What is the recommended initial management of a 5th metatarsal fracture in the Emergency Department (ED)?

Initial Management of 5th Metatarsal Fractures in the Emergency Department

For uncomplicated 5th metatarsal fractures in the ED, discharge patients with early weight-bearing as tolerated using a removable boot or elasticated support, provide structured written advice with a helpline number for concerns, and avoid routine fracture clinic follow-up unless specific high-risk features are present. 1

Immediate Assessment and Imaging

Clinical Evaluation

• Assess for vascular compromise immediately: If the foot appears blue, purple, or pale, this indicates poor perfusion requiring emergent intervention 2, 3
• Examine for obvious deformity, swelling, bruising, severe pain with movement, or inability to move the foot 4
• Check for open wounds that would require wound coverage with clean dressing to reduce contamination risk 2

Radiographic Workup

• Obtain three standard views (anteroposterior, lateral, and oblique) for accurate diagnosis and classification 3, 4
• Apply Ottawa ankle rules to determine imaging necessity: radiographs are indicated if there is point tenderness at the base of the 5th metatarsal or inability to bear weight for four steps 2, 3

Pain Management

• Provide multimodal analgesia: Start with scheduled paracetamol (acetaminophen) unless contraindicated 2
• Add opioids cautiously, particularly if renal function is unknown 2
• Early immobilization provides the most effective pain relief for fracture-related pain 2, 3
• Avoid NSAIDs if renal dysfunction is suspected (approximately 40% of patients with fractures have at least moderate renal impairment) 2

Immobilization Strategy

For Non-Displaced Fractures (Majority of Cases)

• Apply a removable walking boot or elasticated support rather than rigid casting 1, 5
• Splinting reduces pain, prevents further injury, and facilitates safe ambulation 2
• Immobilize in the position found unless deformity prevents safe transport 2

Weight-Bearing Instructions

• Allow immediate weight-bearing as pain tolerates - this is safe and accelerates recovery 1, 5
• Patients treated with functional bracing and early weight-bearing return to full activity in approximately 33 days versus 46 days with rigid casting 6
• Full weight-bearing typically occurs within 9 days with this approach 5

Disposition and Follow-Up

Discharge Criteria (Applies to ~80% of Cases)

• Discharge directly from ED without routine fracture clinic referral for non-displaced tuberosity avulsion fractures and minimally displaced shaft fractures 1, 7
• Provide structured written advice on expected recovery timeline 1
• Give helpline number for access to fracture clinic staff if concerns arise 1
• Expected sick leave duration: approximately 19 days 5

Indications for Fracture Clinic Referral

Refer for orthopedic follow-up if any of the following are present:

• Displacement >2mm at tuberosity or >30% cubometatarsal joint involvement 7
• Shaft fractures with >3-4mm displacement or >10° angulation 7
• Jones fractures (meta-diaphyseal junction, 1.5-3cm from tuberosity base) - these have prolonged healing and higher non-union risk 7
• Open fractures requiring wound management 2
• Patients with diabetes and neuropathy requiring specialized offloading 3, 4

Special Considerations

Pitfalls to Avoid

• Do not apply compression wraps too tightly - this can compromise circulation 2
• Do not place ice directly on skin if using cryotherapy for pain/swelling 2
• Avoid prolonged rigid immobilization - this leads to stiffness and muscle atrophy without improving outcomes 3, 4
• Do not routinely follow all 5th metatarsal fractures in clinic - studies show only 1% require operative intervention, making routine follow-up clinically unnecessary 1

Evidence Quality Note

The shift away from routine follow-up is supported by high-quality prospective audit data showing no difference in operative intervention rates (1% in both groups) but dramatic reduction in unnecessary clinic visits (96% attendance pre-protocol vs 18% post-protocol) 1. Early functional treatment with removable boots demonstrates 92% patient satisfaction and no long-term complications 5.