Treatment of Nondisplaced 3rd Metatarsal Fracture
Nondisplaced 3rd metatarsal fractures should be treated conservatively with protected weight-bearing in a cast shoe or CAM-walker boot for 4-6 weeks. 1, 2
Initial Management
- Confirm the fracture is truly nondisplaced using three standard radiographic views (anteroposterior, lateral, and mortise) 1
- Immobilize immediately with a cast shoe or CAM-walker boot 1, 2
- Allow protected weight-bearing immediately based on pain tolerance—complete non-weight-bearing is unnecessary 1, 2
- Removable splints are an acceptable alternative to rigid immobilization for minimally displaced fractures 1
Radiographic Monitoring Protocol
- Obtain follow-up radiographs at 3 weeks to verify the fracture has not displaced during treatment 1
- Repeat imaging at the end of the immobilization period (4-6 weeks) to confirm healing before advancing activity 1
- Monitor specifically for displacement exceeding surgical thresholds: shortening >3-4 mm, angulation >10 degrees, or any intra-articular displacement 1, 3, 4
Surgical Indications
Surgery is only indicated if the fracture displaces during conservative treatment beyond the following thresholds: 1, 3, 4
- Shortening >3-4 mm
- Angulation >10 degrees
- Intra-articular displacement
- Horizontal plane displacement that cannot be maintained with conservative treatment
If surgery becomes necessary, percutaneous K-wire fixation is suitable for most lesser metatarsal fractures, while fractures with joint involvement and multiple fragments may require open reduction and plate fixation 2
Rehabilitation After Immobilization
- Begin early physical training and muscle strengthening exercises after the 4-6 week 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 Considerations for High-Risk Patients
For patients with diabetes and peripheral neuropathy: 1
- Implement aggressive offloading strategies to prevent ulceration at the fracture site
- Consider non-removable knee-high offloading devices if ulceration develops
- Monitor closely for skin breakdown during immobilization, as proper fitting of all devices is critical in this population
Common Pitfalls to Avoid
- Do not immobilize the ankle joint unnecessarily—this leads to prolonged stiffness without improving outcomes 4
- Do not mandate strict non-weight-bearing for nondisplaced fractures—protected weight-bearing as tolerated is appropriate 1, 2
- Do not skip the 3-week radiographic follow-up, as this is when occult displacement is most likely to be detected 1
- Do not confuse 3rd metatarsal shaft fractures with proximal 5th metatarsal fractures (Jones fractures), which require different management with longer immobilization and higher surgical consideration 5, 6, 3