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Metatarsal fracture

64 citationsUpdated Sep 2026

For patients: a plain-language version of this topic is available. See the patient guide.

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 children, 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]. Overall outcome in metatarsal fractures is high, as almost all fractures healed without complaints at 33 months [9]. For athletes, Major League Soccer players sustaining sports-related fifth metatarsal fractures can expect a high rate of return to sport, with time to radiographic healing and risk of refracture similar to other professional cohorts [8]. Elite athletes also demonstrate a high rate of union and reliably return to the same level of competition after surgical management of fifth metatarsal fractures, irrespective of the surgical construct used [15].

Treatment strategies vary based on fracture location and displacement. Undisplaced metatarsal fractures are better treated without a cast [5], while zone 1 fractures of the fifth 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]. In cases 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]. For central metatarsal fractures, alignment can be restored and good clinical outcomes achieved using closed antegrade or retrograde intramedullary fixation [6].

Several adjunctive and alternative techniques influence recovery. Metatarsal fractures treated with low-intensity pulsed ultrasound (LIPUS) alone have a heal rate comparable to fractures treated by surgical intervention [11], although the routine use of LIPUS to shorten time to bone union after intramedullary screw fixation for proximal fifth metatarsal stress fractures is not recommended [16]. Point-of-care ultrasonography (POCUS) can be applied successfully in the diagnosis and determination of the treatment method in low-energy induced metatarsal fractures [19]. Routine outpatient follow-up of fifth metatarsal fractures showed no added clinical value [13]. While operative treatment may rarely be required to ensure adequate fracture healing for stress fracture nonunion at the base of the second metatarsal [14], 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].

Anatomy & Pathophysiology

General Metatarsal Anatomy and Biomechanics

Metatarsal fractures account for 35% of all foot fractures [42]. The first metatarsal is shorter and wider than the lesser four metatarsals [38]. It is stronger than the other metatarsals and accounts for approximately 1.5% of all metatarsal fractures [38]. The first metatarsal bears approximately one-third of body weight [47, 48], specifically 40% of the weight of the foot, with half of that load distributed on each sesamoid bone [86]. There are no interconnecting ligaments between the first and second metatarsals, allowing independent motion [38]. The tibialis anterior inserts on the plantar medial aspect of the first metatarsal base to elevate the first metatarsal [38], while the peroneus longus attaches to the plantar lateral base of the first metatarsal to plantarflex the head [38].

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]. Stability of the central metatarsals is achieved by bony architecture and intermetatarsal ligaments at the bases and necks [47, 48]. Severe displacement of central metatarsal shaft fractures is uncommon unless multiple metatarsals are fractured [47, 48]. The first and fifth metatarsals are more mobile and susceptible to injury than the central metatarsals [47, 48]. Fracture of all five metatarsals is predictive of amputation in the setting of midfoot or hindfoot fractures after high-energy trauma [47, 48].

The arterial arch, dorsalis pedis artery, and dorsal and plantar metatarsal arteries are susceptible to injury in association with metatarsal fractures [38, 40]. Compartment syndrome is relatively common with soft tissue trauma in the metatarsal area [38]. The plantar fascia and auxiliary plantar flexors are important for maintaining normal strains in the metatarsals during gait [85].

Fifth Metatarsal Anatomy and Blood Supply

Fractures of the fifth metatarsal account for approximately 68% of all metatarsal fractures [71]. The base of the fifth metatarsal 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 of the fifth metatarsal [71], and the peroneus tertius attaches on the dorsal aspect at the proximal metaphyseal–diaphyseal junction [71]. The plantar fascia has a strong attachment to the plantar aspect of the fifth metatarsal tubercle [71].

A single nutrient artery enters the fifth metatarsal from the medial cortex at the junction of the proximal and middle third of the diaphysis [71]. Secondary epiphyseal and metaphyseal arteries supply the base and tuberosity of the fifth metatarsal [71]. The metaphyseal–diaphyseal junction of the fifth metatarsal 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 in the watershed area of the fifth metatarsal are at risk for delayed union or nonunion due to limited vascularity [55, 71].

The sural nerve, peroneus brevis insertion, peroneus tertius insertion, and lateral anchor for the extensor retinaculum are within the surgical margins of the proximal fifth metatarsal [71]. 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]. Zone I fractures are avulsion types of injuries 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 for Zone II fractures 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]. Some experts recommend combining Zones II and III because they carry a similar risk of nonunion and refracture, and surgical treatment and outcomes are similar in both zones [32].

Pediatric Anatomy

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% of metatarsal fractures overall and 73% in children under five years of age [3].

The apophysis at the base of the fifth metatarsal appears at approximately 8 years of age and fuses by age 12 in girls and age 15 in boys [43]. The proximal apophyseal growth center of the fifth metatarsal is usually visible radiographically at age 9 and becomes united to the diaphysis between 12 and 15 years of age [55]. The os vesalianum is found just proximal to the base of the fifth metatarsal medial to the insertion of the peroneus brevis [71]. The os peroneum is located within the tendon of the peroneus longus and can be found on the lateral border of the cuboid [71]. The smooth contours of ossicles such as the os vesalianum and os peroneum distinguish them from acute fractures [71].

Pathophysiology of Stress Fractures

Stress fractures of the metatarsal bones account for 38% of all stress fractures of the lower limb [31]. The second and third metatarsals are most commonly involved in stress fractures, although fourth and fifth 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 approximately 2 weeks to achieve remodeling [17]. Fatigue microdamage may be the normal stimulus for the realignment of Haversian systems to provide structural strength [17]. The stretching of the sensitive periosteum may serve as an early warning system for fatigue fractures [17]. Scintigraphic evidence of increased bone turnover can precede the pain of a developing fatigue fracture [17].

Non-union is remarkably uncommon in metatarsal stress fractures, 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]. 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]. Weak toe-grip strength is associated with fifth metatarsal fracture, suggesting that weak toe-grip may lead to an increase in load applied onto the lateral side of the foot [52]. Alteration of the rollover process with increased forefoot loading under fatiguing conditions may help explain the incidence of metatarsal stress fractures [101]. During running, forces are highest under the second metatarsal, with bending strain being 6.9 times greater than that of the first metatarsal [105].

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]. Long, narrow, and straight fifth metatarsals with an adducted forefoot are most at risk for fifth metatarsal fractures [25]. A foot type characterized by metatarsus adductus and a curved fifth metatarsal with a prominent base is associated with higher rates of fifth metatarsal fractures [25]. Cavovarus foot alignment is a predisposing factor for fifth metatarsal base stress fractures [31]. An increasing inter-metatarsal angle between the 4th and 5th metatarsals and a protruding 5th metatarsal head are predisposing factors for fifth metatarsal base stress fractures [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]. Hereditary sensorimotor neuropathy and diabetic neuropathy may predispose to type III fifth metatarsal fractures by causing inability to sense overloading of the bone [86].

Classification

General Metatarsal Fractures

AO/OTA: The OTA classification designates the first metatarsal with an identifier in parentheses beside the major designation 87() [89]. Fractures are categorized by articular involvement and comminution: extra-articular simple fractures are designated A [89], partial articular involvement or wedge fractures of the shaft are designated B [89], and complete articular involvement and/or comminuted shaft fractures are designated C [89]. While this system permits a detailed description of the fracture pattern, it does not offer insight into overall stability or treatment [89].

Other Considerations: 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 pediatric fractures [26] and approximately 7% of all physeal fractures [26]. Fractures of the first metatarsal accounted for 20 per cent overall in children [3], but represented 73 per cent in children under five years of age [3]. Hand and foot fractures often have accompanying injuries that require attention during diagnosis and treatment [46]. In polytrauma patients, one in twenty sustains at least one foot fracture, necessitating a high index of suspicion for foot injuries [33]. A substantial amount of these foot fractures are diagnosed in a delayed fashion [33].

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 includes the metatarsocuboid articulation but is proximal to the fourth and fifth metatarsal articulation [25]. These are avulsion injuries, usually secondary to an inversion injury to the foot [25], and represent 93% of all proximal fifth metatarsal injuries according to Bowes and Buckley [96]. Zone II extends from Zone I to the metaphyseal/diaphyseal junction and includes the fourth and fifth metatarsal articulation [25]. This area contains the true Jones fracture [25], which accounts for 4% of proximal fifth metatarsal injuries [96]. Zone III comprises the proximal 1.5 cm of the diaphysis, where stress fractures usually occur [25], accounting for the remaining 3% of injuries [96].

Torg: The Torg classification of stress fractures in Zone III includes type I, which is an acute fracture [25]; type II, which is a delayed union with some periosteal reaction, widening of the fracture site, and some intramedullary sclerosis [25]; and type III, which is a nonunion with intramedullary sclerosis and blunted fracture edges [25].

Lawrence and Botte (Fracture Types): Type I fractures are acute, presenting with a narrow fracture line without fibrosis [96]. Type II fractures are characterized by a widened fracture line with intramedullary sclerosis, indicating ongoing bone stress [96]. Type III fractures refer to symptomatic nonunions, characterized by the complete obliteration of the medullary canal attributed to sclerotic bone formation [96].

Other Considerations: 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]. Significant attention is directed toward treating proximal fifth metatarsal fractures due to potentially poor healing secondary to a watershed area of the blood supply [25]. 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].

Tarsometatarsal (Lisfranc) Injuries

Quénu and Küss: Introduced in 1909, this is the most commonly used classification system for Lisfranc fracture–dislocations [88]. It describes three types of injury patterns: homolateral, isolated, and divergent [88].

Hardcastle: This system is based on radiographic morphology and distinguishes three main groups [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 a medial dislocation pattern, the first metatarsal or a variable number of metatarsals excluding the fifth are involved [88]. In a lateral dislocation pattern, one or more of the lateral metatarsals are dislocated, while the first ray remains stable and intact [88]. Type C (divergent) fracture–dislocations show complete and partial injury patterns [88]. In the AP projection of a divergent dislocation, medialization of the first metatarsal is found in conjunction with lateral translation of a variable number of the lateral four metatarsal bones [88].

Myerson: This classification incorporates osseous injuries of the medial column of the foot and differentiates three types of injury pattern [88]. Type A injuries include complete incongruity of the TMT joint line in any plane or direction [88]. Type B1 injuries are determined by partial incongruity involving the first ray [88]. Type B2 injuries are characterized by dislocation of one or more of the lateral four metatarsal bones [88]. Type C1 injuries have a diverging injury pattern comprised of medialization of the first ray associated with dislocation and partial incongruity of the lateral metatarsals [88]. Type C2 injuries have a diverging injury pattern with complete incongruity [88].

Nunley and Vertullo: This system classifies nondisplaced and displaced TMT sprains in athletes based on weight-bearing radiographic analyses and scintigraphic findings [88]. Stage I injuries are characterized by no displacement at the Lisfranc complex, constituting a sprain of the Lisfranc ligament without diastasis or loss of medial column height [88]. These injuries are nondisplaced on weight-bearing radiographs but showed increased uptake on bone scintigrams [88]. Stage II injuries showed 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 injuries presented with diastasis of the first/second intermetatarsal space greater than 5 mm and loss of medial column height [88].

AO/OTA: The revised version of the AO/OTA classification system distinguishes Lisfranc fracture-dislocations according to the resulting deformity [88]. It allows both a type of dislocation pattern and an associated fracture pattern of the foot to be described [88].

Other Considerations: Pediatric Lisfranc fracture-dislocations are rare, and to date a nongeneric system has not been implemented within trauma [88]. 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 the current classification systems [88].

Clinical Presentation

General Presentation and Diagnosis

Metatarsal fractures predominantly affect patients between 20 and 50 years of age [42]. The clinical presentation typically includes pain, ecchymosis, and swelling, with weight bearing often proving painful and difficult [47, 48]. Plantar ecchymosis may signify a more significant injury involving the Lisfranc joint complex [47, 48]. Standard AP, lateral, and oblique radiographs are usually suitable for detection [47, 48]. Point-of-care ultrasonography (POCUS) can be applied with success in the diagnosis and determination of the treatment method in low-energy induced metatarsal fractures [19]. Advanced imaging provides additional diagnostic value: MRI can provide additional information related to soft tissue injuries and may give a hint toward stress fractures [38, 40], while CT can provide additional information regarding intra-articular fracture lines and fragments [38, 40]. In polytrauma patients, one in twenty sustains at least one foot fracture, and a substantial amount of these fractures are diagnosed in a delayed fashion [33]. 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]. The neurovascular status should be evaluated because the arterial arch and the dorsal and plantar metatarsal arteries are particularly susceptible to injuries in association with metatarsal fractures [38]. 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].

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]. 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]. The arterial arch, the dorsalis pedis artery, and the dorsal and plantar metatarsal arteries are particularly susceptible to injury in association with central metatarsal fractures [40]. Monitoring of compartment pressures should be performed routinely especially following direct trauma [40].

Fifth Metatarsal

Fractures of the fifth metatarsal are the most common metatarsal fractures [42]. They typically show pain, swelling, and tenderness on the outside of the foot, with patients usually complaining about difficulties with walking [58]. Bruising may occur following direct trauma to the fifth metatarsal [58]. Fifth metatarsal base fractures present with lateral foot pain, and tenderness at the 5th metatarsal base exacerbated by inversion [31]. 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 of the foot appear normal, an AP radiograph of the ankle that includes the proximal fifth metatarsal is recommended to rule out a tuberosity avulsion fracture [58]. The apophysis at the base of the fifth metatarsal can be confused with an avulsion fracture [43]. This secondary ossification center appears at approximately 8 years of age and fuses by the age of 12 years in girls and 15 years in boys [43].

Stress Fractures

The 2nd and 3rd metatarsals are most commonly involved in stress fractures [31]. Second metatarsal stress fracture is the most common and is classically described in amenorrheal ballet dancers [47, 48]. Fractures of the 2nd metatarsal present with non-specific midfoot pain of insidious onset, often in ballet dancers [31]. In female athletes, the triad of anorexia, osteoporosis/stress injuries, and menstrual dysfunction must be considered [47, 48]. Proximal fifth metatarsal stress fractures are most common in athletes who participate in sports such as basketball, football, or soccer [32]. These present with 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]. Weak toe-grip strength is associated with fifth metatarsal fracture [52]. 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]. MRI or bone scan aids in the diagnosis of metatarsal stress fractures, as radiographs may be normal for 3 weeks [47, 48]. A normal radiograph prior to 3 weeks does not exclude a stress fracture [47, 48]. Radiographs may demonstrate periosteal reaction or evidence of callus formation near diaphyseal region of affected metatarsal after 3 to 4 weeks [47, 48].

Investigations

Plain radiography: Three views (AP, lateral, and oblique) are mandatory to judge shortening, deviation, angulation, and displacement in metatarsal fractures [38]. Weight-bearing films usually reveal subtle instabilities not seen on non-weight-bearing films [40]. Any displacement or diastasis of more than 2 mm between the base of the first and second metatarsals on an AP radiograph should raise suspicion of a Lisfranc ligament injury [40]. If clinical findings are suggestive of a fracture at the base of the fifth metatarsal but foot 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]. Stress radiographs are used to determine operative or nonoperative treatment by identifying instability via manual displacement of the first metatarsal through the joint or fracture site [59].

Point-of-care ultrasonography: 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].

MRI: MRI allows for early visualization of stress-related marrow edema and proper diagnosis before progression to fracture [106]. MRI can demonstrate the degree of ligament disruption but is not usually required in the diagnosis of midfoot fracture-dislocations nor does it usually alter treatment [40].

CT: A CT scan is helpful when there are fractures involving the base of the central 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].

Other Considerations: Any fracture of the base of the first three metatarsals should raise suspicion of a midtarsal injury [38]. Small avulsion fractures involving the medial base of the first or second metatarsal suggest disruption of the tarsometatarsal (TMT) ligaments [38]. The arterial arch and the dorsal and plantar metatarsal arteries are particularly susceptible to injuries in association with first metatarsal fractures [38]. Compartment pressures should be monitored routinely, especially following direct trauma to the first metatarsal area [38]. The plantar gap might add to the decision-making process for surgery and improve the prediction of patient prognosis [18]. A study found a significantly increased time to bony union in fractures with at least 1 mm of fracture margin separation, regardless of Torg classification [32]. A 2015 radiographic study using three-dimensional CT of 119 patients 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 was found to be 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]. 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]. Careful evaluation of the feet during primary and secondary survey is needed particularly when a tibia or femur fracture is diagnosed [51]. Routine outpatient follow-up of fifth metatarsal fractures showed no added clinical value in a 2015 study [13]. 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].

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]. Point-of-care ultrasonography (POCUS) can be applied successfully in the diagnosis and determination of the treatment method in low-energy induced metatarsal fractures [19].

First Metatarsal Fractures

Fractures of the first metatarsal accounted for 20% overall and 73% in the under-fives in a study of metatarsal fractures in children [3]. Nondisplaced first metatarsal fractures are treated with a boot or hard-soled shoe and weight bearing as tolerated [47, 48]. Displaced first metatarsal fractures are treated with surgical fixation, specifically open reduction and internal fixation (ORIF) with lag screws or plate fixation [47, 48]. Isolated first metatarsal fractures can be adequately treated in 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 (Second, Third, Fourth)

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 quite 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]. Pin fixation after closed reduction is rarely needed with an isolated central metatarsal injury because of the stability provided by surrounding soft tissues [44, 87]. For isolated distal central metatarsal fractures, closed reduction is performed by using finger trap distraction to restore alignment followed by weight bearing as tolerated in a hard-sole shoe [44]. Metatarsal fractures may be treated using low-intensity pulsed ultrasound with comparable healing rates to fractures treated by surgical intervention [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]. 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 central metatarsal fractures are inherently unstable because intermetatarsal ligaments cannot provide stability [47, 48]. Surgical fixation for central metatarsal fractures involves ORIF with plate-and-screw fixation or intramedullary antegrade-retrograde pinning technique [47, 48]. Closed Antegrade/Retrograde intramedullary fixation of central metatarsal fractures can restore alignment and achieve good clinical outcome [6]. 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].

An unstable base fracture of the second metatarsal requires limited open reduction and intramedullary pinning to maintain proper position if it has a tendency to shift laterally [44, 87]. Closed reduction for metatarsal base fractures with lateral displacement can be achieved by simultaneously plantarflexing and forcing the TMT joint medially under traction and counter-traction [44]. Multiple metatarsal head or neck fractures are difficult to treat by open means due to the risk of devascularization of the head and loss of stability [87]. Closed reduction with traction and local anesthesia is the preferred method of treatment for multiple metatarsal head or neck fractures [87]. The goal of closed reduction for multiple metatarsal head or neck fractures is to bring a plantarflexed head back to a neutral position and impale the head on the neck of the metatarsal [87]. Realignment for multiple metatarsal head or neck fractures can be supplemented by percutaneous pin fixation [87]. When using a pin for multiple metatarsal head or neck fractures, it is recommended to enter the base of the proximal phalanx or metatarsal head from the lateral aspect and aim to bend the pin down the medial wall of the shaft [87]. An elastic bend in the K-wire exerts a medially directed force to balance the natural tendency for these fractures to drift laterally [87]. Closed reduction can be attempted for multiple adjacent central metatarsal fractures but is usually unstable, so ORIF should be performed [87]. The choice of fixation for multiple central metatarsal fractures depends more on the condition of the surrounding soft tissue than on the fracture pattern or location [87]. Great care must be taken during reduction of multiple central metatarsal fractures to avoid dorsiflexion or plantar flexion of the distal fragment causing sagittal malalignment [87].

Fifth Metatarsal Fractures: Zone 1 (Avulsion)

Zone I injuries are traction-type fractures resulting in avulsion of the proximal aspect of the metatarsal [55]. Minimal treatment is needed for Zone I fractures because the outcome is universally good, with healing of the fracture and full return to activities [55]. Most Zone 1 cases are treated with protected weight bearing in a shoe or boot [47, 48]. Zone I fractures are treated in a short-leg cast or fracture boot with weight bearing as tolerated for 3 to 6 weeks [55]. Other authors have recommended a hard-soled shoe, an elastic wrap, or a functional brace for Zone I fractures, all of which have produced good results [55]. Fractures in zone I generally are treated satisfactorily in a postoperative shoe, walking boot, or short leg walking cast depending on the level of 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]. Zone 1 injuries as well as distal fractures can be treated quite well by closed means such as with a stiff-soled shoe, cast, or fracture boot, regardless of treatment method [30].

In a study of proximal fifth metatarsal fractures, the fracture healed in all 60 patients at an average of 44 days, with no fracture taking longer than 65 days to heal [25]. Patients treated with a compressive soft dressing and allowed to bear weight in a cast boot required a significantly shorter recuperation time and had a better modified foot score than patients treated with cast immobilization [25]. Another study confirms the shorter recuperation time for patients treated with a walking boot instead of a walking cast [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]. Radiographic union generally lags behind the time to resolution of the patient's symptoms and is not a prerequisite for removal of the cast or return to activities at 3 to 4 weeks [55]. Reports of nonunion for Zone I fractures are most often displaced more than 3 mm at the time of injury, and these injuries are preferred to be immobilized in a cast for 6 weeks [55]. Nonunions of zone I fractures may occur but rarely are painful and can be treated with excision of the fragment [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].

Open reduction is required for Zone 1 fractures 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 1 fractures [47, 48]. For zone I fractures with gross displacement or articular involvement in young active patients, open reduction and fixation can be considered [25]. ORIF for zone I fractures rarely is necessary and generally is reserved for displaced intraarticular fractures in highly competitive individuals [25]. A lag screw placed obliquely from base of fifth metatarsal into medial cortex of fifth metatarsal is the surgical treatment of choice for Zone 1 fractures [47, 48]. A variety of methods of fixation are described for zone I fractures, including plating, screw fixation, and a tension-band technique [25]. Plates in the zone I area are generally not well tolerated and often require removal [25].

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

The proximal fifth metatarsal is considered a high-risk site for stress fracture due to poor blood supply, making both stress and traumatic injuries prone to nonunion [49]. Zone II fractures have the greatest risk for delayed healing due to the limited vascularity of the watershed area at the metaphyseal–diaphyseal junction [49]. Treatment for stress fractures of the proximal fifth metatarsal should be aggressive [49]. Acute nondisplaced or minimally displaced fractures, avulsion fractures (zone 1), zone 2 fractures, and acute zone 3 fractures are indications for nonoperative treatment [30]. Displaced fractures, persistent nonunions, and zone 3 fractures with prodromal symptoms are relative contraindications for nonoperative treatment [30]. Proximal fifth metatarsal fractures can safely be treated nonoperatively with a low risk for nonunion, with fewer complications compared to a surgical treatment and at lower health care costs [30].

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]. Longer immobilization may be required if no radiographic evidence of healing has occurred during the initial 6 to 8 week period [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]. Even with non-weight-bearing immobilization for 6 to 8 weeks, Jones fractures have a reported nonunion rate of 7% to 28% [25]. Both acute and prodromal proximal diaphyseal fractures are placed in a short leg non–weight-bearing casts for 6 weeks [30]. At 6 weeks, acute fractures (no prodromal symptoms) are changed to a removable short leg walker and weight bearing is allowed to progress as tolerated [30]. When full asymptomatic weight bearing occurs, physical therapy can begin as well as a return to sporting activities, which takes up to 10 weeks in most cases [30]. Fractures that present with a history of localized pain with activity (stress fractures) are left in a non–weight-bearing cast for an additional 8 weeks [30]. At that time, reexamination of the fracture is done to look for clinical and radiographic signs of healing [30]. Radiographically, dissolution of the sclerotic margins of the fracture and reconstitution of the medullary canal are signs of active healing [30]. Lack of pain with direct palpation of the fracture site and with motion of the distal metatarsal can be seen clinically as healing occurs [30]. Non–weight-bearing casting is usually continued for a full 3 months for stress fractures [30]. In a more recent study, incomplete stress (Jones) fractures were successfully treated with low-intensity pulsed ultrasound with promising results and without taking a break from sport practice [30]. 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].

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]. In competitive athletes, consideration should be given to early ORIF to decrease disability time for Jones fractures [25]. There is 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]. Surgery should be considered for zone II and III fractures that are not healing clinically at 8 to 12 weeks [25]. Surgery should be considered for acute fractures in competitive athletes and others whose occupational demands do not allow prolonged non-weight bearing immobilization [25]. Two operative treatments have proved successful for zones II and III fractures that require surgical intervention: fixation with an intramedullary screw and corticocancellous inlay bone grafting with clearing of the medullary canal of all sclerotic bone [25]. Most authors currently use an intramedullary screw technique for zones II and III fractures, but both methods have a satisfactory success rate [25]. If nonunion is not present, bone grafting usually is not necessary at the time of IM fixation for proximal fifth metatarsal fractures [49]. Weight bearing should be initiated 7 to 14 days postoperatively after IM screw fixation, 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 [49]. Risk remains for fracture nonunion and fatigue failure of the screw after IM fixation [49].

Zone 3 injuries are those that occur distal to the proximal tuberosity and present with prodromal symptoms before complete fracture occurs [30]. Zone 3 injuries pose problems because of their tendency toward nonunion [30]. Successful treatment of zone 3 fractures requires more aggressive treatment than that used for other fracture patterns in the fifth metatarsal [30]. Initial treatment for zone 3 fractures ranges from casted non-weight bearing for up to 3 months to surgical intervention with grafting and internal compression [30]. In the fractures with a short period of localized pain with activity before diagnosis, non-weight-bearing casting offers results comparable to surgery [30]. In zone III, fractures with clinical or radiographic evidence of chronic injury manifested by partial or complete canal obliteration and sclerosis may yield satisfactory results with non-weight-bearing casting [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]. Dancer's fractures of the distal shaft of the fifth metatarsal usually heal well with nonoperative cast immobilization [30]. It is important to assess for biomechanical or biological reasons why a zone III fracture developed, such as cavovarus foot posture or hypovitaminosis D [25]. A study of 51 elite athletes showed that long, narrow, and straight fifth metatarsals with an adducted forefoot were most at risk for fifth metatarsal fractures [25]. O'Malley et al. showed in 10 professional NBA players that a unique foot type seemed to be associated with higher rates of fifth metatarsal fractures: metatarsus adductus and a curved fifth metatarsal with a prominent base [25].

Complications

General Prognosis and Malunion: Most metatarsal fractures do not cause significant problems in treatment or outcome, but they can lead to significant limitations if ignored [42]. Malunion may result in prolonged disability [1].

Nonunion and Delayed Union: Non-union is remarkably uncommon in fatigue fractures of the foot, with the exception of the Jones fracture of the proximal fifth metatarsal [17]. Jones fractures have a reported nonunion rate of 7% to 28% even with non-weight-bearing immobilization for 6 to 8 weeks [25]. 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 playing professional football following fixation of 5th metatarsal stress fractures may lead to delayed union [94]. Specifically, return to play at 8 weeks or less after intramedullary screw fixation of 5th metatarsal stress fractures resulted in a higher risk of delayed radiological union (24% at 3 months) [94].

Refracture: Refracture is common in zone III fifth metatarsal fractures with clinical or radiographic evidence of chronic injury [25]. A refracture occurred in 1 patient (3%) at 10 months after intramedullary screw fixation of a 5th metatarsal stress fracture, who had previously achieved 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: 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]. Plates used for fixation of zone I fifth metatarsal fractures are generally not well tolerated and often require removal [25]. There is a risk of sural nerve injury with intramedullary screw fixation of fifth metatarsal fractures [10].

Functional and Gait Alterations: Gait alterations after a second metatarsal stress fracture can result in a decrease in maximum force in the middle forefoot [23]. Early return to play after intramedullary screw fixation of 5th metatarsal stress fractures does not increase the risk of long-term non-union [94]. The ultimate risk of non-union for 5th metatarsal stress fractures treated with intramedullary screw fixation is 3% overall [94].

Recovery

Light activity (weeks): Zone 1 fractures of the 5th metatarsal base managed conservatively are expected to achieve union within 8 weeks [7]. The XS-nail provides rapid full-weight-bearing mobilization for proximal fifth metatarsal fractures [36].

Full activity (months): 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 similar to other professional cohorts [8]. Elite athletes reliably return to the same level of competition after surgical management of fifth metatarsal fractures, irrespective of the surgical construct used [15].

Complete recovery / outcome plateau (months): Overall outcome in metatarsal fractures is high, with almost all fractures healed without complaints at 33 months [9]. The XS-nail shows good long-term results for the treatment of proximal fifth metatarsal fractures [36].

Rehabilitation protocol: Routine use of LIPUS is not recommended to shorten the time to bone union after intramedullary screw fixation for proximal fifth metatarsal stress fractures [16]. There is no added clinical value for routine outpatient follow-up of fifth metatarsal fractures [13].

Functional milestones: Zone 1 fractures of the 5th metatarsal base managed conservatively result in good VAS and AOFAS scores [7]. Elite athletes have a high rate of union after surgical management of fifth metatarsal fractures [15].

Other Considerations: Metatarsal fractures have a generally favorable prognosis if adequately assessed [1], and fractures of the foot in children usually have a good prognosis [4]. The risk of refracture for MLS athletes with fifth metatarsal fractures is similar to other professional cohorts [8]. Players who complete at least one full year of collegiate football after a fifth metatarsal fracture are less likely to have a residual fracture gap [21]. Foot fractures in elite soccer players result in a moderate loss of play time averaging 69.41 days [109]. Non-union is remarkably uncommon in fatigue fractures of the foot, apart from the Jones' fracture of the proximal fifth metatarsal [17]. Non-union of Jones' fractures is more likely related to unresolved stress than to the quality or vascularity of the bone [17]. The 4th and 5th metatarsals have a greater potential for non-union compared to other metatarsals [31]. Progression to non-union of 5th metatarsal base fractures is contributed to by the presence of a perfusion watershed at the metaphysis/diaphysis junction [31]. Cavovarus foot alignment is a predisposing factor for non-union of 5th metatarsal base fractures [31]. An increasing inter-metatarsal angle between the 4th and 5th metatarsals is a predisposing factor for non-union of 5th metatarsal base fractures [31]. A protruding 5th metatarsal head is a predisposing factor for non-union of 5th metatarsal base fractures [31]. Functional outcomes in multitrauma patients with midfoot or hindfoot fractures are comparable [22]. Decreased maximum force in the middle forefoot in patients with a previous second metatarsal stress fracture could result 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)
• [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)
• [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

References

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