![]() The second, third and fourth metatarsals are slender and may be sites of stress fracture or acute fractures from twisting mechanisms or a direct blow. The first metatarsal is larger than the others and most important for weight-bearing and balance therefore, malunion or malalignment at this location is especially poorly tolerated. There are no interconnecting ligaments between the 1st and 2nd metatarsals, allowing for independent motion. The medial three rays act as a rigid lever to aid in propulsion while the lateral two rays provide some mobility in the sagittal plane to permit accommodation to uneven ground. As a unit, the five metatarsals serve as the major weight-bearing complex of the forefoot. The bases of each metatarsal also articulate with each other at the intermetatarsal joints. The base of each metatarsal articulates with one or more of the tarsal bones and the head articulates with the proximal phalanges. They are numbered from 1 to 5, medial to lateral or largest to smallest (Figure 1). The metatarsals are dorsally convex tubular bones of the forefoot consisting of a head, neck, shaft, and base. The metatarsals are also subject to stress fractures and can be seen in conjunction with other injuries of the mid-foot. However, metatarsal fractures that go on to malunion or nonunion can lead to disabling metatarsalgia or midfoot arthritis. Early surgical fixation reduces time to healing and time to return to sports.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. Nondisplaced avulsion fractures of the fifth metatarsal tuberosity require symptomatic therapy only (elastic or soft bandage followed by firm shoe when tolerated).įractures of the proximal fifth metatarsal diaphysis require more aggressive treatment, such as early surgical fixation or prolonged casting with no weight bearing. Stress fractures of the metatarsal shaft usually heal well without immobilization and typically respond well to cessation of the causative activity for four to eight weeks. Most nondisplaced metatarsal shaft fractures require only a soft elastic dressing or firm, supportive shoe and progressive weight bearing. If there is more than 3 to 4 mm displacement in a dorsal or plantar direction, or if dorsal/plantar angulation exceeds 10 degrees, reduction is usually required. If radiography reveals a normal position seven to 10 days after injury, progressive weight bearing may be started, and the cast may be removed three to four weeks later.įractures of a single metatarsal with lateral or medial displacement usually heal well without correction and may be managed like nondisplaced fractures. Nondisplaced fractures of the proximal portion of metatarsals 1 through 4 can be managed acutely with a posterior splint followed by a molded, non–weight-bearing, short leg cast. Treatment of fractures distal to the tuberosity should be individualized based on the characteristics of the fracture and patient preference. Radiographs should be carefully examined to distinguish these fractures from tuberosity fractures. Proximal fifth metatarsal fractures that are distal to the tuberosity have a poorer prognosis. Avulsion fractures of the proximal fifth metatarsal tuberosity can usually be managed with a soft dressing. ![]() Stress fractures of the first to fourth metatarsal shafts typically heal well with rest alone and usually do not require immobilization. Nondisplaced fractures of the metatarsal shaft usually require only a soft dressing followed by a firm, supportive shoe and progressive weight bearing. Injuries to this ligament require referral or specific treatment based on severity. If the midfoot is injured, care should be taken to evaluate the Lisfranc ligament. Referral is generally indicated for intra-articular or displaced metatarsal fractures, as well as most fractures that involve the first metatarsal or multiple metatarsals. The fracture should then be characterized and treatment initiated. ![]() ![]() Initial evaluation should focus on identifying any conditions that require emergent referral, such as neurovascular compromise and open fractures. Patients with metatarsal fractures often present to primary care settings. ![]()
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