Metatarsal Fracture

Aka: Metatarsal Fracture, Metatarsal Shaft Fracture

1. Mechanism: Metatarsal Shaft Fracture
   1. Direct blow to foot
   2. Twisting injury
2. Types: Metatarsal Fracture
   1. Metatarsal Shaft Fracture (described on this page)
   2. Metatarsal Stress Fracture
   3. Proximal Fifth Metatarsal Fracture
   4. Proximal First to Fourth Metatarsal Fractures
      1. Requires additional vigilence to evaluate for associated Lisfranc Fracture-Dislocation
      2. Also, a normal first Metatarsal physis in children may be mistaken as Fracture
      3. In absence of Lisfranc joint injury, these Fractures are treated as Stress Fractures as below
3. Symptoms
   1. Painful ambulation
   2. Localized swelling, pain and Ecchymosis
4. Signs
   1. Marked localized swelling
   2. Point tenderness over Fracture site
   3. Provocative: Axial loading
      1. Axial loading of digit from Metatarsal head results in Fracture site pain
      2. Distinguishes from Soft Tissue Injury (in which maneuver is non-painful)
5. Imaging: Xray
   1. Views: Standard foot (consider oblique or modified lateral view)
   2. Fracture Types: Oblique or transverse Fractures are most common
6. Management: Uncomplicated non-displaced or minimally displaced shaft Fractures
   1. Indications
      1. Nondisplaced Metatarsal Shaft Fractures
      2. Single Fractures with medial or lateral displacement
   2. Protocol: Initial Evaluation
      1. Apply Soft Bulky Dressing or Posterior Splint
      2. Use Crutches, but may weight bear as tolerated
   3. Protocol: Follow-up visit at 1 week after injury
      1. Repeat XRay
      2. Use Soft Bulky Dressing, supportive shoe or cast boot
         1. Consider CAM walker or Short Leg Walking Cast if refractory pain
      3. Progressively increase weight bearing
   4. Protocol: Third and final visit at 6 weeks after injury
      1. Anticipate resolution of point tenderness over Fracture site
      2. Institute Ankle and calf Stretching and strengthening Exercises
7. Management: Nondisplaced Proximal first to fourth Metatarsal Fractures
   1. Indications
      1. No findings suggestive of Lisfranc Fracture Dislocation
   2. Protocol
      1. Step 1 (initial): Posterior splint and non-weight bearing
      2. Step 2 (day 5): Non-weight bearing Short Leg Cast
      3. Step 3 (day 10)
         1. Recheck XRay for Fracture alignment
         2. If good alignment, continue cast for 3-4 weeks and progressively increase ambulation
      4. Step 4 (day 30)
         1. Start physical therapy for ankle and foot range of motion, Stretching and strengthening
8. Management: Displaced Fractures (require reduction)
   1. Indications
      1. Shaft Fractures with >3-4 mm dorsal or plantar displacement
      2. Shaft Fractures with >10 degrees dorsal or plantar angulation
   2. Protocol
      1. Reduce Fracture
      2. Apply posterior splint
      3. Crutch walking only and no weight bearing
      4. Follow-up with Orthopedics
9. Management: Complicated Fractures (require orthopedic consultation)
   1. Indications: Urgent Consultation
      1. See Fracture
   2. Indications: Prompt Consultation
      1. See Displaced Fracture above
      2. Multiple Metatarsal Fractures or first Metatarsal Fracture (typically unstable)
      3. Fifth Metatarsal styloid Fracture with displacement
      4. Metatarsal Shaft Fracture near the Metatarsal head
      5. Intra-articular Fracture
      6. Metatarsal Fracture with associated Lisfranc Dislocation or Lisfranc Fracture
   3. Protocol
      1. Apply posterior splint
      2. Crutch walking only and no weight bearing
      3. Follow-up with Orthopedics
10. Complications: Pitfalls
    1. See Proximal Fifth Metatarsal Fracture (high risk for non-union)
    2. See Metatarsal Stress Fracture (often missed)
    3. See Displaced and Complicated Fractures above
    4. Consider Lisfranc Fracture Dislocation (associated with Proximal 1-4 Metatarsal Fracture)
11. References
    1. Hatch (2007) Am Fam Physician 76(6):817-26