Treatment of Displaced Zone 1 Fifth Metatarsal Fractures
For displaced zone 1 fifth metatarsal fractures, surgical fixation with percutaneous bicortical screw fixation is recommended to prevent delayed union and achieve faster healing, with excellent outcomes reported at mean healing time of 6.3 weeks. 1
Surgical Intervention Criteria
Displaced intraarticular zone 1 fractures require operative management due to the vascular watershed area predisposing to delayed nonunion. 1 The key considerations include:
- Displacement >3mm warrants surgical intervention to restore anatomical alignment and maintain the metatarsal parabola 2
- Intraarticular involvement with displacement increases risk of delayed healing without fixation 1
- Mean displacement of 3.20 ± 1.22 mm in surgically treated cases demonstrates the threshold where operative management becomes necessary 2
Recommended Surgical Technique
Percutaneous bicortical screw fixation is the preferred technique for displaced zone 1 fractures, offering superior outcomes compared to traditional intramedullary fixation:
- Bicortical fixation achieves mean healing time of 6.3 weeks (range 4-10 weeks) with 100% union rate 1
- Average AOFAS score of 94 (range 90-99) demonstrates excellent functional outcomes 1
- This technique avoids the complications commonly associated with intramedullary screw fixation 1
- Hardware removal is performed at mean 23.2 weeks with no refractures reported 1
Alternative Surgical Approach
For markedly shortened or multifragment fractures, open reduction with plate fixation may be necessary:
- Use interlocking plates with 2.0-2.4 mm screw diameter to minimize soft tissue irritation 3
- Perform anatomic reconstruction under longitudinal traction with reduction clamps 3
- Consider interfragmentary lag screws for compression if fragments are adequate size 3
Postoperative Protocol
Immediate postoperative management includes rest, elevation, and local cooling, followed by partial weight bearing (20 kg) in foot orthosis or cast shoe for 6 weeks. 3
- Early fracture stabilization provides superior analgesia compared to medications alone 4
- Surgical consultation should be arranged within 24-48 hours for displaced fractures 4
- Regular radiographic assessment ensures proper healing and alignment 4
Rehabilitation Strategy
Early introduction of physical training and muscle strengthening followed by long-term balance training optimizes functional recovery: 4
- Prolonged immobilization leads to stiffness and muscle atrophy, requiring appropriate rehabilitation 4
- Progressive weight-bearing does not compromise healing and may improve outcomes 4
Clinical Outcomes
Surgical management of displaced zone 1 fractures demonstrates:
- Overall complication rate of 6.25% with minimal postoperative issues 2
- Nonunion rate of only 1.56% with surgical fixation 2
- Mean healing time of 7.73 ± 4.74 weeks across surgical cases 2
- No malunions reported in surgical series 2
Critical Pitfall to Avoid
Do not attempt conservative management for displaced zone 1 fractures, as the vascular watershed area significantly increases risk of delayed union and nonunion without surgical stabilization. 1 While non-displaced zone 1 fractures can be managed conservatively with CAM-walker boot or hard-soled shoe 5, displacement necessitates operative intervention to restore anatomical alignment and prevent complications.