Treatment for Non-Displaced Fifth Metatarsal and Distal Phalanx Fractures
Non-displaced fractures of the fifth metatarsal and distal phalanges should be treated conservatively with protected weight-bearing in a rigid-soled shoe or cast shoe for 4-6 weeks, with immediate active toe motion exercises to prevent stiffness. 1, 2
Initial Management
Immobilize the foot in a rigid-soled shoe or cast shoe rather than a CAM-walker boot, as patients treated in a rigid-soled shoe return to pain-free walking faster (4.6 vs 8.4 weeks) and report the treatment as significantly less restrictive 2, 3
Allow immediate full weight-bearing with the protective footwear, as this approach produces excellent functional outcomes without compromising fracture healing 2, 4
Never restrict toe motion at any point during treatment—the immobilization device must allow full range of motion of all toes, as finger/toe motion does not adversely affect adequately stabilized fractures and restriction increases stiffness risk 5, 6
Initiate active toe flexion and extension exercises immediately to prevent the most common complication of these fractures: digital stiffness 5
Follow-Up Protocol
Obtain radiographs at 3-4 weeks to confirm maintenance of alignment and assess early healing 5, 3
Continue immobilization for 4-6 weeks total for metatarsal fractures, with most patients achieving bony union by 8 weeks 1, 2
Obtain final radiographs at the time of immobilization removal to document healing 5
Average time to return to normal footwear is 6-7 weeks, with return to prior activity levels by 8-10 weeks 2, 3
Critical Monitoring Points
Watch for displacement during healing—if post-reduction displacement exceeds 2-3mm or angulation exceeds 10 degrees, surgical fixation becomes indicated 1, 4
Reevaluate any patient with unremitting pain, as this may indicate complications requiring intervention 6
Monitor for delayed union, which occurs in approximately 10% of fifth metatarsal fractures and may require extended immobilization or surgical intervention 2, 7
Common Pitfalls to Avoid
Do not use a CAM-walker boot as first-line treatment—while it may show slightly faster radiographic healing (7.2 vs 8.6 weeks), patients report significantly worse functional restriction and no difference in return to activities 2, 3
Do not immobilize beyond 6 weeks unless healing is delayed, as prolonged immobilization increases stiffness risk and complications occur in approximately 14.7% of cases 5, 6
Do not restrict weight-bearing—protected full weight-bearing produces excellent outcomes in non-displaced fractures 2, 4