Metatarsal Shaft Fractures

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Summary

The metatarsals are the long bones in the forefoot that lead up to the toes.  Metatarsal shaft fractures are associated with pain and swelling in the forefoot. They are typically caused by a heavy object being dropped on the foot.  Direct loading and twisting of the foot, such as might occur in an automobile accident, can also cause a metatarsal fracture. Some metatarsal fractures occur after minimal trauma when bones are fragile (osteoporosis).  In addition to acute fractures of the metatarsals, repetitive intense activity (military marching is one example) can lead to a “stress fracture” of one of the metatarsals.   Most metatarsal shaft fractures can be treated non-surgically, with limited weightbearing in a stiff-soled shoe or a boot for 6 to 8 weeks, provided that the bones are in an acceptable position.  Some displaced fractures will benefit from surgery to reposition and stabilize the bones.

Clinical Presentation

Metatarsals are the long bones of the forefoot that connect the forefoot to the midfoot. A break (fracture) in one or more of the metatarsals is often associated with significant swelling, and also pain in the arch of the foot or at the pads of the forefoot area. Usually the soft tissue overlying the bones remains intact but, in some instances, the bones will break through the skin, creating an open injury which is a surgical emergency. Common mechanisms for having metatarsal shaft fracture(s) include falling from a high height and landing on the feet, jamming the foot into the brake pedals in the course of a motor vehicle collision, loading the foot and twisting it in the course of changing directions during a sporting event, and most commonly, dropping a heavy object on the forefoot.

Physical Exam

In the case of an isolated metatarsal shaft fracture, there will be tenderness and swelling localized to the injured area. In the case of multiple fractures, the painful, swollen area will be larger and will correlate to the involved bones. There may also be some numbness in the toes. It will be important to assess the blood supply to the toes; at times this can be affected.

It is important to assess the position of the metatarsal heads. These are the ends of the metatarsals that represent the “ball of the foot”. This is the area that we walk on, and it is possible to have a problematic position of the metatarsal head resulting from a displaced metatarsal fracture.

Imaging Studies

Plain x-rays of the foot will usually identify the fracture. The location of fracture, as well as the fracture pattern will be identified and assessed, along with the position of nearby foot bones. The rotation of the bones and the associated angulations are all things that the treating physician will consider.

Treatment

Most metatarsal fractures can be treated non-surgically. If the fractured metatarsals are in an acceptable position, these fractures can be treated without surgery. Occasionally, a manipulation of the bones to reposition them is necessary. Occasionally, an “open reduction internal fixation” procedure is required to stabilize the bones in an acceptable position. This may involve placement of small plates and/or screws or pin fixation.

Treatment involves protecting the area until the bones have healed. It typically takes 6-8 weeks for the bones to knit together enough for full weightbearing. Prior to this, limited weight bearing through the heel in a very stiff soled walker boot or shoe may be possible. It is often 4 to 6 months before a full recovery is obtained (ex. return to unrestricted activities such as jumping and sprinting).

Surgery may be indicated in the case of either a significantly displaced metatarsal shaft fracture, or in the case of multiple metatarsal shaft fractures that are displaced. There is some suggestion that for a displaced metatarsal shaft fracture, surgical stabilization can produce a slightly faster recovery time, albeit with the associated risks of surgery.


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