Treatment of Metatarsal Fractures
Most metatarsal fractures should be treated conservatively with initial immobilization followed by protected weight-bearing in a walking boot or cast shoe for 4-6 weeks, with treatment varying based on specific fracture location and displacement.
Initial Management
Non-Displaced Metatarsal Shaft Fractures (2nd-4th Metatarsals)
- Begin with a posterior splint and strict avoidance of weight-bearing activities initially 1
- Transition to a short leg walking cast or boot for 4-6 weeks 1
- Protected weight-bearing in a cast shoe is appropriate for non-displaced fractures and those with displacement only in the horizontal plane 2
Displaced Metatarsal Shaft Fractures
- Most displaced fractures require closed reduction followed by internal fixation to maintain alignment 2
- Percutaneous pinning is the preferred method for most lesser metatarsal fractures requiring fixation 2
- Fractures with joint involvement or multiple fragments frequently require open reduction and plate fixation 2
Location-Specific Treatment Algorithms
Fifth Metatarsal Base Fractures (Zone 1 - Tuberosity Avulsion)
- Treat acutely with a compressive dressing, then transition to a short leg walking boot for 2 weeks with progressive mobility as tolerated 1
- Alternative treatment with hard-soled shoes achieves similar clinical outcomes, though CAM-walker boots demonstrate faster radiographic healing (7.2 weeks vs 8.6 weeks) 3
- If displaced more than 2 mm or involving more than 30% of the joint, open reduction with tension-band wiring or screw fixation is indicated 2
Fifth Metatarsal Jones Fractures (Zone 2 - Metaphyseal-Diaphyseal Junction)
- These fractures carry high nonunion risk and require at least 6-8 weeks in a short leg non-weight-bearing cast 1
- Healing time can extend to 10-12 weeks 1
- Recent evidence suggests immediate weight-bearing in a walking boot may be acceptable for low-demand patients, with 93.6% avoiding surgery 4
- Treatment should be individualized based on activity level, with surgical fixation considered for high-demand patients 2
Great Toe (First Metatarsal) Fractures
- Treat with a short leg walking boot or cast with toe plate for 2-3 weeks 1
- Follow with a rigid-sole shoe for an additional 3-4 weeks 1
Lesser Toe Metatarsal Fractures
- Buddy taping combined with a rigid-sole shoe for 4-6 weeks is sufficient 1
Special Populations: Diabetic Patients
Critical Considerations for Offloading
- Proper fitting of orthotic devices is essential to prevent pressure sores and ulceration at the fracture site 5, 6
- Special attention to offloading with focus on wound care and management is mandatory 5, 6
- Appropriately fitting footwear that cushions the feet and redistributes pressure is recommended, particularly for patients with neuropathy 7
Surgical Options When Conservative Treatment Fails
- For neuropathic plantar metatarsal head ulcers unresponsive to non-surgical offloading, consider Achilles tendon lengthening combined with an offloading device 5
- Metatarsal head resection combined with an offloading device is recommended when osteomyelitis or metatarsophalangeal joint infection is identified 5
- Joint arthroplasty may be considered for hallux ulcers with limited range of motion of the first metatarsophalangeal joint 5
Common Pitfalls to Avoid
- Do not use conventional footwear or standard therapeutic shoes in place of proper offloading devices in diabetic patients 7
- Jones fractures are frequently undertreated with inadequate immobilization duration, leading to nonunion 1
- Displaced fractures of the lesser metatarsals often lose reduction without internal fixation 2
- Stress fractures of the metatarsals are common and typically require only conservative management, but should not be confused with acute traumatic fractures 2