What is the recommended treatment procedure for a patient with a fifth metatarsal head fracture?

Treatment of Fifth Metatarsal Head Fractures

For fifth metatarsal head fractures, initiate conservative management with protected weight-bearing in a CAM-walker boot or hard-soled shoe for 4-6 weeks, as these fractures typically heal well without surgery. 1

Initial Assessment and Imaging

• Obtain three standard radiographic views (anteroposterior, lateral, and oblique) to confirm the diagnosis and assess displacement 2
• Apply Ottawa ankle rules: imaging is required if there is point tenderness at the base of the 5th metatarsal or inability to bear weight for four steps 2
• Assess immediately for vascular compromise by checking for signs of poor perfusion (blue, purple, or pale foot) requiring emergent intervention 2
• Check for open wounds requiring clean dressing coverage to reduce contamination risk 2

Conservative Management (First-Line Treatment)

Non-displaced and minimally displaced metatarsal head fractures should be treated conservatively, as this approach yields excellent outcomes with union rates exceeding 95%. 3, 1

Immobilization Options

• CAM-walker boot: Provides faster radiographic healing (average 7.2 weeks) with similar functional outcomes 4
• Hard-soled shoe: Acceptable alternative with slightly longer healing time (average 8.6 weeks) but equivalent clinical results 4
• Duration: 4-6 weeks of protected weight-bearing 1

Weight-Bearing Protocol

• Allow weight-bearing as pain tolerates from initial presentation 3
• Use elasticated support or removable boot for comfort 3
• No strict non-weight-bearing period required for non-displaced fractures 3

Pain Management

• Provide multimodal analgesia starting with scheduled acetaminophen unless contraindicated 2
• Add opioids cautiously if needed, particularly if renal function is unknown 2
• Avoid NSAIDs if renal dysfunction is suspected 2
• Early immobilization provides the most effective pain relief 2

Follow-Up Strategy

Routine fracture clinic follow-up is unnecessary for uncomplicated fifth metatarsal head fractures. 3

• Discharge patients from emergency department with structured advice and helpline access 3
• A study of 339 patients showed only 1% required operative intervention when managed with this protocol 3
• Reserve clinic appointments for complex cases or patients with concerning symptoms 3

Surgical Indications (Rare for Head Fractures)

Surgery is indicated only for:

• Displaced fractures with >2mm displacement involving >30% of the joint surface 1
• Multiple fragments with joint involvement requiring open reduction and plate fixation 1
• Fractures not responding to conservative management 1

Special Considerations for Diabetic Patients

Patients with diabetes require meticulous attention to offloading and wound surveillance to prevent ulceration at the fracture site. 5

• Ensure proper fitting of orthotic devices to prevent pressure sores 5
• Monitor closely for ulceration development, as infections arising from the fifth metatarsal head spread through the lateral compartment 6
• Consider surgical intervention if osteomyelitis develops with spreading soft tissue infection or destroyed soft tissue envelope 6

Common Pitfalls to Avoid

• Do not apply compression wraps too tightly, as this compromises circulation 2
• Do not place ice directly on skin if using cryotherapy 2
• Do not immobilize for prolonged periods unnecessarily, as this leads to stiffness and muscle atrophy requiring extensive rehabilitation 2
• Do not confuse metatarsal head fractures with Jones fractures (zone 2 metaphyseal-diaphyseal junction), which have higher nonunion rates and different management 1