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Orthopedics

Metatarsal Fractures

Metatarsal fractures are one of the most common foot injuries encountered in trauma and emergency. They usually occur as a result of direct trauma to the forefoot. The common presentation involves foot pain and swelling with difficulty in ambulating without support. The treatment involves conservative management in the form of cast or operative treatment in selected cases. This activity reviews the evaluation and management of metatarsal fractures and highlights the role of the interprofessional

v1 · Reviewed Nov 7, 2026 by Automated Clinical Reviewer (Strict Verbatim v1)
  • Metatarsal fractures are one of the most common foot injuries encountered in trauma and emergency.
  • The common presentation involves foot pain and swelling with difficulty in ambulating without support.
  • Lisfranc fracture-dislocation can result due to falling from height or stairs.
  • Management of open metatarsal fractures includes thorough debridement, wound lavage, fracture stabilization using external or minimal internal fixation followed by the postoperative use of antibiotics, and planned second-look surgery.
  • This type of injury should be highly suspected if a gap of more than 5 mm is noted in between the medial and middle cuneiforms or in between the bases of the first and second metatarsals.
  • The radiographic evaluation consists of standard views of the foot, including anteroposterior, 45 degrees oblique, and lateral projection.
  • To diagnose metatarsal overload, additional weight-bearing roentgenograms, including the lateral view of the foot and tangential view of metatarsal heads, are helpful.
  • Acute stress fractures are usually not detected with a standard X-ray.
  • To confirm the diagnosis of stress fractures, the x-rays can be repeated after 10 to 14 days of the onset of symptoms.
  • Alternatively, MRI and Technetium scans can be ordered as they have a high sensitivity in detecting such fractures.
  • In scenarios of multiple fractures of the base of metatarsals, computed tomography is advised to rule out the possibility of Lisfranc fracture-dislocation.
  • Stress X-rays which include passive adduction and abduction of the forefoot, can be performed under local anesthesia to reveal ligamentous instability at the Lisfranc joint.
  • The treatment involves conservative management in the form of cast or operative treatment in selected cases.
  • Conservative management can be offered to undisplaced metatarsal fractures, including stress fractures which include adhesive strapping, short leg walking cast for 4 to 6 weeks, or a non-weight-bearing cast for 3 weeks followed by a walking cast for another 3 weeks, except in professional athletes to avoid long duration of immobilization.
  • In second to fourth metatarsal fractures, which are displaced only in the frontal plane without shortening, can also be managed nonoperatively.
  • The first and fifth metatarsal fractures which are displaced in the horizontal plane should be managed operatively to avoid secondary deformities like posttraumatic hallux valgus and digitus quintus varus.
  • Metatarsal fractures displaced in the sagittal plane may result in painful callosities, metatarsalgia, and neuroma formation; hence need to be managed operatively.
  • Shereff suggests the reduction of any metatarsal fracture with angulation of more than 10 degrees and displacement of more than 3 to 4 mm.
  • Lisfranc joint complex fractures, if displaced more than 2 mm and involving more than 30% of the joint, need to be managed operatively with open reduction and internal fixation.
  • Multiple implants are available for metatarsal fractures, including K-wires, mini fragment plates, and interfragmentary screws from the AO small fragment system (3.5 mm) and the AO Foot Set (2.7 mm).
  • First metatarsal fractures are difficult to keep reduced after closed reduction because of the pull of the intrinsic and extrinsic muscles and hence commonly require internal fixation.
  • In the shaft of the first metatarsal fractures, stable fixation can be obtained with the help of two crossed K-wires of 1.8-2 mm diameter.
  • The comminuted fractures can be managed with plates that should be placed over the medial-plantar aspect because of the minimum soft tissue cover on the dorsal aspect.
  • If there is extensive comminution of the first metatarsal fracture, then external fixation is more favorable as compared to internal fixation accounting for the poor soft tissue condition and high chances of postoperative infection.
  • Open reduction and internal fixation will be the preferred treatment option for the fractures of the first metatarsal head, which shows joint incongruity to achieve desired functional outcome.
  • Cancellous bone grafting can be considered in the management of metatarsal head fractures which show significant impaction.
  • The management of choice for simple fractures is retrograde percutaneous pinning.
  • In scenarios where closed manipulation failed to provide the desired outcome, open procedures using minimally invasive options need to be performed, which will help achieve the reduction by providing direct visualization of fractured ends with minimum soft tissue dissection.
  • Comminuted fractures can be managed using mini-fragment plates.
  • Undisplaced Jones fracture shows delayed fracture healing due to the poor blood supply and instability.
  • In acute scenarios, they can be managed with restricted weight-bearing and immobilization for 6 to 8 weeks.
  • Operative management should be considered in scenarios of professional athletes or cases of delayed fracture healing beyond ten weeks.
  • One of the common forms of operative management is intramedullary screw fixation.
  • Other operative treatment options include tension band wiring, percutaneous pinning, and external fixation.
  • Avulsion fractures that involve a small portion of the tuberosity can be managed by excision.
  • In patients where the diagnosis of delayed healing has been made, intramedullary fixation using screws along with bone grafting can be offered.
  • In scenarios where a nonunion is the diagnosis, further management can be decided based on the periosteal reaction.
  • If on roentgenogram features of periosteal reaction are present such patients can be managed by either intramedullary fixation using a screw or extramedullary fixation using mini fragment plates.
  • If roentgenogram suggests sclerosis of medullary canal with no signs of periosteal reaction, in such patients, multimodal approach including curettage of the sclerotic bone, stabilization of fracture ends, and corticocancellous bone grafting can be advised.
  • The most common complication noticed after non-operative management of metatarsal fractures includes metatarsalgia, which is secondary to mal-union or residual deformity(16).
  • The other common complications include non-union, delayed union, posttraumatic deformities like digitus quintus varus, and arthrosis.
  • The less common complications include nonunion, implant failure, hardware irritation, and sural nerve injury.
  • Patients having foot pain for long-duration should get their foot pathology evaluated, as stress fractures of metatarsals can present without any antecedent history of trauma and can remain undiagnosed.
  • These fractures may be missed on plain radiographic examination and should be evaluated with higher imaging investigations.
  • Also, patients with metatarsal fractures should get them adequately treated and rehabilitated as neglected fractures can lead to painful conditions like Morton's neuroma, with persistent disability.
  • As these injuries sometimes lead to foot and ankle stiffness, appropriate physiotherapy advice should be sought.
  • review
    Metatarsal Fractures. StatPearls [Internet] — Udit Agrawal, Vivek Tiwari — StatPearls Publishing, 2023

Decision support only. Verify against local protocols and current labeling. Source: www.ncbi.nlm.nih.gov