What is the recommended treatment for a non-displaced or minimally displaced metatarsal fracture?

Treatment of Non-Displaced or Minimally Displaced Metatarsal Fractures

Non-displaced and minimally displaced metatarsal fractures (2nd-5th metatarsals) should be treated conservatively with protected weight-bearing in a cast shoe or walking boot for 4-6 weeks, allowing immediate weight-bearing as tolerated. 1, 2, 3

Initial Management

• Obtain radiographic confirmation with three standard views (anteroposterior, lateral, and oblique) to confirm the fracture is truly non-displaced and assess for any joint involvement 1
• Begin immediate protected weight-bearing with a cast shoe, walking boot, or even pressure bandage—strict non-weight-bearing is not necessary for stable, non-displaced fractures 2, 3, 4

Immobilization Protocol

For 2nd-4th Metatarsal Fractures:

• Use a short leg walking boot or cast shoe for 4-6 weeks with weight-bearing as tolerated from the outset 2, 3
• Alternatively, pressure bandage with full weight-bearing is effective for simple fractures, with patients typically walking fully by 3 weeks 4
• Rigid immobilization is preferred over removable splints only if there is concern about displacement 1

For 1st Metatarsal Fractures:

• Treat more aggressively due to critical role in weight-bearing: use a short leg walking boot or cast with toe plate for 2-3 weeks, followed by rigid-sole shoe for additional 3-4 weeks 3, 5
• First metatarsal fractures require closer monitoring as malunion can drastically alter gait mechanics 5

For 5th Metatarsal Tuberosity Avulsion Fractures:

• Apply compressive dressing acutely, then transition to short leg walking boot for 2 weeks with progressive mobility as tolerated 3
• This is distinct from Jones fractures (metaphyseal-diaphyseal junction), which require more aggressive treatment 2, 3

Monitoring Requirements

• Obtain follow-up radiographs at approximately 3 weeks to ensure no displacement has occurred during healing 1
• Repeat imaging at end of immobilization period (4-6 weeks) to confirm union 1
• Most simple metatarsal fractures heal without complications when treated conservatively 4

Red Flags Requiring Surgical Intervention

Refer for surgical fixation if any of the following occur during conservative treatment:

• Shortening >3 mm 1
• Dorsal angulation >10° 1
• Intra-articular displacement 1
• Displacement in the sagittal plane (particularly for 1st metatarsal, which causes nonplantigrade foot) 5
• Multiple fragments with joint involvement 2

Rehabilitation Phase

• Begin early physical training and muscle strengthening once immobilization is complete 1
• Implement long-term balance training to prevent re-injury 1
• Fit proper orthotic devices after immobilization to prevent pressure complications 1
• Prolonged immobilization leads to stiffness and muscle atrophy, making appropriate rehabilitation essential 1

Special Populations

Diabetic Patients with Neuropathy:

• Pay special attention to offloading the fracture site to prevent ulceration during healing 1, 6
• Consider forefoot offloading shoe or half-shoe if fracture involves forefoot metatarsals 6
• Ensure proper fitting of any orthotic devices to prevent pressure sores 1

Common Pitfalls to Avoid

• Do not routinely use non-weight-bearing protocols—evidence shows weight-bearing as tolerated is safe and effective for non-displaced fractures 4
• Do not miss Jones fractures (proximal 5th metatarsal at metaphyseal-diaphyseal junction)—these require 6-8 weeks non-weight-bearing cast or surgical fixation due to high nonunion risk 3, 7
• Do not undertake first metatarsal fractures—they require more aggressive treatment than lesser metatarsals due to their critical weight-bearing role 5
• Do not skip follow-up radiographs—displacement can occur during treatment and requires surgical intervention 1