Should a patient with a fifth metatarsal shaft fracture wear a post-operative (post-op) shoe until healing is evident on X-ray?

Management of Fifth Metatarsal Shaft Fractures: Duration of Post-Op Shoe Use

For uncomplicated fifth metatarsal shaft fractures, patients do not need to remain in a post-op shoe until radiographic healing is evident and can be safely discharged from the emergency department with weight-bearing as tolerated, structured advice, and access to follow-up only if problems arise. 1

Evidence-Based Rationale

Clinical Healing vs. Radiographic Healing

• Most fifth metatarsal shaft fractures are clinically healed well before radiographic union is visible, with only 29% showing radiological healing at final clinic visit despite successful clinical outcomes 2
• Radiographic follow-up before 6-8 weeks does not alter patient management in the vast majority of cases 2
• A large audit demonstrated that routine follow-up and serial X-rays provide no added clinical value, with only 1% requiring operative intervention for delayed/non-union 1

Recommended Treatment Protocol

Initial Management:

• Weight-bearing as pain allows with an elasticated support or removable boot from the time of initial presentation 1
• Discharge with structured advice and helpline access to experienced fracture clinic staff 1
• No routine face-to-face follow-up appointments needed 1

Duration of Immobilization:

• The post-op shoe or boot should be used for comfort and protection during the acute pain phase (typically 2-4 weeks), not until radiographic healing 1
• Early introduction of physical training and muscle strengthening should follow initial immobilization to prevent stiffness and muscle atrophy 3
• Prolonged immobilization beyond what is needed for pain control leads to unnecessary complications 3

When to Deviate from This Approach

Require closer follow-up and potentially longer immobilization:

• Displaced fractures (>3-4mm displacement or >10 degrees angulation) 4
• Fractures involving >30% of the cubometatarsal joint 4, 5
• Comminuted fractures 5
• Jones fractures (within 1.5cm of tuberosity) - these are problematic and may require 6-8 weeks non-weight-bearing or surgical fixation 6, 5

Special populations requiring modified approach:

• Patients with diabetes and neuropathy need special attention to offloading 7
• High-level athletes may benefit from earlier surgical intervention to avoid prolonged immobilization 6

Common Pitfalls to Avoid

• Do not routinely order serial radiographs - they rarely change management and only 1% develop complications requiring intervention 1
• Do not keep patients immobilized waiting for radiographic union - clinical healing precedes radiographic healing and prolonged immobilization causes harm 3, 2
• Do not schedule routine follow-up appointments - a protocol with structured discharge advice and helpline access is safer and more patient-centered 1

Monitoring Strategy

• Provide clear return precautions: increasing pain, inability to bear weight after initial improvement, or concerns about healing 1
• Reserve radiographic follow-up for patients with persistent symptoms beyond 6-8 weeks 2
• Virtual clinic review can be used for more complex cases without requiring in-person visits 1