Chapter 198  Metatarsal Fractures
Chapter 198  Metatarsal Fractures
Scott Van Aman and M. Truitt Cooper
ICD-9 CODE
825.25 Metatarsal Fracture
Key Concepts
● Most metatarsal fractures may be treated nonopera-
tively with excellent results.
● The fifth metatarsal is most commonly fractured,
usually by an avulsion of the base as the result of a
twisting injury.
● The goal of treatment is to maintain alignment of all
five metatarsals to preserve longitudinal and trans-
verse arches of the foot and normal weight-bearing
distribution under the metatarsal heads.
● The first and fifth metatarsals are most important
for weight bearing, and malalignment is poorly
tolerated.
● The history is important to rule out a previous stress
fracture.
● High-risk fractures include the proximal fifth metatar-
sal, first metatarsal shaft, proximal second metatarsal
(Lisfranc joint injury), and multiple fractures of the
middle metatarsals.
History
● Multiple injury mechanisms include falls, direct crush
injuries, and indirect twisting injuries of the leg with
the forefoot fixed. Avulsion fractures of the base of
the fifth metatarsal may result from the supination
mechanism.
● Severe trauma may lead to multiple fractures.
● Swelling, pain, and ecchymosis
● Usually able to bear some weight, except in cases of
severe trauma
Physical Examination
● Observation
● Gait
● Swelling, ecchymosis
● Deformity, including rotation and angulation of
toes
● Check for open wounds.
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● Palpation
● Determine the area of maximum tenderness.
● Careful sensory and vascular examinations
● Palpate the hindfoot and ankle to rule out addi-
tional injuries.
● Range of motion
● Must range toes; pain out of proportion to what
would be expected on passive extension of toes,
in conjunction with massive swelling, may indicate
compartment syndrome
● Ankle range of motion
Imaging
● Radiographs: weight-bearing (if possible) anteropos-
terior, lateral, and 45-degree oblique views
● Usually sufficient to diagnose fracture
● Check alignment of second metatarsal base with
middle cuneiform to rule out Lisfranc joint injury.
● Occasionally, a nondisplaced fracture will not
appear for more than 2 weeks on plain
radiographs.
● Advanced imaging
● Computed tomography scan only indicated for
complex intra-articular fractures
● Magnetic resonance imaging and bone scan rarely
indicated for acute injuries; more commonly used
with stress fractures
Differential Diagnosis
● Lisfranc joint injury: pain located at tarsometatarsal
joint, exacerbated by pronating/supinating forefoot;
may see fracture at base of second metatarsal
● Tendon rupture/avulsion: pain located over tendon
insertion or tendon proper; weakness to resistance
testing
● Stress fracture: prodromal pain present
● Charcot’s arthropathy: patients with neuropathy (any
type); erythema of foot that decreases with elevation
Treatment
● At diagnosis
● Dependent on the metatarsal involved, location
(head, neck, shaft, base), and displacement 829
8 Section 8  The Ankle and Foot

Figure 198-1  A, Anteroposterior radiograph of the foot displays a

fracture of the fifth metatarsal at the junction of the diaphysis and
A metaphysis. B, Postoperative radiograph shows a healed fracture
treated with an intramedullary screw.

●
Treatment is primarily symptomatic and includes
compressive wrapping with a hard-soled shoe and
weight bearing as tolerated for 5 to 6 weeks.
● If necessary, a fracture boot may be applied to
further immobilize the foot.
● Close follow-up is recommended with early repeat
radiographs to check for changes in alignment.
● Avulsions of the fifth metatarsal base should be
treated with a walking cast or fracture boot with
restricted weight bearing until the foot is com-
pletely pain free.
● Later
● Rarely, metatarsal fractures go on to symptomatic
malunion or nonunion, and surgical osteotomy,
bone grafting, and internal fixation may be
beneficial.
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When to Refer
● Several fracture patterns require referral for surgical
consideration.
● Displaced fractures of the first or fifth metatarsal;
may lead to abnormal loading patterns
● Fractures of the proximal fifth metatarsal (with the
exception of small avulsions); high risk of non-
union; frequently treated with intramedullary screw
fixation (Fig. 198-1)
● Multiple metatarsal shaft or neck fractures: treated
with percutaneous wires or plate and screw
constructs
● Possible Lisfranc joint injury: fixed with screws or
fusion of the tarsometatarsal joints depending on
the extent of injury

● Intra-articular fractures of the proximal or distal first
metatarsal; may lead to posttraumatic arthritis;
fixation frequently includes plate and screw
constructs
Prognosis
● Generally good, especially for isolated mid–metatarsal
shaft fractures
● Appropriate management of neck fractures, as well as
first and fifth metatarsal fractures, should also lead to
a good outcome.
● Although good outcomes can be anticipated for fifth
metatarsal base avulsion fractures, it may be several
months before a return to preinjury activity level
● Intra-articular fractures may lead to posttraumatic
arthritis.
● Missed Lisfranc joint injuries may lead to devastating
arthritic collapse of the arch of the foot.
Troubleshooting
● Patients should be counseled on the risks associated
with certain fractures as discussed previously.
● Surgical risks include bleeding, infection, superficial
nerve injury, and hardware irritation.
Patient Instructions
● Patients should be counseled on the nature of their
injury.
● They should be instructed in the importance of ice and
elevation in the acute period in an effort to reduce
swelling.
● For most fractures other than isolated mid-metatarsal
shaft fractures, patients should be instructed in appro-
priate crutch use and the importance of non-weight
Chapter 198  Metatarsal Fractures 8
bearing on the affected limb to allow for proper
healing.
Considerations in Special Populations
● Diabetic patients require longer periods of treatment
due to delayed healing, even in young patients.
● Fractures may precipitate Charcot’s arthropathy.
● Malalignment is poorly tolerated as altered weight
bearing predisposes the patient to the develop-
ment of skin ulceration.
● High-level athletes/dancers may benefit from surgical
fixation.
● Patients with previous or recurrent stress fractures
may also benefit from surgical fixation.
Suggested Reading
●● Egol K, Walsh M, Rosenblatt K, et al: Avulsion fractures of the
fifth metatarsal base: A prospective outcome study. Foot Ankle
Int 2007;28:581–583.
●● Fetzer GB, Wright RW: Metatarsal shaft fractures and fractures of
the proximal fifth metatarsal. Clin Sports Med 2006;25:139–150.
●● Jones R: Fracture of the base of the fifth metatarsal bone by
indirect violence. Ann Surg 1902;35:697–700.
●● Kell IP, Glisson RR, Fink C, et al: Intramedullary screw fixation of
Jones fractures. Foot Ankle Int 2001;22:585–589.
●● Petrisor BA, Ekrol I, Court-Brown C: The epidemiology of
metatarsal fractures. Foot Ankle Int 2006;27:172–174.
●● Reese K, Litsky A, Kaeding C, et al: Cannulated screw fixation of
Jones fractures. A clinical and biomechanical study. Am J Sports
Med 2004;32:1736–1742.
●● Sanders RW, Papp S: Fractures of the midfoot and forefoot. In
Coughlin MJ, Mann RA, Saltzman CL (eds): Surgery of the Foot
and Ankle, 8th ed. Mosby: Philadelphia, 2007, p 2199.
●● Schenck RC, Heckman JD: Fractures and dislocations of the
forefoot: Operative and non-operative treatment. J Am Acad
Orthop Surg 1995;3:70–78.
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