Management of Non-Displaced Proximal First Metatarsal Fracture in a 3-Year-Old
A rigid short leg walking cast or CAM-walker boot is the recommended immobilization for this fracture, as first metatarsal fractures require aggressive treatment due to their critical role in weight-bearing and gait, and plaster immobilization is the consensus approach for closed, non-displaced first metatarsal fractures. 1
Immobilization Strategy
Primary Splinting Options
- Apply a short leg walking cast as the standard treatment for non-displaced first metatarsal fractures, which provides rigid immobilization while allowing the child to bear weight as tolerated 1
- A CAM-walker boot is an acceptable alternative that has demonstrated effective healing in pediatric metatarsal fractures, though most evidence exists for fifth metatarsal injuries 2
- The immobilization should extend from below the knee to the toes, ensuring the first ray is adequately stabilized 1
Weight-Bearing Protocol
- Allow immediate pain-oriented weight-bearing in the cast or boot, as this approach has been validated in pediatric metatarsal fractures without compromising healing 3, 4
- The child can bear weight as comfort permits, which facilitates faster return to normal activities 2
Duration of Immobilization
- Continue immobilization for 6-8 weeks based on clinical and radiographic healing, as first metatarsal fractures typically require this timeframe for adequate consolidation 1, 3
- Obtain radiographic follow-up at 3-4 weeks to assess healing progress and ensure no displacement has occurred 5
- Complete healing typically occurs by 6-8 weeks, at which point the cast or boot can be discontinued 3, 2
Critical Considerations for First Metatarsal Fractures
Why Aggressive Treatment Matters
- First metatarsal fractures drastically alter normal gait and weight-bearing patterns, making adequate immobilization essential to prevent long-term disability 1
- The first ray bears significant load during ambulation, and any malunion (particularly in the sagittal plane) can result in a non-plantigrade foot with prolonged functional impairment 1
- Displacement exceeding 3-4 mm or angulation exceeding 10° in any plane would require surgical consideration, but this fracture is non-displaced 6
Common Pitfalls to Avoid
- Do not use simple buddy taping or soft splinting for first metatarsal fractures, as these provide inadequate immobilization for this weight-bearing bone 1
- Avoid under-immobilization, which is the primary risk with first metatarsal fractures given their critical biomechanical role 1
- Do not delay immobilization, as early rigid stabilization prevents displacement and facilitates optimal healing 1
- Ensure the cast or boot is not overtightened, as this can compromise circulation, particularly important to monitor in young children 7
Special Pediatric Considerations
- At age 3, the child has excellent bone remodeling potential, but this does not justify accepting displacement in first metatarsal fractures due to their functional importance 8, 1
- Monitor for any signs of vascular compromise (blue, purple, or pale toes), which would require immediate intervention 7
- The child's family should be educated on signs of complications and the importance of maintaining immobilization despite the child's activity level 8