Courtesy: Prof Nabil Ebraheim, University of Toledo, Ohio, USA

Metatarsal Fractures

Metatarsal fractures can involve:

• First metatarsal

• Fifth metatarsal

• Second, third, and fourth metatarsals (including stress fractures)

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1. First Metatarsal Fractures

Key Points

• Different from fractures of the second, third, and fourth metatarsals.

• The first metatarsal carries a greater load.

• Malunion may cause:

  • Transfer lesions

  • Uneven weight distribution.

Management

• Aim for perfect alignment and fixation.

• More likely to require:

  • Open reduction

  • Internal fixation (ORIF)

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2. Fifth Metatarsal Fractures

Jones Fracture (Zone 2)

• Occurs in a vascular watershed area.

• Located in the proximal fifth metatarsal.

• Often enters the fourth and fifth intermetatarsal articulation.

• Healing may be difficult without surgery.

Management

• Commonly treated with screw fixation in:

  • Athletes

  • Young active individuals

• Percutaneous intramedullary screw fixation:

  • Typically a 4.5 mm screw

  • Offers shortest time to union

  • Lowest risk of nonunion

  • Allows early return to activity.

Surgical Risk

• Sural nerve injury is a risk during intramedullary screw fixation.

Nonoperative Treatment

• Casting and non-weight bearing acceptable if:

  • Acute fracture

  • Non-displaced.

• Risk of recurrent fracture after nonsurgical healing: approximately 30%.

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Zone 1 Fracture (Pseudo-Jones)

• Enters the tarsometatarsal joint (metatarsocuboid joint).

• Treated conservatively.

• Initiate weight-bearing as tolerated.

• Use fracture shoe.

• Heals well.

• Less serious than Zone 2 and Zone 3 fractures.

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Zone 3 Fracture

• Proximal diaphyseal fracture distal to the fourth and fifth articulation.

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Shaft Fractures of the Fifth Metatarsal

• Treated with:

  • Weight-bearing

  • Walking cast

  • Walking boot

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Midfoot Injuries

• Maintain high suspicion for associated injury to:

  • Tarsometatarsal joint (Lisfranc joint).

• Obtain:

  • Standing X-rays

  • Stress X-rays

• Rule out Lisfranc injury.

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3. Second Metatarsal Fractures

Stress Fracture in Ballet Dancers

• Common at the base of the second metatarsal.

March Fractures

• Occur in:

  • Second metatarsal

  • Third metatarsal.

Clinical Presentation

• Forefoot pain

• Swelling

• No history of trauma

• Tenderness along the metatarsal shaft

Treatment

• Protected weight-bearing

• Walking boot

• Walking cast

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Summary

• First metatarsal fractures require accurate fixation due to load-bearing role.

• Jones fractures (Zone 2) have higher risk of nonunion and often require surgical fixation in active patients.

• Zone 1 fractures heal well with conservative treatment.

• Always rule out Lisfranc injury in midfoot trauma.

• Stress fractures commonly involve the second and third metatarsals and are treated conservatively