II. Mechanism: Metatarsal Shaft Fracture

  1. Direct blow to foot
  2. Twisting injury
  3. Fall from height

III. 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

IV. Symptoms

  1. Painful ambulation
  2. Localized swelling, pain and Ecchymosis

V. Signs

  1. Marked localized swelling, Ecchymosis
  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)

VI. Imaging

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

VII. 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 3-5 days 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
      1. Transition to rigid-sole shoe at 4-6 weeks
  4. Protocol: Follow-up every 2-4 weeks
  5. 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

VIII. Management: Nondisplaced Proximal first to fourth Metatarsal Fractures

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

IX. 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

X. Management: Complicated Fractures (require orthopedic Consultation)

  1. Indications: Urgent Consultation
    1. See Fracture
  2. Indications: Prompt Consultation
    1. See Displaced Fracture above
    2. First Metatarsal Fracture (regardless of displacement)
    3. Multiple Metatarsal Fractures (typically unstable)
    4. Fifth Metatarsal styloid Fracture with displacement
    5. Metatarsal Shaft Fracture near the Metatarsal head
    6. Intra-articular Fracture
    7. 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

XI. 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)

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Ontology: Fracture of one or more tarsal and metatarsal bones (C1963546)

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