What is the recommended treatment for a 12-year-old patient with a zone 1 fifth metatarsal fracture showing evidence of union after more than 8 weeks, who has been using crutches (assistive walking devices)?

Treatment of Zone 1 Fifth Metatarsal Fracture with Evidence of Union at >8 Weeks in a 12-Year-Old

For a 12-year-old with a zone 1 fifth metatarsal fracture showing radiographic evidence of union after more than 8 weeks of crutch use, transition to progressive weight-bearing without immobilization is appropriate, with focus on rehabilitation and return to full activity.

Rationale for Treatment Transition

At this stage, the primary goal shifts from fracture healing (which has been achieved) to functional recovery and prevention of complications from prolonged immobilization:

• Radiographic union has been documented, indicating the fracture has healed sufficiently to progress treatment 1
• Prolonged immobilization beyond 8 weeks leads to stiffness and muscle atrophy, requiring appropriate rehabilitation 1
• Zone 1 fractures (avulsion fractures at the base of the fifth metatarsal) typically heal within 44-65 days with conservative treatment 2

Recommended Management Protocol

Immediate Steps (Week 8+)

• Discontinue crutches and begin progressive weight-bearing as pain permits, since the fracture shows union 1
• Remove any immobilization device (boot or cast) if still in use, as continued immobilization is counterproductive once union is achieved 2
• Initiate early physical training and muscle strengthening to restore function 1

Rehabilitation Program (Weeks 8-12)

• Begin ankle range-of-motion exercises immediately to address stiffness from prolonged immobilization 1
• Progress weight-bearing rapidly: patients can safely bear weight immediately if pain permits once union is confirmed 1
• Implement balance training and fall prevention exercises, particularly important in pediatric patients returning to activities 1
• Advance to functional activities including walking, pool exercises, and sport-specific training as tolerated 3

Monitoring Requirements

• Obtain repeat radiographs at 10-14 days after transitioning to full weight-bearing to ensure fracture position remains stable 4
• Clinical assessment should focus on pain levels, gait mechanics, and functional capacity rather than continued fracture monitoring 1

Expected Timeline for Full Recovery

• Return to full physical activity typically occurs within 96 days (approximately 14 weeks) from initial injury for zone 1 fractures 2
• Since this patient is already at 8+ weeks with union, expect return to unrestricted activities within 4-6 additional weeks with appropriate rehabilitation 2
• Average modified foot scores reach 86-92 (good to excellent range) by completion of treatment 2

Critical Pitfalls to Avoid

• Do not continue immobilization once union is documented, as this unnecessarily prolongs recovery and increases complications 1, 2
• Do not restrict weight-bearing once union is confirmed, as progressive weight-bearing does not compromise healing and may improve outcomes 1
• Do not overlook rehabilitation needs: the 8+ weeks of immobilization and crutch use has likely resulted in significant deconditioning requiring structured physical therapy 1

Special Considerations for Pediatric Patients

• Pediatric patients typically heal faster than adults, and this patient's documented union at 8 weeks is consistent with expected healing 5
• Return to sports and high-impact activities should be gradual but can proceed once pain-free full weight-bearing is achieved 5
• No surgical intervention is indicated for zone 1 fractures with documented union, regardless of any residual displacement 5, 6