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Metatarsal fracture

67 citationsUpdated Sep 2026

Overview

Metatarsal fractures are frequent injuries that may lead to prolonged disability if malunited, yet they are easy to treat with a generally favorable prognosis when adequately assessed [1]. In pediatric populations, foot fractures usually have a good prognosis and are generally treated nonoperatively [4], with first metatarsal fractures accounting for 20 per cent overall and 73 per cent in the under-fives [3]. A combined fracture of the lateral malleolus and the base of the fifth metatarsal has been described in five patients [2]. Overall outcome in metatarsal fractures is high, as almost all fractures healed without complaints at 33 months [9].

Undisplaced metatarsal fractures are better treated without a cast [5], and routine outpatient follow-up of fifth metatarsal fractures showed no added clinical value [13]. Point-of-care ultrasonography (POCUS) could be applied with success in the diagnosis and determination of the treatment method in low-energy induced metatarsal fractures [19]. For central metatarsal fractures, alignment can be restored and good clinical outcome is achieved using closed antegrade/retrograde intramedullary fixation [6]. In the treatment of Lisfranc injuries accompanied by multiple metatarsal fractures, fusion results in a better outcome than non-fusion with longer and more conservative postoperative management [12]. Functional outcomes in multitrauma patients with midfoot or hindfoot fractures were comparable [22].

Surgical intervention is indicated for specific subtypes and complications. Zone 1 fractures of the 5th metatarsal base may be managed conservatively regardless of the initial fracture gap, with union expected within 8 weeks and good VAS and AOFAS scores [7]. Conversely, surgical treatment is advocated as the initial method of choice for both zone II and III proximal fifth metatarsal fractures in athletes [34]. Operative treatment may rarely be required to ensure adequate fracture healing for stress fracture nonunion at the base of the second metatarsal [14]. The tension-band wire technique gives good results in the treatment of proximal metaphysial/diaphysial fractures of the fifth metatarsal in cases of primary unsuccessful nonoperative treatment or primary unsuccessful intramedullary screw fixation [27].

Anatomy & Pathophysiology

General Metatarsal Anatomy and Biomechanics

Metatarsal fractures constitute 35% of all foot fractures, occurring most frequently in patients aged 20 to 50 years [42]. The first metatarsal is shorter and wider than the lesser four metatarsals, lacks interconnecting ligaments to the second metatarsal to allow independent motion, and accounts for approximately 1.5% of all metatarsal fractures [38]. The tibialis anterior inserts on the plantar medial aspect of the first metatarsal base to elevate it, while the peroneus longus attaches to the plantar lateral base to plantarflex the head [38]. This metatarsal bears approximately one-third of body weight and experiences among the highest peak pressures during most activities [38, 47, 48].

Stability of the central metatarsals is achieved by midfoot bony architecture and ligamentous attachments at the bases and necks [47, 48]. Severe displacement of central metatarsal shaft fractures is uncommon unless multiple metatarsals are fractured [47, 48]. Conversely, the first and fifth metatarsals are more mobile and susceptible to injury than the central metatarsals [47, 48]. Fractures of the central metatarsals account for approximately 10% of all metatarsal fractures [40]. Fractures of the third metatarsal are related to fractures of the second or fourth metatarsal approximately 63% of the time [40]. The fourth metatarsal is the least commonly injured central metatarsal due to its protected position and flexibility [40]. The plantar fascia and auxiliary plantar flexors maintain normal strains in the metatarsals during gait [85]. During running, forces are highest under the second metatarsal, with bending strain being 6.9 times greater than that of the first metatarsal [105].

Fifth Metatarsal Anatomy and Blood Supply

Fractures of the fifth metatarsal account for approximately 68% of all metatarsal fractures [71]. The base is a complex anatomic site with the insertion of three muscles: peroneus brevis, peroneus tertius, and abductor digiti quinti [71]. The peroneus brevis attaches on the dorsal aspect of the tubercle, while the peroneus tertius attaches on the dorsal aspect at the proximal metaphyseal–diaphyseal junction [71]. A strong attachment of the plantar fascia exists on the plantar aspect of the fifth metatarsal tubercle [71].

The nutrient artery enters the medial cortex of the fifth metatarsal at the junction of the proximal and middle third of the diaphysis [71]. Secondary epiphyseal and metaphyseal arteries supply the base and tuberosity [71]. The metaphyseal–diaphyseal junction represents a watershed region between the nutrient artery and metaphyseal blood supplies [71]. The proximal branch of the nutrient artery is significantly shorter than the distal branch, creating a watershed proximally in zones 2 and 3 [32]. Fractures occurring in zone II have the greatest risk for delayed healing due to limited vascularity [49]. The os vesalianum is found just proximal to the base medial to the peroneus brevis insertion, while the os peroneum is located within the peroneus longus tendon on the lateral border of the cuboid [71]. In adolescents, an apophysis at the tuberosity can be confused for a fracture [71]. The proximal apophyseal growth center is usually visible radiographically at age 9 and becomes united to the diaphysis between 12 and 15 years of age [55]. Proximal fifth metatarsal fractures distal to the peroneus brevis insertion are significantly more unstable than more proximal fractures due to a deforming force exerted by the tendon [99].

Fifth Metatarsal Fracture Zones

Zone I comprises the cancellous tuberosity, including the insertion of the peroneus brevis tendon and the calcaneometatarsal ligament of the plantar fascia [55]. These fractures are avulsion types usually secondary to an inversion injury to the foot [25]. Zone II is the distal aspect of the tuberosity, with dorsal and plantar ligamentous attachments to the fourth metatarsal [55]. Zone II fractures extend from zone I to the metaphyseal/diaphyseal junction and include the fourth and fifth metatarsal articulation [25]. The mechanism of injury is usually a strong abduction force to the forefoot causing a bending moment at the metaphyseal-diaphyseal junction [25]. Zone III begins distal to the ligamentous attachments and extends to the mid-diaphyseal area [55]. Zone III fractures occur in the proximal 1.5 cm of the diaphysis and are the area where stress fractures usually occur [25]. The relative frequency of proximal fifth metatarsal fractures in a busy general orthopedic practice was approximately 93% zone 1, 4% zone 2, and 3% zone 3 [71].

Tarsometatarsal (Lisfranc) Joint Anatomy

The tarsometatarsal articulation has transverse stability provided by the wedge-shaped metatarsal bases and their corresponding cuneiform-cuboid articulations [41]. The second metatarsal is recessed between the medial and lateral cuneiforms as the keystone of the tarsometatarsal joint [41]. The base of the second metatarsal fits into a mortise formed by the proximally recessed middle cuneiform [81, 82]. In the coronal plane, the second metatarsal base serves as the cornerstone in a Roman arch configuration [81, 82]. The tarsometatarsal joints have little longitudinal stability, provided only by strong ligamentous support [41]. There are multiple intermetatarsal ligaments at the metatarsal bases except between the first and second metatarsals [41]. The Lisfranc ligament runs from the medial cuneiform to the second metatarsal and provides stability in this area [41]. It is 8 to 10 mm wide and 5 to 6 mm thick [81, 82]. The interosseous ligament at the tarsometatarsal joint is the stiffest and strongest, while the dorsal ligament is the weakest [81, 82]. The plantar ligament inserts on the bases of the second and third metatarsals [81, 82].

Pathophysiology of Stress Fractures

Stress fractures of the metatarsal bones account for 38% of all stress fractures of the lower limb [31]. The 2nd and 3rd metatarsals are most commonly involved, although 4th and 5th metatarsal fractures remain clinically significant given their greater potential for non-union [31]. Excessive stress applied to a bone before it has time to remodel results in fatigue failure, with bone taking some 2 weeks to achieve remodeling [17]. Non-union of fatigue fractures is remarkably uncommon, apart from the Jones' fracture of the proximal fifth metatarsal [17]. Non-union of Jones fractures is more likely to be related to unresolved stress than to the quality or vascularity of the bone [17].

Fractures of the 2nd metatarsal present with non-specific midfoot pain of insidious onset, often in ballet dancers [31]. The mechanism of injury is repeated extreme plantar flexion at the Lisfranc joint [31]. A prominent 2nd metatarsal, naturally pronated foot, and poor ankle plantar flexion contribute to these stress fractures [31]. The decrease in maximum force in the middle forefoot in patients with a previous second metatarsal stress fracture could have resulted from gait alterations after the fracture [23].

5th metatarsal base stress fractures present with lateral foot pain and tenderness at the 5th metatarsal base exacerbated by inversion [31]. Progression to non-union is contributed to by the presence of a perfusion watershed at the metaphysis/diaphysis junction [31]. Cavovarus foot alignment is a predisposing factor [31]. An increasing inter-metatarsal angle between the 4th and 5th metatarsals and a protruding 5th metatarsal head are also predisposing factors [31]. The majority of patients sustaining Jones fractures have evidence of varus hindfoot alignment, which may be a predisposing factor to developing the fracture or refracture [62]. Weak toe-grip strength is associated with fifth metatarsal fracture, suggesting it may lead to an increase in the load applied onto the lateral side of the foot [52]. Weightbearing CT can identify specific alignment and density characteristics, such as increased bone density and altered alignment, in patients with fifth metatarsal stress fractures [28]. Alteration of the rollover process with increased forefoot loading may help explain the incidence of stress fractures of the metatarsals under fatiguing loading conditions [101]. Risk factors for lower extremity overuse injuries include dynamic pes planus, pes cavus, restricted ankle dorsiflexion, and increased hindfoot inversion [95].

Pediatric Anatomy and Pathophysiology

Foot fractures account for 5% to 8% of all pediatric fractures and for approximately 7% of all physeal fractures [26]. Metatarsal fractures are the most common pediatric foot fracture, accounting for 5% to 7% of all pediatric fractures and up to 60% of all pediatric foot fractures [43]. Fractures of the first metatarsal accounted for 20 per cent overall and 73 per cent in the under-fives in a study of metatarsal fractures in children [3]. The apophysis at the base of the fifth metatarsal appears at approximately 8 years of age and fuses by the age of 12 years in girls and 15 years in boys [43]. The secondary ossification center at the base of the fifth metatarsal can be confused with an avulsion fracture in children [43].

Classification

General Metatarsal Fractures

AO/OTA: The OTA classification provides a detailed description of fracture patterns for each metatarsal bone but offers no insight into overall stability or treatment [89]. It designates extra-articular simple metatarsal fractures as Type A [89]. Partial articular involvement or wedge fractures of the shaft are designated Type B [89]. Complete articular involvement and/or comminuted shaft fractures are designated Type C [89]. The system further subdivides fractures by location into proximal, central, or distal groups [89].

Epidemiology: Foot fractures and dislocations are common traumatic injuries associated with high rates of morbidity and dysfunction [50]. In pediatric populations, foot fractures account for 5% to 8% of all fractures and approximately 7% of all physeal fractures [26]. Fractures of the first metatarsal accounted for 20% of metatarsal fractures overall in a study of children [3]. In children under five years of age, first metatarsal fractures accounted for 73% of metatarsal fractures [3].

Proximal Fifth Metatarsal Fractures (Lawrence and Botte)

Lawrence and Botte: This classification categorizes proximal fifth metatarsal fractures into three distinct zones based on anatomic location [96]. Zone 1 injuries are tuberosity avulsion fractures occurring near the insertion of the peroneus brevis tendon [96]. Zone 1 injuries represent 93% of all proximal fifth metatarsal injuries [96]. Zone 2 Jones fractures involve the metaphyseal-diaphyseal region and account for 4% of proximal fifth metatarsal injuries [96]. Zone 3 diaphyseal stress fractures account for 3% of proximal fifth metatarsal injuries [96].

Zone Definitions: Zone I is the most proximal zone, including the metatarsocuboid articulation but remaining proximal to the fourth and fifth metatarsal articulation [25]. Zone II extends from Zone I to the metaphyseal/diaphyseal junction and includes the fourth and fifth metatarsal articulation; this is the area of the true Jones fracture [25]. Zone III comprises the proximal 1.5 cm of the diaphysis, where stress fractures usually occur [25]. One study suggested that no distinction needs to be made between Zone II and Zone III fractures because treatment and outcomes are the same in the two groups [25].

Treatment Implications: Zone 1 fractures are generally treated symptomatically and usually nonoperatively [96]. Operative treatment may be considered for Zone 1 fractures with displacement greater than 3 mm in any plane [96]. Nondisplaced Zone 2 Jones fractures can be treated with nonweightbearing immobilization for 6 to 8 weeks [96]. Zone 3 fractures are further classified into subtypes according to Torg's classification of diaphyseal stress fractures based on the degree of sclerosis [96]. Torg Type I fractures are acute and present with a narrow fracture line without fibrosis [96]. Torg Type II fractures are characterized by a widened fracture line with intramedullary sclerosis, indicating ongoing bone stress [96]. Torg Type III fractures refer to symptomatic nonunions characterized by the complete obliteration of the medullary canal attributed to sclerotic bone formation [96].

Tarsometatarsal (Lisfranc) Injuries

Quénu and Küss: This classification describes three types of Lisfranc injury patterns: homolateral, isolated, and divergent [88].

Hardcastle: This classification distinguishes three main groups of Lisfranc injuries: complete, partial, and divergent dislocation patterns [88]. Type A (complete) fracture-dislocations involve all parts of the Lisfranc joint complex with dislocation within one plane [88]. Type B (partial) fracture-dislocations are identified by partial incongruity of the joint complex [88]. In Type B medial dislocation, the first metatarsal or a variable number of metatarsals excluding the fifth are involved [88]. In Type B lateral dislocation, one or more of the lateral metatarsals are dislocated while the first ray remains stable and intact [88]. Type C (divergent) fracture-dislocations exhibit complete and partial injury patterns simultaneously [88]. In Type C divergent patterns, medialization of the first metatarsal is found in conjunction with lateral translation of a variable number of the lateral four metatarsal bones [88].

Myerson: Type A injury includes complete incongruity of the TMT joint line in any plane or direction [88]. Type B1 injury is determined by partial incongruity involving the first ray [88]. Type B2 injury is characterized by dislocation of one or more of the lateral four metatarsal bones [88]. Type C1 injury has a diverging injury pattern comprised of medialization of the first ray associated with dislocation and partial incongruity of the lateral metatarsals [88]. Type C2 injury has a diverging injury pattern with complete incongruity [88].

Nunley and Vertullo: Stage I injury is characterized by no displacement at the Lisfranc complex, constituting a sprain of the Lisfranc ligament without diastasis or loss of medial column height [88]. Stage I injuries are nondisplaced on weight-bearing radiographs but show increased uptake on bone scintigrams [88]. Stage II injury shows diastasis of 1 to 5 mm at the first/second intermetatarsal space resulting from a rupture of the Lisfranc ligament, but no medial column sag [88]. Stage III injury presents with diastasis of the first/second intermetatarsal space greater than 5 mm and loss of medial column height [88].

AO/OTA: The revised AO/OTA classification system distinguishes Lisfranc fracture-dislocations according to the resulting deformity [88].

Other Considerations: Current classification systems for Lisfranc injuries lack evidence regarding their impact in the prediction of treatment or clinical and functional outcomes [88]. Pure ligamentous injuries and nondisplaced Lisfranc injury patterns are not sufficiently represented in current classification systems [88].

Clinical Presentation

General Presentation and Diagnosis

Patients with metatarsal fractures present with pain, ecchymosis, and swelling [47, 48]. Weight bearing is often painful and difficult [47, 48]. Plantar ecchymosis may signify a more significant injury involving the Lisfranc joint complex [47, 48]. AP, lateral, and oblique radiographs are usually suitable to detect metatarsal fractures [47, 48]. Three weight-bearing views (AP, lateral, and oblique) are mandatory to judge shortening, deviation, angulation, and displacement [38, 40]. Weight-bearing films usually reveal subtle instabilities not seen on non-weight-bearing films [40]. MRI can provide additional information related to soft tissue injuries and may give a hint toward stress fractures [38, 40]. CT can provide additional information regarding intra-articular fracture lines and fragments [38, 40]. Compartment syndrome is relatively common with soft tissue trauma in the metatarsal area, and compartment pressures should be monitored routinely, especially following direct trauma [38, 40]. The arterial arch and the dorsal and plantar metatarsal arteries are particularly susceptible to injuries in association with metatarsal fractures [38, 40]. As one in twenty polytrauma patients sustains at least one foot fracture, physicians should have a high index of suspicion for injuries of the feet in polytrauma patients [33]. Careful evaluation of the feet is required during primary and secondary survey, particularly when a tibia or femur fracture is diagnosed [51].

First Metatarsal

First metatarsal fractures account for approximately 1.5% of all metatarsal fractures [38]. Patients normally describe pain with weight bearing and active motion of the foot and have difficulties with ambulation [38]. Physical examination reveals tenderness and swelling [38]. Crepitation and palpable motion may be present at the fracture site and reproduce the patient's symptoms [38]. Any fracture of the base of the first three metatarsals should raise suspicion of a midtarsal injury [38, 40]. Small avulsion fractures involving the medial base of the first or second metatarsal suggest disruption of the TMT ligaments [38, 40].

Central Metatarsals (Second, Third, Fourth)

Patients with central metatarsal fractures normally describe pain with weight bearing and active motion of the foot and have difficulties with ambulation [40]. Physical examination reveals tenderness and swelling [40]. Crepitation and palpable motion may be present at the fracture site and reproduce the patient's symptoms [40]. Any displacement or diastasis of more than 2 mm between the base of the first and second metatarsals on an AP radiograph of the foot should raise suspicion of a Lisfranc ligament injury [40].

Stress Fracture Risk Factors and Diagnosis: 2nd metatarsal stress fractures may be contributed to by a prominent 2nd metatarsal, naturally pronated foot and poor ankle plantar flexion [31]. The 2nd and 3rd metatarsals are most commonly involved in metatarsal stress fractures [31]. Second metatarsal stress fracture is the most common and is classically described in amenorrheal ballet dancers [47, 48]. In female athletes with metatarsal stress fractures, the triad of anorexia, osteoporosis/stress injuries, and menstrual dysfunction must be considered [47, 48]. MRI or bone scan aids in the diagnosis of metatarsal stress fractures, as radiographs may be normal for 3 weeks [47, 48]. Radiographs may demonstrate periosteal reaction or evidence of callus formation near the diaphyseal region of the affected metatarsal after 3 to 4 weeks [47, 48]. A normal radiograph prior to 3 weeks does not exclude a stress fracture [47, 48]. Excessive loading of the second metatarsal can lead to injury, particularly with a long second metatarsal or hallux rigidus/valgus [47, 48].

Fifth Metatarsal

The most common metatarsal fractures are those of the fifth metatarsal [42]. Fractures of the fifth metatarsal typically show pain, swelling, and tenderness on the outside of the foot [58]. Patients usually complain about difficulties with walking [58]. Bruising may occur following direct trauma to the fifth metatarsal [58]. The Ottawa Foot Rules have been found to be 100% sensitive and 79% specific for the identification of fifth metatarsal fractures [58]. If clinical findings are suggestive of a fracture at the base of the fifth metatarsal but radiographs appear normal, an AP radiograph of the ankle that includes the proximal fifth metatarsal is recommended to rule out a tuberosity avulsion fracture [58].

Zone I and II Fractures: 5th metatarsal base fractures present with lateral foot pain, and tenderness at the 5th metatarsal base exacerbated by inversion [31]. Zone I fifth metatarsal fractures are avulsion types of injuries, usually secondary to an inversion injury to the foot [25]. Zone II fifth metatarsal fractures (Jones fractures) are caused by a strong abduction force to the forefoot, causing a bending moment at the metaphyseal-diaphyseal junction [25].

Zone III Stress Fractures: Zone III fifth metatarsal fractures are the area where stress fractures usually occur [25]. Proximal fifth metatarsal stress fractures are most common in athletes who participate in sports such as basketball, football, or soccer [32]. Patients have worsening activity-related pain along the lateral aspect of the midfoot over a period of several weeks [32]. Physical examination may reveal point tenderness over the base of the fifth metatarsal as well as pain with passive inversion or resisted eversion of the foot [32]. A cavovarus foot shape is commonly noted with proximal fifth metatarsal stress fractures [32]. The majority of patients sustaining Jones fractures have evidence of varus hindfoot alignment [62].

Torg Classification: Torg type I: Sharp margins with no evidence of widening of the fracture line, sclerosis, periosteal reaction, or cortical hypertrophy [31]. Torg type II: Widening of the fracture line, periosteal reaction and/or intramedullary sclerosis [31]. Torg type III: Nonunions with intramedullary sclerosis and blunted fracture edges [25].

Imaging and Anatomical Risk Factors: The plantar gap might add to the decision-making process for surgery and improve the prediction of patient prognosis in fifth metatarsal fractures [18]. Weightbearing CT can identify specific alignment and density characteristics to potentially detect higher-risk patients for fifth metatarsal stress fractures [28]. Fifth metatarsal stress fractures are associated with increased bone density and altered alignment on weightbearing CT [28]. Long, narrow, and straight fifth metatarsals with an adducted forefoot are most at risk for fifth metatarsal fractures [25]. Metatarsus adductus and a curved fifth metatarsal with a prominent base are associated with higher rates of fifth metatarsal fractures in professional NBA players [25].

Pediatric Presentation

The apophysis at the base of the fifth metatarsal can be confused with an avulsion fracture [43]. The secondary ossification center at the base of the fifth metatarsal appears at approximately 8 years of age and fuses by the age of 12 years in girls and 15 years in boys [43]. Callus formation may be seen on radiographs for adolescent metatarsal stress fractures but not in all cases [43]. Hand and foot fractures in children have many accompanying injuries that require attention during diagnosis and treatment [46].

Investigations

Plain radiography: Three views (AP, lateral, and oblique) are mandatory to judge shortening, deviation, angulation, and displacement in metatarsal fractures [38]. For isolated first metatarsal fractures, stress radiographs are the best method to determine operative or nonoperative treatment; manual displacement of the first metatarsal through the joint or fracture site represents an instability that requires fixation [59]. If clinical findings suggest a fracture at the base of the fifth metatarsal but foot radiographs appear normal, an AP radiograph of the ankle including the proximal fifth metatarsal is recommended to rule out a tuberosity avulsion fracture [58].

CT: CT provides additional information regarding intra-articular fracture lines and fragments [38]. It is helpful when fractures involve the base of the metatarsals to identify intra-articular extension and any comminution [40]. Weightbearing CT can identify specific alignment and density characteristics to potentially detect higher-risk patients with fifth metatarsal stress fractures [28].

MRI: MRI provides additional information related to soft tissue injuries and may give a hint toward stress fractures [38]. It allows for early visualization of stress-related marrow edema and proper diagnosis before progression to fracture [106]. In midfoot fracture-dislocations, MRI can demonstrate the degree of ligament disruption but is not usually required for diagnosis nor does it usually alter treatment [40].

Point-of-care ultrasonography (POCUS): POCUS may be helpful in the diagnosis and follow-up of metatarsal fractures [38]. It could be applied with success in the diagnosis and determination of the treatment method in low-energy induced metatarsal fractures [19].

Other Considerations: The plantar gap might add to the decision-making process for surgery and improve the prediction of patient prognosis [18]. As one in twenty polytrauma patients sustains at least one foot fracture and a substantial amount of these fractures are diagnosed in a delayed fashion, physicians should have a high index of suspicion for injuries of the feet in polytrauma patients [33]. Careful evaluation of the feet during primary and secondary survey is needed particularly when a tibia or femur fracture is diagnosed [51].

Treatment

General Principles and Prognosis

Metatarsal fractures are frequent injuries that may lead to prolonged disability if malunited, but are easy to treat with a generally favorable prognosis if adequately assessed [1]. Overall outcome in metatarsal fractures is high, with almost all fractures healing without complaints at 33 months [9]. Fractures of the foot in children usually have a good prognosis and are generally treated nonoperatively [4]. In a review of 337 children with metatarsal fractures, only 10 required surgical treatment [43]. Fracture of all five metatarsals is predictive of amputation in the setting of mid/hindfoot fractures after high-energy trauma [47, 48]. When multiple metatarsals are fractured, a Lisfranc injury must be ruled out [47, 48]. Careful evaluation of the feet during primary and secondary survey is necessary, particularly when a tibia or femur fracture is diagnosed [51].

First Metatarsal Fractures

The first metatarsal bears approximately one-third of body weight, making maintenance of alignment very important [47, 48]. Nondisplaced first metatarsal fractures are treated with a boot or hard-soled shoe and weight bearing as tolerated [47, 48]. Displaced first metatarsal fractures require surgical fixation via open reduction and internal fixation (ORIF) with lag screws or plate fixation [47, 48]. Isolated first metatarsal fractures can be treated nonoperatively if there is no instability on stress radiographs and no other midfoot or metatarsal injuries [59]. Nonoperative treatment for isolated first metatarsal fractures involves a short leg cast with no weight bearing for 3 weeks, followed by an additional 3 weeks with weight bearing as tolerated [59]. Casting for first metatarsal fractures should be performed with the foot in a plantigrade position without placing dorsally directed pressure on the first metatarsal [59].

Central Metatarsal Fractures (2nd, 3rd, 4th)

The majority of second, third, and fourth metatarsal fractures are minimally displaced and treated with a low-tide walking boot or hard-soled shoe with arch support [47, 48]. Isolated central metatarsal fractures are stable secondary to intermetatarsal ligaments present at the base and neck [47, 48]. Most isolated individual central metatarsal fractures can be treated nonoperatively [44]. Isolated midshaft central metatarsal fractures are usually stable with little shortening and can be managed with hard-sole or stiff shoes and progressive weight bearing as tolerated [44]. Individual head or neck fractures that appreciably deviate dorsally or plantarly are treated with closed reduction using finger trap distraction to restore alignment [44]. A stable base fracture of the third or fourth metatarsal can be reduced closed without fixation [44].

Surgical fixation is indicated for central metatarsal fractures with significant sagittal plane deformity (>10 degrees) or if the three central metatarsals are fractured [47, 48]. Multiple central metatarsal fractures are inherently unstable because intermetatarsal ligaments cannot provide stability [47, 48]. An unstable base fracture of the second metatarsal requires limited open reduction and intramedullary pinning if it has a tendency to shift laterally due to the absence of stabilizing ligaments between the first and second metatarsals [44, 87]. Fractures displaying more than 10 degrees of deviation in the sagittal plane or 3 to 4 mm of translation in any plane should be actively corrected [44]. Multiple adjacent metatarsal fractures or significant comminution often require ORIF because closed reduction is usually unstable [87].

Surgical fixation for central metatarsal fractures includes ORIF with plate-and-screw fixation or intramedullary antegrade-retrograde pinning [47, 48]. Closed Antegrade/Retrograde intramedullary fixation of central metatarsal fractures can restore alignment and achieve good clinical outcomes [6]. Multiple metatarsal head or neck fractures are difficult to treat by open means due to the risk of devascularization of the head; closed reduction with traction and local anesthesia is preferred [87]. Closed reduction for multiple metatarsal head or neck fractures aims to bring a plantarflexed head back to a neutral position and impale the head on the neck of the metatarsal [87]. Percutaneous pin fixation for multiple metatarsal head or neck fractures should incorporate both the metatarsal shaft and the base of the proximal phalanx to ensure stable fixation [87]. Care must be taken to maintain proper metatarsal length during central metatarsal fracture treatment to minimize the risk of transfer metatarsalgia or plantar keratosis [47, 48].

Fifth Metatarsal Fractures: Zone 1 (Avulsion)

Zone I injuries are traction-type fractures resulting from avulsion of the proximal aspect of the metatarsal by the peroneus brevis tendon and lateral plantar aponeurosis [55]. Zone 1 fractures of the 5th metatarsal base may be managed conservatively regardless of the initial fracture gap, with union expected within 8 weeks and good VAS and AOFAS scores [7]. Zone I fractures are generally treated satisfactorily in a postoperative shoe, walking boot, or short leg walking cast depending on symptoms [25]. Nonoperatively treated nondisplaced avulsion fractures of the tuberosity of the fifth metatarsal tend to heal uneventfully within 3 to 12 weeks in nearly all patients with few residual symptoms up to 1 year [30]. In a study of proximal fifth metatarsal fractures, all 60 patients healed at an average of 44 days, with no fracture taking longer than 65 days [25]. Patients treated with a compressive soft dressing and allowed to bear weight in a cast boot required significantly shorter recuperation time and had better modified foot scores than those treated with cast immobilization [25]. Patients on average missed 22 days of work, and it took 6 months or more for most patients to return to preinjury levels of activities [25]. The study showed no added clinical value for routine outpatient follow-up of fifth metatarsal fractures [13].

Open reduction and fixation can be considered for Zone I fractures with gross displacement or articular involvement in young active patients [25]. ORIF for Zone I fractures is rarely necessary and generally reserved for displaced intraarticular fractures in highly competitive individuals [25]. A lag screw placed obliquely from the base of the fifth metatarsal into the medial cortex is the surgical treatment of choice for displaced Zone I fractures [47, 48]. Open reduction is required if the fifth metatarsal–cuboid articular surface is displaced or if the fracture is rotated so that the fractured surface of the proximal fragment no longer faces the distal fragment [47, 48]. Tenting of the skin is an indication for fixation in Zone I fractures [47, 48]. Plates in the Zone I area are generally not well tolerated and often require removal [25]. Chronic pain from a previous avulsion fracture may be addressed with excision of the fragment and reattachment of the peroneus brevis tendon [47, 48]. Nonunions of Zone I fractures may occur but are rarely painful and can be treated with excision of the fragment [25].

Fifth Metatarsal Fractures: Zone 2 (Jones) and Zone 3 (Proximal Diaphyseal)

Zone II extends from Zone I to the metaphyseal/diaphyseal junction and includes the fourth and fifth metatarsal articulation, representing the area of the true Jones fracture [25]. The blood supply to the fifth metatarsal includes a watershed area between the proximally tracking nutrient artery and the metaphyseal artery, contributing to nonunion risk in Zones 2 and 3 [31, 32]. Treatment for stress fractures of the proximal fifth metatarsal should be aggressive due to poor blood supply and risk of nonunion [49]. It is important to assess for biomechanical or biological reasons why a fracture developed, such as cavovarus foot posture or hypovitaminosis D [25]. Long, narrow, and straight fifth metatarsals with an adducted forefoot were most at risk for fifth metatarsal fractures in a study of 51 elite athletes [25].

Treatment of Jones fractures and Torg type I diaphyseal fractures depends on the type of fracture and the activity demands of the patient [25]. Nonsurgical management with strict non–weight bearing in a short leg cast for 6 to 8 weeks is an option for a Torg type I fracture (acute fracture with sharp margins and no sclerosis) [32]. In nonathletes, a short leg non–weight-bearing cast or fracture brace for 6 to 8 weeks is recommended for proximal fifth metatarsal stress fractures [49]. An initial non-weight bearing, short leg cast is worn for 6 to 8 weeks followed by a weight-bearing cast until union has been achieved for Jones fractures, with a reported healing rate of 75% [25]. Longer immobilization may be required if no radiographic evidence of healing has occurred during the initial 6 to 8 week period for proximal fifth metatarsal stress fractures [49]. For Zone III fractures with clinical or radiographic evidence of chronic injury manifested by partial or complete canal obliteration and sclerosis, non-weight-bearing casting may yield satisfactory results [25]. The period of immobilization and non-weight bearing for chronic Zone III fractures is approximately 8 weeks [25]. Refracture is common in the category of chronic Zone III fractures [25]. Jones fractures have a reported nonunion rate of 7% to 28% even with non-weight-bearing immobilization for 6 to 8 weeks [25].

Surgery should be considered for Zone II and III fractures that are not healing clinically at 8 to 12 weeks and for acute fractures in competitive athletes or those whose occupational demands do not allow prolonged non-weight bearing immobilization [25]. In competitive athletes, consideration should be given to early ORIF to decrease disability time for Jones fractures [25]. Many active individuals and elite athletes opt for surgical fixation for Torg type I fractures to minimize the risk of nonunion and refracture and allow a more rapid return to sport [32]. If there is evidence of delayed union or nonunion (Torg type II or III), surgical fixation is generally recognized as the standard of care with selective open débridement and bone grafting [32]. There is now a greater tendency to use surgical fixation as the primary treatment for proximal fifth metatarsal stress fractures due to potentially prolonged healing time and risk of refracture or nonunion following conservative treatment [49]. The authors advocate surgical treatment as the initial method of choice for both zone II and III proximal V MT fractures [34].

Two operative treatments have proved successful for Zones II and III fractures requiring surgical intervention: fixation with an intramedullary screw and corticocancellous inlay bone grafting with clearing of the medullary canal of all sclerotic bone [25]. Intramedullary screw fixation is currently used by most authors for Zones II and III fractures [25]. Fixation for proximal fifth metatarsal stress fractures is usually performed with an intramedullary screw and has a good to excellent result [32]. In high-demand athletes, IM screw fixation with a 4.0- or 4.5-mm cannulated screw permits faster return to play since casting alone has been shown to have a high failure rate [49]. If nonunion is not present, bone grafting usually is not necessary at the time of IM fixation for proximal fifth metatarsal stress fractures [49]. The use of electrical and pulsed ultrasound bone stimulation for Jones fractures may improve healing but cannot take the place of internal fixation in a high-performance athlete [25]. The tension-band wire technique seems to give good results in the treatment of proximal metaphysial/diaphysial fractures of the fifth metatarsal in cases of primary unsuccessful nonoperative treatment or primary unsuccessful intramedullary screw fixation [27]. The XS-nail proved to be an effective and technically optimized implant for the treatment of proximal fifth metatarsal fractures that provides a rapid full-weight-bearing mobilization and shows good long-term results [36]. Both intramedullary screw fixation and shock wave therapy are effective treatments for fracture nonunion in the metaphyseal-diaphyseal region of the fifth metatarsal [66].

A 2015 radiographic study found the average straight-segment length of the fifth metatarsal to be 52 mm, which was 68% of the overall length from the proximal end [32]. The medullary canal of the fifth metatarsal is elliptical, with an average coronal canal diameter at the isthmus of 5 mm [32]. In 81% of men, the diameter of the fifth metatarsal medullary canal was greater than 4.5 mm [32]. The use of a solid, partially threaded screw with a 4.5-, 5.5-, or 6.5-mm diameter is recommended for fifth metatarsal fixation [32]. Headed screws are recommended over headless screws for fifth metatarsal fixation because of their superior pullout strength and easier removal [32]. Plate fixation is growing in popularity for fifth metatarsal nonunion cases as it is technically easier to apply in areas of increased bony sclerosis when the fracture is already exposed for bone grafting [32]. Plantarlateral plating of the fracture has been described and shown to increase cycles to failure and ultimate load to failure in Jones fracture fixation [32].

There is no definitive literature to support or refute the routine use of bone graft in the primary setting for fifth metatarsal fractures, but it should be considered in the revision scenario [32]. The plantar gap is a possible prognostic indicator, with a significantly increased time to bony union in fractures with at least 1 mm of fracture margin separation, regardless of Torg classification [32]. Weight bearing should be initiated 7 to 14 days postoperatively after IM screw fixation for proximal fifth metatarsal stress fractures, with training progressing to full unrestricted activity over 9 weeks [49]. Return to sports activities is expected at approximately 3 to 9 weeks postoperatively in patients with zone II or III fractures treated with IM screw fixation [49]. Risk remains for fracture nonunion and fatigue failure of the screw after IM fixation for proximal fifth metatarsal stress fractures [49].

A study of 10 National Basketball Association players treated with intramedullary screw fixation noted a 100% union rate but a refracture rate of 30% [32]. Autograft bone placed in the fracture site was used in three NBA players, and none of these patients went on to refracture [32]. Elite athletes appeared to have a high rate of union and reliably returned to the same level of competition after surgical management of fifth metatarsal fractures, irrespective of surgical construct used [15]. MLS athletes who sustain a sports-related fifth metatarsal fracture can expect a high rate of return to sport with time to radiographic healing and return to play as well as risk of refracture similar to other professional cohorts [8]. Players who are able to complete at least one full year of collegiate football after a fifth metatarsal fracture are less likely to have re-injury or a residual fracture gap [21]. In a study of basketball players, 50% of non-surgically treated acute fractures achieved union in an average of 9 weeks [63]. In a study of basketball players, acute fractures that showed no radiological signs of union at 12 weeks were treated with screw fixation and healed by 8 to 12 weeks following the operation [63]. In a study of basketball players, nine cases of stress fracture treated primarily with screw fixation healed completely between 8 and 14 weeks (average 9.5 weeks) [63]. Dancer's fractures of the distal shaft of the fifth metatarsal usually heal well with nonoperative cast immobilization [30].

Complications

General and Pediatric

Malunion of metatarsal fractures may lead to prolonged disability [1]. Fractures of the first metatarsal accounted for 20% of metatarsal fractures overall and 73% in children under five years of age [3]. Foot fractures account for 5% to 8% of all pediatric fractures and approximately 7% of all physeal fractures [26]. In this population, foot fractures generally have a good prognosis and are usually treated nonoperatively [4].

Nonunion and Delayed Union

Nonunion is remarkably uncommon in fatigue fractures of the foot, with the exception of the Jones fracture of the proximal fifth metatarsal [17]. Stress fracture nonunion at the base of the second metatarsal is a rare complication that may require operative treatment to ensure adequate fracture healing [14]. Early return to play at 8 weeks or less following intramedullary screw fixation of fifth metatarsal stress fractures results in a higher risk of delayed radiological union (24% at 3 months) [94]. However, early return to play following this fixation method does not increase the risk of long-term non-union, with an overall non-union rate of 3% [94].

Refracture

Refracture is common in zone III fifth metatarsal fractures with clinical or radiographic evidence of chronic injury [25]. In a study of intramedullary screw fixation for fifth metatarsal stress fractures, a refracture occurred in 1 patient (3%) at 10 months, despite previous complete radiographic union at 9 weeks [94]. Players who complete at least one full year of collegiate football after a fifth metatarsal fracture are less likely to have re-injury [21].

Surgical Complications

Plates used for fixation of zone I fifth metatarsal fractures are generally not well tolerated and often require removal [25]. In a study of basketball players, one patient required screw removal due to discomfort at the screw head following fixation of an acute fifth metatarsal fracture [63]. In the same study, one patient suffered a persistent dull ache in the lateral aspect of the foot following screw fixation of an acute fifth metatarsal fracture [63].

Functional and Biomechanical Outcomes

Gait alterations after a second metatarsal stress fracture can result in a decrease in maximum force in the middle forefoot [23]. The plantar gap may add to the decision-making process for surgery and improve the prediction of patient prognosis [18]. Weightbearing CT can identify specific alignment and density characteristics associated with fifth metatarsal stress fractures to potentially detect higher-risk patients [28].

Recovery

General Prognosis and Healing: Bone healing of metatarsal fractures proceeds as normal, and non-union is remarkably uncommon apart from the Jones' fracture of the proximal fifth metatarsal [17].

Non-Operative Management and Follow-up: Satisfactory treatment of 2nd metatarsal stress fractures is normally achieved via rest or weight bearing cast immobilisation, potentially with adjunctive shock wave therapy [31].

Operative Management and Outcomes: Using closed antegrade/retrograde intramedullary fixation, metatarsal alignment can be restored and good clinical outcome is achieved [6]. With longer and more conservative postoperative management, fusion results in a better outcome than non-fusion in the treatment of Lisfranc injuries accompanied by multiple metatarsal fractures [12].

Athlete-Specific Recovery: Foot fractures in elite soccer players resulted in moderate loss of play time (69.41 days) [109].

Adjunctive Therapies: Metatarsal fractures treated with LIPUS alone have a heal rate comparable to fractures treated by surgical intervention [11]. The routine use of LIPUS to shorten the time to bone union after intramedullary screw fixation for proximal fifth metatarsal stress fractures is not recommended [16].

Gait and Biomechanics: The decrease in maximum force in the middle forefoot in patients with a previous stress fracture could have resulted from gait alterations after the fracture [23].

Key Evidence

• [Paper] Metatarsal fractures are frequent injuries that may lead to prolonged disability if malunited; however, if adequately assessed, they are easy to treat with a generally favorable prognosis. [1] (10.1016/j.injury.2004.07.016)
• [L4] Five patients are described with a combined fracture of the lateral malleolus and the base of the fifth metatarsal, a combination not hitherto reported. [2] (10.2106/00004623-196143040-00006)
• [L4] Fractures of the first metatarsal accounted for 20 per cent overall and 73 per cent in the under-fives. [3] (10.1016/0020-1383(95)00121-o)
• [L4] Fractures of the foot in children usually have a good prognosis and generally are treated nonoperatively. [4] (10.1097/01.blo.0000156451.40395.fc)
• [L1] This randomised controlled trial has shown that undisplaced metatarsal fractures are better treated without a cast. [5] (10.1016/j.injury.2004.12.001)
• [L4] Using this technique, metatarsal alignment can be restored and good clinical outcome is achieved. [6] (10.1016/j.injury.2020.03.001)
• [L2] Zone 1 fractures of the 5th metatarsal base may be managed conservatively regardless of the initial fracture gap, with union expected within 8 weeks and good VAS and AOFAS scores. [7] (10.1016/j.injury.2016.05.016)
• [L4] MLS athletes who sustain a sports-related fifth metatarsal fracture can expect a high rate of return to sport with time to radiographic healing and return to play as well as risk of refracture similar to other professional cohorts. [8] (10.1177/03635465211030279)
• [L3] Overall outcome in metatarsal fractures is high, as almost all fractures healed without complaints at 33 months. [9] (10.1007/s00402-010-1164-6)
• [L3] Metatarsal fractures treated with LIPUS alone have a heal rate comparable to fractures treated by surgical intervention. [11] (10.1016/j.injury.2016.09.023)
• [L4] With longer and more conservative postoperative management, fusion results in a better outcome than non-fusion in the treatment of Lisfranc injuries accompanied by multiple metatarsal fractures. [12] (10.1016/j.injury.2018.12.023)
• [L3] The study showed no added clinical value for routine outpatient follow-up of fifth metatarsal fractures. [13] (10.1016/j.injury.2015.05.041)
• [L4] This previously unreported stress fracture nonunion at the base of the second metatarsal suggests that operative treatment may rarely be required to ensure adequate fracture healing. [14] (10.1177/0363546503262174)
• [L4] Elite athletes appeared to have a high rate of union and reliably returned to the same level of competition after surgical management of fifth metatarsal fractures, irrespective of surgical construct used. [15] (10.1177/23259671211037647)
• [L3] Therefore, we cannot recommend the routine use of LIPUS to shorten the time to bone union after intramedullary screw fixation for proximal fifth metatarsal stress fractures. [16] (10.1186/s12891-021-04611-z)
• [L5] [17] (10.1016/0020-1383(90)90039-w)
• [L3] The findings suggest that the plantar gap might add to the decision-making process for surgery and improve the prediction of patient prognosis. [18] (10.1177/0363546511414856)
• [L2] POCUS could be applied with success in the diagnosis and determination of the treatment method in low-energy induced metatarsal fractures. [19] (10.1016/j.injury.2016.12.018)
• [L4] Refracture after intramedullary screw fixation of proximal fifth metatarsal fractures is a rare but serious complication in athletes. [20] (10.1177/03635465000280051901)
• [L3] Players who are able to complete at least one full year of collegiate football after a fifth metatarsal fracture are less likely to have re-injury or a residual fracture gap. [21] (10.1177/2325967113s00020)
• [L3] Functional outcomes in multitrauma patients with midfoot or hindfoot fractures were comparable. [22] (10.1016/j.injury.2018.11.021)
• [L3] The decrease in maximum force in the middle forefoot in patients with a previous stress fracture could have resulted from gait alterations after the fracture. [23] (10.1177/0363546508324967)
• [L5] Foot fractures account for 5% to 8% of all pediatric fractures and for approximately 7% of all physeal fractures. [26] (10.5435/00124635-200109000-00004)
• [L4] The tension-band wire technique seems to give good results in the treatment of proximal metaphysial/diaphysial fractures of the fifth metatarsal in cases of primary unsuccessful nonoperative treatment or primary unsuccessful intramedullary screw fixation. [27] (10.1177/0363546505281803)
• [L3] Weightbearing CT can identify these specific alignment and density characteristics to potentially detect higher-risk patients. [28] (10.1097/corr.0000000000003613)
• [L5] [31] (10.1016/j.injury.2015.06.015)
• [L3] As one in twenty polytrauma patients sustains at least one foot fracture and a substantial amount of these fractures are diagnosed in a delayed fashion, physicians, regardless of their specialty, should have a high index of suspicion for injuries of the feet in polytrauma patients. [33] (10.1016/j.injury.2018.04.009)
• [L3] The authors advocate surgical treatment as the initial method of choice for both zone II and III proximal V MT fractures. [34] (10.1016/j.injury.2015.10.052)
• [L3] The XS-nail proved to be an effective and technically optimized implant for the treatment of proximal fifth metatarsal fractures that provides a rapid full-weight-bearing mobilization and shows good long-term results. [36] (10.1007/s00402-009-1025-3)
• [L4] Hand and foot fractures have many accompanying injuries that require attention during diagnosis and treatment. [46] (10.1186/s12891-024-07407-z)
• [L3] Our data highlights the need of careful evaluation of the feet during primary and secondary survey particularly when a tibia or femur fracture is diagnosed. [51] (10.1186/s12891-019-2501-8)
• [L3] The association between weak toe-grip strength and fifth metatarsal fracture suggests that weak toe-grip may lead to an increase in the load applied onto the lateral side of the foot, resulting in stress fracture. [52] (10.1177/2325967115603654)
• [L4] The majority of patients sustaining Jones fractures have evidence of varus hindfoot alignment, which may be a predisposing factor to developing the fracture or refracture. [62] (10.1177/0363546508314401)
• [L4] [63] (10.1007/s001670050183)
• [L3] Both intramedullary screw fixation and shock wave therapy are effective treatments for fracture nonunion in the metaphyseal-diaphyseal region of the fifth metatarsal. [66] (10.2106/jbjs.i.00653)
• [L4] Intramedullary screw fixation of proximal fifth-metatarsal fractures is a safe procedure leading to very-high patient-satisfaction, a high union rate, and a fast return to sports time. [67] (10.1007/s00402-008-0709-4)
• [L5] The plantar fascia and the auxiliary plantar flexors are important for maintaining normal strains in the metatarsals during gait. [85] (10.2106/00004623-199909000-00005)
• [L4] [94] (10.1007/s00167-018-5104-2)
• [L2] Risk factors for lower extremity overuse injuries include dynamic pes planus, pes cavus, restricted ankle dorsiflexion, and increased hindfoot inversion, all of which are subject to intervention and possible correction. [95] (10.1177/03635465990270050701)
• [L5] [96] (10.1097/corr.0000000000003516)
• [L5] Proximal fifth metatarsal fractures distal to the peroneus brevis insertion are significantly more unstable than more proximal fractures due to a deforming force exerted by the tendon. [99] (10.1177/2325967114s00076)
• [L3] The demonstrated alteration of the rollover process with an increased forefoot loading may help to explain the incidence of stress fractures of the metatarsals under fatiguing loading conditions. [101] (10.1177/0363546504265191)
• [L5] [105] (10.1177/03635465010290010201)
• [L5] MRI has revolutionized the evaluation of soft tissue injury with or without associated occult osseous injury, allowing for early visualization of stress-related marrow edema and proper diagnosis before progression to fracture. [106] (10.1016/j.csm.2006.06.006)
• [L3] Foot fractures in elite soccer players resulted in moderate loss of play time (69.41 days). [109] (10.1177/23259671221078308)

See Also

• Lisfranc injury
• Hallux rigidus

References

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