Management of Fifth Metatarsal Neck Fractures
Nondisplaced or minimally displaced fifth metatarsal neck fractures should be treated with immediate weight-bearing as tolerated in a removable boot or elasticated support, with discharge from the emergency department and no routine follow-up required. 1, 2, 3
Initial Imaging Requirements
- Standard ankle radiographs (AP, lateral, and mortise views) must extend distally to include the base and neck of the fifth metatarsal to adequately visualize these fractures 1, 2
- Weight-bearing radiographs provide important information about fracture stability when the patient can tolerate them 2
- Avoid ordering separate foot radiographs when ankle films already capture the fifth metatarsal 2
Conservative Management Protocol
For nondisplaced neck fractures, immediate functional treatment produces excellent outcomes:
- Allow full weight-bearing as pain permits from the time of initial presentation 3, 4
- Provide a removable boot or elasticated support for comfort during the first 4-6 weeks 5, 3
- Discharge patients directly from the emergency department with structured written advice and a helpline number for concerns 3
- No routine face-to-face follow-up appointments are necessary 3
Evidence Supporting This Approach
A 2015 study of 339 patients with fifth metatarsal fractures showed that only 1% required operative intervention when managed with immediate weight-bearing and discharge, compared to 1% in the traditional follow-up group—demonstrating no added clinical value from routine clinic visits 3. A 2017 study of 39 patients with immediate full weight-bearing showed return to work in 17 days, return to sports in 53 days, and excellent functional scores (VAS-FA 96/100) with zero complications and no surgeries required 4.
Follow-Up Strategy
Routine radiographic follow-up before 6-8 weeks does not alter management and should be avoided 6:
- Clinical assessment of healing (pain resolution, ability to bear weight) should guide discharge decisions rather than radiographic confirmation 6
- Only 29% of fifth metatarsal fractures show radiographic union at final follow-up, yet patients can be safely discharged based on clinical healing 6
- Reserve follow-up imaging for patients with persistent pain or inability to weight-bear at 4-6 weeks 1
- MRI can confirm complete healing if radiographs remain inconclusive and clinical concern persists 1
Rehabilitation Protocol
- Begin progressive weight-bearing immediately as pain allows—do not enforce prolonged immobilization 2, 4
- Introduce early physical training and muscle strengthening after the initial 2-3 week comfort period 2
- Add balance training once pain subsides to prevent stiffness and muscle atrophy 2
Indications for Surgical Referral
Neck fractures rarely require surgery, but consider operative management if:
- Displacement exceeds 3-4 mm 7
- Angulation exceeds 10 degrees 7
- Multiple fragments with significant comminution are present 5
These criteria apply primarily to shaft fractures; isolated neck fractures with these characteristics are uncommon but would warrant orthopedic consultation 5, 7.
Critical Pitfalls to Avoid
- Do not routinely schedule follow-up appointments—this wastes resources without improving outcomes 3
- Do not enforce non-weight-bearing—immediate functional loading accelerates recovery 3, 4
- Do not obtain repeat radiographs before 6-8 weeks unless clinically indicated—early films do not change management 6
- Do not confuse neck fractures with Jones fractures (zone 2 metaphyseal-diaphyseal junction)—Jones fractures have high nonunion rates (15-30%) and often require surgical fixation 7, 8