Management of Fifth Metatarsal Fractures
For nondisplaced fifth metatarsal fractures, immediate weight-bearing as tolerated with a hard-soled shoe or CAM-walker boot is recommended, with discharge from the emergency department and no routine follow-up required. 1, 2
Initial Diagnostic Evaluation
- Obtain three standard radiographic views (anteroposterior, lateral, and mortise) that include the base of the fifth metatarsal 1, 2
- Weight-bearing radiographs should be obtained when possible to assess fracture stability 1, 2
- Apply the Ottawa Ankle Rules to determine imaging necessity in ankle trauma patients 1
Treatment Algorithm by Fracture Type
Zone 1 (Tuberosity Avulsion) Fractures - Most Common
Nondisplaced (<2mm displacement):
- Allow immediate weight-bearing as tolerated with either a hard-soled shoe or CAM-walker boot 1, 3
- CAM-walker boots demonstrate faster radiographic healing (7.2 weeks vs 8.6 weeks) but similar functional outcomes compared to hard-soled shoes 3
- Discharge from emergency department with structured advice and helpline access—no routine clinic follow-up needed 1, 4
- Progressive weight-bearing after initial immobilization period 1
Displaced (>2mm displacement):
- Surgical management with open reduction internal fixation or closed reduction with percutaneous fixation is recommended 5
- Surgery eliminates nonunion risk (0% vs 35.5% with conservative management) and ensures timely return to activity 5
Zone 2 (Jones Fractures - Acute Metaphyseal-Diaphyseal Junction)
- Non-weight-bearing cast immobilization for 6-8 weeks achieves 72-93% union rates 6
- For high-performance athletes, early intramedullary screw fixation is the preferred treatment option 6
Zone 3 (Diaphyseal Stress Fractures)
- Operative fixation with closed axial intramedullary screw fixation or autogenous corticocancellous grafting 6
Rehabilitation Protocol
- Early introduction of physical training and muscle strengthening after immobilization 1, 2
- Follow with long-term balance training and fall prevention 2
- Avoid prolonged immobilization beyond 6 weeks to prevent stiffness and muscle atrophy 7
Follow-Up and Monitoring Strategy
The evidence strongly supports minimal follow-up for most fifth metatarsal fractures:
- Routine outpatient follow-up provides no added clinical value for uncomplicated fractures 4
- Follow-up radiographs before 6-8 weeks do not alter management 8
- Only 1% of conservatively managed fractures require operative intervention for delayed/nonunion 4
- Regular radiographic assessment is only necessary for displaced fractures or those with concerning clinical features 1, 2
Pain Management
- Early fracture stabilization through proper immobilization provides the most effective analgesia 2, 7
- Rigid immobilization is preferred over removable splints for displaced fractures 7
Critical Pitfalls to Avoid
- Do not fail to include the base of the fifth metatarsal in ankle radiographs 1, 2
- Do not routinely schedule follow-up appointments for nondisplaced fractures—this creates unnecessary healthcare utilization without improving outcomes 4
- Do not obtain serial radiographs before 6-8 weeks as they rarely change management 8
- Do not prolong immobilization beyond 6 weeks as this leads to stiffness requiring extensive rehabilitation 7
- Address smoking preoperatively as it significantly increases nonunion risk 7