Initial Management of Fifth Metatarsal Fracture Prior to Surgical Evaluation
Immobilize the fracture with a rigid splint or CAM-walker boot, provide multimodal analgesia, and allow weight-bearing as tolerated while arranging timely surgical consultation. 1
Immediate Assessment
Before applying any splint, perform a focused vascular assessment:
- Check for signs of vascular compromise including blue, purple, or pale discoloration of the foot, which requires emergent intervention 1
- Inspect for open wounds and cover any breaks in skin with clean dressing to reduce contamination risk 1, 2
- Assess for gross deformity that may prevent safe immobilization 1
Immobilization Strategy
Apply rigid immobilization immediately as this provides the most effective pain relief and prevents further injury 1, 3:
- Use a CAM-walker boot or rigid splint rather than elastic bandages for displaced or uncertain fractures 2, 3
- Immobilize in the position found unless significant deformity prevents safe transport 1
- Avoid compression wraps that are too tight as this can compromise circulation 1
The evidence strongly supports rigid immobilization over elastic support, particularly when displacement is uncertain prior to surgical evaluation 2, 3. While one randomized trial found elastic bandages non-inferior for simple avulsion fractures 4, this applies only to confirmed non-displaced injuries—not the pre-surgical evaluation scenario where fracture characteristics may be incompletely assessed.
Pain Management Protocol
Provide multimodal analgesia immediately 1:
- Start with scheduled acetaminophen (paracetamol) unless contraindicated 1
- Add opioids cautiously if pain is severe, particularly if renal function is unknown 1
- Avoid NSAIDs if renal dysfunction is suspected 1
- Consider ice application for swelling, but never place directly on skin 1
Early fracture stabilization through proper immobilization provides superior analgesia compared to medications alone 1, 3.
Weight-Bearing Instructions
Allow weight-bearing as tolerated with the immobilization device 5, 6:
- Patients can safely bear weight immediately if pain permits 5
- Progressive weight-bearing does not compromise healing and may improve outcomes 2, 6
This represents a shift from older protocols that mandated strict non-weight-bearing, which research has shown to be unnecessary for most fifth metatarsal fractures 5, 6.
Critical Pitfalls to Avoid
- Do not delay immobilization waiting for definitive imaging—splint first based on clinical suspicion 1
- Do not apply casts or definitive treatment in the emergency setting when surgical evaluation is pending, as this may need to be removed for operative planning 7, 8
- Do not restrict all weight-bearing unless there is severe displacement or vascular compromise 5, 6
- Do not apply ice directly to skin in patients with neuropathy or diabetes 1
Surgical Referral Timing
Arrange surgical consultation within 24-48 hours for evaluation 9:
- Displaced fractures (>2-3mm displacement or >10 degrees angulation) typically require operative fixation 7, 8
- Jones fractures (metaphyseal-diaphyseal junction) have high non-union rates and may benefit from early surgical intervention 7, 8
- Most avulsion fractures can be managed non-operatively but require surgical assessment to determine displacement 7, 8
The surgeon will determine definitive treatment based on fracture location, displacement, patient activity level, and Torg classification for Jones fractures 7, 8.