What is it?

Metatarsal fractures are common injuries to the foot often sustained with direct blows or twisting forces. Many of these fractures are easy to treat and have a favorable prognosis. However, metatarsal fractures that go on to malunion or nonunion can lead to disabling metatarsalgia or midfoot arthritis. The metatarsals are also subject to stress fractures and can be seen in conjunction with other injuries of the mid-foot.

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Signs & symptoms

Symptoms include:
* Sudden pain at the time of injury.
* Difficulty bearing weight.
* Loss of function of your foot.
* Tenderness over a specific area, depending on which bone has fractured.
* You may also have deformity.
* If you pain is more gradual and worse during weight-bearing, then it is more likely you have stress fracture.


A good questioning of the patient is needed since Most metatarsal fractures result from an acute injury, although chronic stress fractures and neuropathic related metatarsal fractures do occur. Patients with an acute metatarsal fracture present with pain, swelling, ecchymosis, and tenderness to palpation in the forefoot - along with difficulty bearing weight. Except with major trauma gross deformities are rarely seen.
A history of direct impact suggests a transverse or comminuted fracture of the shaft, while a twisting-type injury typically causes an oblique or spiral fracture pattern.
A physical exam should be performed with specific attention paid to the main areas of pain, which usually correlates to the site of injury. The relative position of the metatarsal heads should be assessed to rule out malposition and other deformities. Gently applying an axial load to the metatarsal head will create pain if that metatarsal is fractured and this may help differentiate a fracture from a soft-tissue injury on clinical exam. A neurovascular examination should be performed to assess for any loss or altered sensation and review the vascularity of the foot and the toes.

Radiographs in the anteroposterior (AP), oblique, and lateral planes should be obtained (Figure 3). The films should include the entire foot to rule out associated injuries that may require treatment. The lateral view is important for judging sagittal plane displacement of the metatarsal heads, and the oblique view can help detect minimally displaced fractures.


The goal of treatment is to restore alignment of the 5 metatarsals to preserve the arches of the foot and allow normal weight distribution over the metatarsal heads.
Management varies widely depending on the location of the injury. Most isolated central (2nd - 4th) metatarsal fractures, as well as non-displaced fractures of the 1st metatarsal, can be treated with a walking boot and progressive weight bearing as tolerated. Displacement of a first metatarsal fracture usually represents an unstable pattern that requires surgical fixation.
Treatment of fifth metatarsal fractures depends on the Zone of injury. Non-displaced and minimally displaced avulsion fractures (Dancer's Fractures or Zone 1) may only require symptomatic therapy with a hard shoe or walking boot until the fracture heals. However, full healing of avulsion-type 5th metatarsal fractures often take 8 weeks or longer.
Most metatarsal fractures will go on to heal uneventfully with appropriate treatment, but complications do occur. Malunion, nonunion, or arthritic degeneration of the TMT and MTP joints can lead to metatarsalgia and significant disability, especially in the 1st metatarsal. In addition, malunion can cause plantar keratoses (painful callus) from significant plantar deviation of the metatarsal heads and dorsal keratoses from uncorrected dorsal angulation. Like with all fractures, insuring adequate levels of Vitamin D prevents delays and non-unions of fracture healing.
Non-surgical treatment is advocated in patients with vascular comprise and neuropathy, as risk of infection and nonunion is elevated. Patients with diabetes are still candidates for fixation providing they have good vascular supply and protective sensation to extremities.

☝️ This is not a substitute for professional medical advice. Please consult with your physician before making any medical decision.

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