Metatarsal Fracture

Metatarsal Shaft Fracture (described on this page)
Metatarsal Stress Fracture
Proximal Fifth Metatarsal Fracture
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

Marked localized swelling, Ecchymosis
Point tenderness over Fracture site
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)

Foot Xray
1. Views: Standard foot (consider oblique or modified lateral view)
2. Fracture Types: Oblique or transverse Fractures are most common
Foot Ultrasound (bedside)
1. May identify subtle, non-displaced Fractures

See Fifth Metatarsal Shaft Fracture
Indications
1. Nondisplaced Metatarsal Shaft Fractures
2. Single Fractures with medial or lateral displacement
Protocol: Initial Evaluation
1. Apply Soft Bulky Dressing, or Posterior Splint (or Short Leg Walking Cast or boot)
2. Use Crutches, but may weight bear as tolerated
Protocol: Follow-up visit at 3-5 days after injury
1. Repeat XRay
2. Use Soft Bulky Dressing, supportive shoe or cast boot
  1. Consider walking boot or Short Leg Walking Cast if refractory pain
3. Progressively increase weight bearing
  1. 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
1. Repeat XRay at 4-6 weeks
2. Anticipate resolution of point tenderness over Fracture site and callus formation on xray
3. Institute Ankle and calf Stretching and strengthening Exercises

See Proximal Fifth Metatarsal Fracture
Indications
1. No findings suggestive of Lisfranc Fracture Dislocation
2. First Metatarsal Fractures should be referred to orthopedics
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

Indications
1. Shaft Fractures with >3-4 mm dorsal or plantar displacement
2. Shaft Fractures with >10 degrees dorsal or plantar angulation
Protocol
1. Reduce Fracture (under Regional Anesthesia or Procedural Sedation)
2. Apply posterior splint initially followed by Casting after 5 days (or short leg boot)
  1. First: Crutch walking only and NO weight bearing for 3 to 4 weeks
  2. Next: Short Leg Walking Cast or boot for an additional 3 to 4 weeks
3. Follow-up with Orthopedics or Podiatry

Indications: Urgent Consultation
1. See Fracture
Indications: Prompt Consultation
1. Displaced Fractures (see above)
2. Open Fractures
3. Compartment Syndrome (emergent Consultation)
4. First Metatarsal Fracture (regardless of displacement, esp. comminuted or intraarticular)
  1. Greater force required to Fracture first Metatarsal than the lesser Metatarsals (2 to 4)
  2. As with the great toe, first Metatarsal alignment is key to weight bearing and walking
5. Multiple Metatarsal Fractures (typically unstable)
  1. Also higher risk for concurrent lisfranc joint Fracture dislocation
6. Fifth Metatarsal styloid Fracture with displacement
7. Metatarsal Shaft Fracture near the Metatarsal head
8. Intra-articular Fracture
9. Metatarsal Fracture with associated Lisfranc Dislocation or Lisfranc Fracture
Protocol
1. Apply posterior splint
2. Crutch walking only and no weight bearing
3. Follow-up with Orthopedics

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)