What is the treatment for a metatarsal fracture?

Treatment of Metatarsal Fractures

For most metatarsal shaft fractures, initial treatment consists of a posterior splint with non-weight-bearing, followed by a short leg walking cast or boot for 4-6 weeks. 1

Initial Management by Fracture Location

Metatarsal Shaft Fractures (2nd-4th Metatarsals)

• Non-displaced fractures and those with displacement only in the horizontal plane can be managed conservatively with protected weight-bearing in a cast shoe for 4-6 weeks. 2
• Begin with a posterior splint and strict avoidance of weight-bearing activities initially. 1
• Transition to a short leg walking cast or boot after the acute phase for the remainder of the 4-6 week period. 1
• Displaced fractures (>3-4mm displacement or >10 degrees angulation) require closed reduction followed by internal fixation, typically with percutaneous K-wires for lesser metatarsals. 2, 3
• Fractures with joint involvement and multiple fragments frequently require open reduction and plate fixation. 2

Fifth Metatarsal Fractures (Location-Specific Treatment)

Zone 1: Tuberosity Avulsion Fractures

• Treat acutely with a compressive dressing, then transition to a short leg walking boot for 2-3 weeks with progressive mobility as tolerated. 1, 4
• A hard-soled shoe is an acceptable alternative to a CAM-walker boot, though bone healing occurs approximately 1.4 weeks faster with the boot (7.2 vs 8.6 weeks). 5
• Surgical treatment (open reduction with tension-band wiring or screw fixation) is indicated if displaced >2mm or when >30% of the cubometatarsal joint is involved. 2, 3
• Nonunion rate is extremely low (1.1%) with conservative treatment. 4

Zone 2: Jones Fractures (Metaphyseal-Diaphyseal Junction)

• Requires at least 6-8 weeks in a short leg non-weight-bearing cast, with total healing time potentially extending to 10-12 weeks. 1
• This fracture has a higher risk of nonunion and requires individualized approach based on activity level and Torg classification. 1, 3
• Type I fractures (acute, no intramedullary sclerosis): non-operative treatment. 3
• Type II fractures (delayed union with widening): operative vs non-operative based on patient activity level. 3
• Type III fractures (nonunion with complete sclerosis): operative treatment due to higher complication rates. 3

Great Toe (First Metatarsal) Fractures

• Treat with a short leg walking boot or cast with toe plate for 2-3 weeks, followed by 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 Considerations for Diabetic Patients

• Ensure proper fitting of orthotic devices to prevent pressure sores and ulceration at the fracture site, as recommended by the American Diabetes Association. 6, 7
• Special attention to offloading is critical to prevent ulceration, with focus on proper wound care and management. 6, 7
• For severe cases with neuropathic ulcers where non-surgical offloading fails, consider Achilles tendon lengthening or metatarsal head resection in combination with offloading devices, per Diabetes/Metabolism Research and Reviews. 6

Common Pitfalls to Avoid

• Do not treat Jones fractures (zone 2) the same as tuberosity avulsion fractures (zone 1)—Jones fractures require longer immobilization and non-weight-bearing status. 1, 3
• Avoid underestimating displacement: fractures with >3-4mm displacement or >10 degrees angulation require surgical fixation, not conservative management. 2, 3
• In diabetic patients, standard therapeutic footwear alone is inadequate—proper offloading devices are essential. 8