What is the recommended treatment for a patient with minimally displaced 2-4 metatarsal head fractures?

Treatment of Minimally Displaced 2-4 Metatarsal Head Fractures

Conservative management with protected weight-bearing in a cast shoe or CAM-walker boot for 4-6 weeks is the recommended treatment for minimally displaced metatarsal head fractures of the 2nd through 4th metatarsals. 1, 2

Initial Management and Immobilization

• Obtain radiographic confirmation with three standard views (anteroposterior, lateral, and mortise) to verify the fracture is truly minimally displaced 1

• Immobilize with a cast shoe or CAM-walker boot allowing protected weight-bearing immediately based on pain tolerance 2, 3

  • For minimally displaced fractures, removable splints are acceptable alternatives to rigid immobilization 1, 4
  • Continue immobilization for 4-6 weeks until clinical and radiographic healing is evident 2

Monitoring Protocol

• Perform radiographic assessment at 3 weeks to ensure the fracture has not displaced during treatment 1

• Repeat imaging at the end of immobilization (4-6 weeks) to confirm healing before advancing activity 1

• Monitor specifically for displacement exceeding surgical thresholds:

  • Shortening >3 mm 1
  • Dorsal tilt >10° 1
  • Any intra-articular displacement 1

Surgical Indications

Surgery is only necessary if the fracture displaces during conservative treatment beyond the thresholds listed above 1. The vast majority of minimally displaced 2nd-4th metatarsal head fractures heal successfully with conservative management 2.

Rehabilitation

• Begin early physical training and muscle strengthening exercises after the immobilization period ends 1

• Progress to long-term balance training to prevent stiffness and muscle atrophy from prolonged immobilization 1

• Ensure proper fitting of orthotic devices after immobilization to prevent pressure complications 1

Special Populations

For patients with diabetes and peripheral neuropathy, implement aggressive offloading strategies to prevent ulceration at the fracture site 5, 1:

• Consider non-removable knee-high offloading devices if ulceration develops 5
• Monitor closely for skin breakdown during immobilization 1
• Proper fitting of all devices is critical in this population 1

Common Pitfalls to Avoid

• Do not use conventional footwear during the healing period - this increases risk of displacement and delayed healing 2
• Do not skip the 3-week radiographic follow-up - this is when occult displacement becomes apparent 1
• Do not allow full unrestricted weight-bearing before radiographic confirmation of healing - premature loading can cause late displacement 2