 2: Percutaneous Screw Fixation (For Long Spiral Fractures)
- Alternative for long spiral shaft fractures with less soft tissue disruption 2
- Minimally invasive approach reduces infection risk and operative time 3
Option 3: Percutaneous K-Wire Fixation
- Consider antegrade or retrograde medullary wiring with two Kirschner wires for transverse shaft fractures 2
- Useful when displacement is moderate (3-4mm range) 1
Post-Operative Protocol
- Weeks 0-2: Non-weight bearing in soft wrap and postoperative boot, keep incision clean and dry 3
- Weeks 2-6: Progressive weight bearing (25% at week 3,50% at week 4,75% at week 5,100% at week 6) in foot orthosis or cast shoe 2, 3
- Weeks 6-8: Increase walking and physical therapy, continue ankle range-of-motion exercises 3
- Weeks 8-12: Begin pool or treadmill activity 3
- Radiographic union expected between weeks 6-10 3
Critical Pitfalls to Avoid
- Do not treat displaced/angulated shaft fractures conservatively - this leads to malunion, prolonged healing, and poor functional outcomes 1
- Avoid making incisions too close to the proximal fifth metatarsal (stay 1-3cm proximal) to prevent soft-tissue tension and wound complications 3
- Protect the sural nerve during lateral approach - use adequate soft-tissue retraction 3
- Do not allow immediate weight-bearing postoperatively - this increases risk of hardware failure and nonunion 3
- Avoid prolonged immobilization beyond 6 weeks as this leads to stiffness and muscle atrophy requiring extensive rehabilitation 4
Special Considerations
- Early fracture stabilization provides the most effective pain relief 4
- Rigid immobilization is preferred over removable splints for displaced fractures 5
- For adolescent patients, these fractures behave similarly to adults and should be treated with the same surgical indications 6
- Smoking increases nonunion risk and should be addressed preoperatively 7