II. Mechanism: Metatarsal Shaft Fracture
- Axial load or crush injury
- Direct blow to foot
- Twisting injury
- Fall from height
III. Types: Metatarsal Fracture
- Metatarsal Shaft Fracture (described on this page)
- Metatarsal Stress Fracture
- Proximal Fifth Metatarsal Fracture
- Proximal First to Fourth Metatarsal Fractures
- Requires additional vigilence to evaluate for associated Lisfranc Fracture-Dislocation
- Also, a normal first MetatarsalPhysis in children may be mistaken as Fracture
- In absence of Lisfranc joint injury, these Fractures are treated as Stress Fractures as below
IV. Symptoms
- Painful ambulation
- Localized swelling, pain and Ecchymosis
V. Signs
- Marked localized swelling, Ecchymosis
- Point tenderness over Fracture site
- Provocative: Axial loading
- Axial loading of digit from Metatarsal head results in Fracture site pain
- Distinguishes from Soft Tissue Injury (in which maneuver is non-painful)
VI. Imaging
-
Foot Xray
- Views: Standard foot (consider oblique or modified lateral view)
- Fracture Types: Oblique or transverse Fractures are most common
- Foot Ultrasound (bedside)
- May identify subtle, non-displaced Fractures
VII. Management: Uncomplicated non-displaced or minimally displaced shaft Fractures
- See Fifth Metatarsal Shaft Fracture
- Indications
- Nondisplaced Metatarsal Shaft Fractures
- Single Fractures with medial or lateral displacement
- Protocol: Initial Evaluation
- Apply Soft Bulky Dressing, or Posterior Splint (or Short Leg Walking Cast or boot)
- Use Crutches, but may weight bear as tolerated
- Protocol: Follow-up visit at 3-5 days after injury
- Repeat XRay
- Use Soft Bulky Dressing, supportive shoe or cast boot
- Consider walking boot or Short Leg Walking Cast if refractory pain
- Progressively increase weight bearing
- Transition to rigid-sole shoe at 4-6 weeks
- Protocol: Follow-up every 2-4 weeks
- Protocol: Third and final visit at 6 weeks after injury
- Repeat XRay at 4-6 weeks
- Anticipate resolution of point tenderness over Fracture site and callus formation on xray
- Institute Ankle and calf Stretching and strengthening Exercises
VIII. Management: Nondisplaced Proximal first to fourth Metatarsal Fractures
- See Proximal Fifth Metatarsal Fracture
- Indications
- No findings suggestive of Lisfranc Fracture Dislocation
- First Metatarsal Fractures should be referred to orthopedics
- Protocol
- Step 1 (initial): Posterior splint and non-weight bearing
- Step 2 (day 5): Non-weight bearing Short Leg Cast
- Step 3 (day 10)
- Recheck XRay for Fracture alignment
- If good alignment, continue cast for 3-4 weeks and progressively increase ambulation
- Step 4 (day 30)
- Start physical therapy for ankle and foot range of motion, Stretching and strengthening
IX. Management: Displaced Fractures (require reduction)
- Indications
- Protocol
- Reduce Fracture (under Regional Anesthesia or Procedural Sedation)
- Apply posterior splint initially followed by Casting after 5 days (or short leg boot)
- First: Crutch walking only and NO weight bearing for 3 to 4 weeks
- Next: Short Leg Walking Cast or boot for an additional 3 to 4 weeks
- Follow-up with Orthopedics or Podiatry
X. Management: Complicated Fractures (require orthopedic Consultation)
- Indications: Urgent Consultation
- See Fracture
- Indications: Prompt Consultation
- Displaced Fractures (see above)
- Open Fractures
- Compartment Syndrome (emergent Consultation)
- First Metatarsal Fracture (regardless of displacement, esp. comminuted or intraarticular)
- Greater force required to Fracture first Metatarsal than the lesser Metatarsals (2 to 4)
- As with the great toe, first Metatarsal alignment is key to weight bearing and walking
- Multiple Metatarsal Fractures (typically unstable)
- Also higher risk for concurrent lisfranc joint Fracture dislocation
- Fifth Metatarsal styloid Fracture with displacement
- Metatarsal Shaft Fracture near the Metatarsal head
- Intra-articular Fracture
- Metatarsal Fracture with associated Lisfranc Dislocation or Lisfranc Fracture
- Protocol
- Apply posterior splint
- Crutch walking only and no weight bearing
- Follow-up with Orthopedics
XI. Complications: Pitfalls
- See Proximal Fifth Metatarsal Fracture (high risk for non-union)
- See Metatarsal Stress Fracture (often missed)
- See Displaced and Complicated Fractures above
- Consider Lisfranc Fracture Dislocation (associated with Proximal 1-4 Metatarsal Fracture)
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Related Studies
| Concepts | Injury or Poisoning (T037) |
| ICD9 | 825 |
| SnomedCT | 208675008, 269100000 |
| English | #Tarsal/metatarsal bones, Fracture of one or more tarsal and metatarsal bones, Fracture metatarsal bone and/or tarsal bone (& one or more) (disorder), Fracture metatarsal bone and/or tarsal bone (& one or more), fracture of one or more tarsal and metatarsal bones (diagnosis), Fracture of one or more tarsal and metatarsal bones (disorder) |
| Dutch | fractuur van een of meer tarsalia en metatarsalia |
| French | Fracture d'un ou plusieurs os du tarse et du métatarse |
| German | Fraktur eines oder mehrerer Fusswurzelknochen und Metatarsalien |
| Italian | Frattura di una o più ossa del tarso e metatarso |
| Portuguese | Fractura de um ou mais ossos do tarso e metatarso |
| Spanish | Fractura de uno o más huesos tarsianos y metatarsianos, fractura de uno o más huesos de tarso y metatarso (trastorno), fractura de uno o más tarsianos y metatarsianos (trastorno), fractura de uno o más tarsianos y metatarsianos, fractura de uno o más huesos de tarso y metatarso |
| Czech | Zlomenina jedné nebo více tarzálních a metatarzálních kostí |
| Hungarian | Egy vagy több tarsalis és metatarsalis csont törése |
