What is the appropriate treatment plan for a patient with nondisplaced fractures of the distal fourth metatarsal head‑neck junction, an equivocal distal third metatarsal lesion (possible fracture), and a nondisplaced fracture of the fourth proximal phalanx shaft in the right foot, accompanied by soft‑tissue swelling and no dislocation?

Treatment Plan for Multiple Nondisplaced Foot Fractures

For this patient with nondisplaced fractures of the fourth metatarsal head-neck junction, fourth proximal phalanx, and equivocal third metatarsal findings, initiate immediate protected weight-bearing in a cast boot or stiff-soled shoe for 3 weeks of non-weight-bearing followed by 3+ weeks of weight-bearing immobilization, with clinical reassessment at 2-3 weeks and radiographic follow-up at 4-6 weeks to confirm healing. 1, 2

Initial Management

Conservative treatment is appropriate since all identified fractures are nondisplaced and there is no dislocation. 3 The treatment approach should account for the specific anatomical locations involved:

Immobilization Protocol

• Begin with 3 weeks of non-weight-bearing in a below-knee cast or walking boot 2
• Follow with 3 or more weeks of protected weight-bearing immobilization 2
• A cast shoe or stiff-soled shoe is acceptable for nondisplaced metatarsal fractures 3

The fourth metatarsal head-neck junction fracture requires particular attention, as proximal fourth metatarsal injuries tend to heal more slowly than typical lesser metatarsal fractures and may remain symptomatic even after 3 months of rest and immobilization. 2

Follow-Up Schedule

• Clinical reassessment at 2-3 weeks to ensure appropriate healing progression 1
• Radiographic follow-up at 4-6 weeks to confirm union 1
• Serial radiographs are essential to detect any late displacement, as even nondisplaced fractures can displace during healing 4

Management of Equivocal Third Metatarsal Finding

If the equivocal third metatarsal lesion remains symptomatic or unclear on follow-up radiographs at 4-6 weeks, obtain MRI without IV contrast to confirm complete healing or identify an occult fracture. 5, 1 MRI is the most sensitive modality for detecting occult fractures and acute bone stress changes. 5

Alternatively, repeat radiographs at 10-14 days can be obtained if clinical suspicion is lower, though this delays definitive diagnosis. 5

Fourth Proximal Phalanx Fracture

The nondisplaced phalangeal shaft fracture can be managed with buddy taping to the adjacent toe and protected weight-bearing in the same boot/shoe used for the metatarsal fractures. 5 Standard 3-view radiographic examination is sufficient for phalangeal injuries. 5

Critical Monitoring Points

Watch for these warning signs requiring urgent reassessment:

• Increasing pain or swelling after initial improvement
• Development of new pain at the equivocal third metatarsal site
• Inability to bear weight as expected during the transition phase
• Any signs suggesting displacement on follow-up radiographs 4

Expected Healing Timeline

Return to normal activities typically occurs in 2-8 months for proximal fourth metatarsal injuries, which is longer than typical lesser metatarsal fractures. 2 Patients should be counseled that healing may be prolonged even with appropriate treatment. 2

When Surgery Becomes Necessary

Surgical intervention is indicated only if:

• Displacement >2mm develops on follow-up imaging 4
• Continued symptoms persist beyond 3 months despite appropriate conservative management 2
• The equivocal third metatarsal finding proves to be a displaced fracture 3