Metatarsal Fractures (long bones of the foot):
A Patient Guide
What is a Metatarsal Fracture?
Metatarsal fracture is a break in one of the long bones of your foot that connect the ankle to the toe. It is a common foot injury that requires careful assessment and management depending on the type and position of the fracture.
Types of Metatarsal Fractures
There are 5 metatarsals numbered 1 through 5 with each corresponding to a toe. The largest is the 1st metatarsal which corresponds to the big toe. The 5th metatarsal corresponds to the little toe and is more commonly broken.
Many metatarsal fractures occur at the base of the fifth metatarsal in line with the little toe. This bone often fractures proximally (at the end closest to the ankle). The distal end (closest to the toe) or the “shaft” (in the middle of the bone) can also break.
Base of 5th metatarsal fractures tend to be treated well with non-surgical treatment such as protected weight-bearing, that is avoiding pressure through the front of the foot. They tend to not heal well and take longer to heal if repetitive pressure is applied (through walking or “weight bearing”). Sometimes these fractures extend into the joint where the fifth metatarsal joins onto the adjacent bones (either the fourth metatarsal or cuboid bone). Fractures into the joint (intra-articular fractures) that are displaced often require surgery. However most occur through the base of the metatarsal not through the joint. Sometimes a CT scan is performed to check if the fracture extends into the joint.
Other metatarsal fractures include fractures of the proximal 4th, 3rd and 2nd metatarsals. These fractures often need to be checked for underlying ligament injuries with an MRI scan or CT scan (a “Lis-Franc injury) which can sometimes go unnoticed and often requires surgery with problems down the track if healing doesn’t occur appropriately.
Stress fractures of the distal end of the metatarsals, especially the 2nd and 3rd metatarsals causes pain in the front of the foot and these often don’t show up on an x-ray. They often require an MRI or bone scan to be diagnosed. These can occur from repetitive walking, running or from bone issues. These fractures require non-surgical treatment with protected weight bearing and take much longer to heal the “acute” fractures. Stress fractures require surveillance over many months and strict avoidance of pressure through the front of the foot, as well as cessation of smoking (or vaping) which prevents healing.
Non-operative Management
As most metatarsal fractures can be managed without surgery, the choice of immobilisation and protected weight bearing depends on the fracture location and pattern and include:
- Protected Weight-bearing Devices which take some of the weight off the foot to allow the bone to heal:
– CAM walker boot (most common – also known as a “moon boot”)
– Post-operative shoe with rigid sole (looks like a sandal)
– Hard-soled shoe with metatarsal pad
– Custom-made orthoses (expensive)
– Pneumatic walking boot (pumps up with air cushion)
Weight-bearing Status:
– Initial non-weight-bearing with crutches (2-3 weeks)
– Progression to partial weight-bearing
– Graduate to full weight-bearing as tolerated
– Duration typically 6-8 weeks total
Immobilisation Options (less common):
– Elastic bandaging
– Below-knee cast for unstable fractures
– Moon boot and CAM walkers
– Forefoot offloading devices (a show with a large heel to prevent weight bearing on the front of the foot)
Surgical Management
Following specific circumstances are common indications for surgical treatment:
– Displaced fractures
– Fractures with ligament involvement (Lis-Franc injuries)
– Multiple metatarsal fractures
– Intra-articular fractures (displaced fractures in the joints)
– Unstable fracture patterns
– Failed non-surgical management (not healing)
– Fifth metatarsal “Jones” fractures
– Professional athletes who may desire expedited return
Surgical Techniques:
– K-wire fixation (temporary pins)
– Plate and screw fixation
– Intramedullary screw fixation (rods or pins inside the bone)
– External fixation in complex cases
Regular Monitoring and Follow-up:
– Initial X-rays at presentation
– Follow-up X-rays at 1 or 2 weeks to ensure alignment
– Further imaging at 6-12 weeks to assess healing
– Final imaging prior to physiotherapy and graduated return to activities
Note – after the fracture has healed it takes many months to rehabilitate and regain normal function
Rehabilitation Protocol
Early Phase (0-6 weeks):
– Protected weight-bearing
– Regular wound care if surgical
– Toe mobilisation exercises
– Ankle pump exercises
– Ice therapy for swelling
Intermediate Phase (6-12 weeks – if fracture healed):
– Progressive weight-bearing
– Gentle range of motion exercises
– Proprioception training
– Graduated strengthening exercises
– Gait training
Late Phase (3-6 months):
– Sport-specific exercises
– Impact activity progression
– Return to running program
– Functional training
– Balance and proprioception advancement
Physiotherapy Program
1. Initial Phase:
– Pain management
– Oedema control
– Maintaining mobility of unaffected joints
– Gait training with assistive devices
2. Progressive Phase:
– Joint mobilisation
– Soft tissue techniques
– Strengthening exercises
– Balance training
– Proprioception exercises
3. Return to Activity Phase:
– Sport-specific training
– Impact absorption exercises
– Agility drills
– Functional movement patterns
Potential Complications
Early Complications:
– Displacement
– Delayed union
– Stiffness (very common)
– Compartment syndrome
– Infection (if surgical)
– Complex regional pain syndrome
Late Complications:
– Nonunion
– Malunion
– Post-traumatic arthritis
– Chronic pain
– Transfer metatarsalgia
Management of Complications:
– Physiotherapy for stiffness
– Surgery if required
– Extended immobilisation for delayed union
– Custom orthotics for residual symptoms
– Pain management programs
– Modified activity programs
Return to Activity Guidelines
– Gradual return based on fracture healing
– Pain-free walking without aids
– Adequate strength restoration
– Normal range of motion
– Sport-specific conditioning achieved
– Typically 8-12 weeks for non-operative cases
– 12-16 weeks for surgical cases
Prevention of Future Injuries
– Appropriate footwear
– Regular stretching
– Gradual activity progression
– Attention to training surfaces
– Proper warm-up routines
– Regular bone health assessment
The successful management of metatarsal fractures requires a comprehensive approach with careful attention to initial assessment, appropriate choice of treatment modality, and structured rehabilitation. Regular monitoring and adjustment of the treatment plan ensures optimal outcomes and minimises complications.
How can I book an appointment at the Fracture Clinic?
You can call their phone number or make an appointment online via their website. The clinic is open from 8 a.m. to 4 p.m., Monday through Friday.
Does the Fracture Clinic accept insurance?
The goal of the Medicare-funded Fracture Clinic is to offer patients high-quality care at comparatively cheap out-of-pocket expenses. It’s best to get in touch with the clinic directly if you have particular insurance questions.
