From the Guidelines
This patient has a 5th metatarsal fracture that requires immediate treatment with non-weight bearing, ice, elevation, and pain management, and should be referred to an orthopedic specialist within 1-2 weeks for definitive management. The recommended approach includes non-weight bearing on the affected foot using crutches or a walking boot, ice application for 20 minutes every 2-3 hours to reduce swelling, elevation of the foot above heart level when sitting or lying down, and pain management with acetaminophen 500-1000mg every 6 hours or ibuprofen 400-600mg every 6-8 hours (if no contraindications) 1. Fifth metatarsal fractures are common injuries that occur when the foot rolls inward (inversion injury), as happened in this case when the patient stepped off a mat onto a wooden floor. The inability to bear weight, along with swelling and bruising, are classic symptoms, and the X-ray confirmation makes the diagnosis clear. Early proper management is essential to prevent complications like malunion or nonunion of the fracture.
Key Considerations
- The patient's age and lack of previous fractures or surgeries are important factors in determining the best course of treatment 1.
- A multidisciplinary approach, including orthogeriatric care, may be necessary for optimal acute fracture care, especially in elderly patients 1.
- The patient's fracture risk should be investigated systematically, and high-risk patients should receive appropriate non-pharmacological and pharmacological treatment to decrease the risk of subsequent fracture 1.
- Complete healing typically takes 6-8 weeks, and the patient should be monitored for any complications or issues that may arise during the healing process.
Treatment Options
- Non-weight bearing on the affected foot using crutches or a walking boot
- Ice application for 20 minutes every 2-3 hours to reduce swelling
- Elevation of the foot above heart level when sitting or lying down
- Pain management with acetaminophen 500-1000mg every 6 hours or ibuprofen 400-600mg every 6-8 hours (if no contraindications)
- Referral to an orthopedic specialist within 1-2 weeks for definitive management, which may include casting, a walking boot, or possibly surgery depending on the fracture location and displacement.
From the Research
Patient Presentation and Diagnosis
- A 53-year-old female presents with a 5th metatarsal fracture after a fall at a gym.
- She reports immediate discomfort, swelling, and bruising, and is unable to bear weight.
- X-ray confirms the fracture.
Management of Acute Fracture Pain
- Studies have compared the efficacy of oxycodone and hydrocodone for the treatment of acute pain associated with fractures 2.
- Oxycodone and hydrocodone have been shown to have similar analgesic effects in the first hour of treatment for emergency department patients with acute fractures 2.
- However, the use of strong opioids like oxycodone may not provide greater analgesia than mild opioids for subacute pain after fractures managed surgically 3.
Use of Splints and Casts
- Splints are noncircumferential immobilizers that accommodate swelling, making them ideal for the management of acute musculoskeletal conditions like fractures or sprains 4.
- Casts are circumferential immobilizers that provide superior immobilization but are less forgiving and have higher complication rates 4.
Pain Management Options
- A randomized controlled trial compared oxycodone/acetaminophen to acetaminophen alone for emergency department patients with musculoskeletal pain refractory to ibuprofen, and found that oxycodone/acetaminophen resulted in slightly greater pain relief but with more medication-related adverse events 5.
- Another study found that treatment with strong opioid medication was not superior to treatment with milder medication for treatment of pain among patients with surgically managed orthopedic fractures 3.
- A prospective, randomized, double-blinded trial comparing acetaminophen, ibuprofen, and oxycodone for pain management after hand surgery found no clinically significant difference in pain experience or capsule consumption based on postoperative opioid vs nonopioid medication 6.