01Approach to the Critical Patient/attcp40

Immediate priorities

›Stabilization priorities

›If hemodynamic instability, resuscitation pathway and alternate injury source

›If major hemorrhage concern, trauma activation

›If open fracture, time-critical infection prophylaxis and orthopedics escalation

›If gross contamination, irrigation and debridement planning

›If neurovascular compromise, emergent reduction or splint adjustment then reassessment

›If persistent absent pulses after reduction, emergent vascular and orthopedics consultation

›Pain control strategy

›Early multimodal analgesia

›Procedural sedation planning if reduction required

Limb threat screen

›Limb-threatening findings

›Compartment syndrome concern

›Pain out of proportion

›Pain with passive toe motion

›Tense compartments

›Vascular compromise

›Pallor

›Cool skin

›Delayed capillary refill

›Diminished dorsalis pedis or posterior tibial pulse

›Open fracture

›Wound probing to bone suspicion

›Gross contamination

›Skin at risk

›Tenting

›Blistering

02History/hx53

Mechanism and timing

›Injury context

›Mechanism category

›Direct crush

›Twisting inversion

›Axial load fall

›Repetitive overuse running or marching

›Timing

›Acute single event

›Subacute progressive pain

›Chronic pain with acute worsening

›Footwear and surface

›Minimalist shoes

›Cleats

›Uneven terrain

›Immediate function

›Able to bear weight immediately

›Immediate swelling or bruising

Symptoms and functional impact

›Symptom profile

›Pain location

›Dorsal forefoot

›Plantar forefoot

›Lateral border at fifth metatarsal

›Midfoot

›Swelling pattern

›Localized over metatarsal shaft

›Diffuse forefoot swelling

03Physical Exam/exam46

Inspection and palpation

›Local exam findings

›Deformity

›Malalignment of forefoot

›Shortening or dorsal displacement contour

›Swelling and ecchymosis distribution

›Dorsal forefoot swelling

›Plantar midfoot ecchymosis

›Skin integrity

›Laceration near fracture site

›Abrasion with contamination

›Tenting

›Point tenderness mapping

›Metatarsal head

›Metatarsal neck

›Metatarsal shaft

›Metatarsal base

›Fifth metatarsal tuberosity

›Mulder-type pain pattern differentiation

›Intermetatarsal neuroma mimic

Function and stability

›Functional assessment

›Weight-bearing ability in department

›Four steps assessment

›Toe alignment and cascade

›Rotational malalignment clue

›Midfoot stability

›Pain with forefoot abduction stress

04Differential Diagnosis/ddx26

Traumatic forefoot and midfoot injuries

›Alternate and associated injuries

›Lisfranc injury ICD-10 S93.324

›Midfoot pain and plantar ecchymosis

›Widened first to second intermetatarsal space

›Phalanx fracture ICD-10 S92.5

›Metatarsophalangeal dislocation ICD-10 S93.12

›Tarsal fracture ICD-10 S92.2

›Cuboid fracture

›Cuneiform fracture

›Fifth metatarsal avulsion fracture ICD-10 S92.351

›Jones fracture ICD-10 S92.354

›Open fracture ICD-10 S92.3 with seventh character

›Soft tissue injuries

›Plantar plate injury

›Extensor tendon strain or rupture

›Peroneus brevis insertion injury mimic

›Foot contusion

Atraumatic and mimic conditions

›Nontraumatic mimics

›Metatarsal stress fracture ICD-10 M84.37

›Activity-related pain with minimal swelling

›Metatarsalgia ICD-10 M77.4

›Mortons neuroma ICD-10 G57.6

›Gout flare ICD-10 M10

›Cellulitis ICD-10 L03.115

›Osteomyelitis ICD-10 M86

›Charcot neuroarthropathy ICD-10 E11.610

05Laboratory Tests/lt18

When labs are needed

›Laboratory selection

›No routine labs for isolated closed metatarsal fracture

›Normal vitals and no anticoagulation

›If open fracture or operative pathway, baseline labs

›Complete blood count for infection baseline and anemia

›Basic metabolic panel for anesthesia planning and renal dosing

›If anticoagulated or bleeding risk concern

›INR for warfarin

›Anti-Xa level when available for factor Xa inhibitor timing guidance

›If infection concern

›C-reactive protein for trend utility

›Blood cultures if systemic toxicity

Metabolic and bone health evaluation

›Stress fracture or fragility pattern workup

›25-hydroxy vitamin D for deficiency

›Deficiency associated with stress fracture risk

›Calcium and phosphate for metabolic bone disease screening

›Thyroid-stimulating hormone for secondary osteoporosis consideration

›Pregnancy test when applicable before imaging or analgesics

06Diagnostic Tests/dt71

Scoring Systems

›Clinical decision support

›Ottawa foot rule for midfoot imaging

›Midfoot zone pain

›Navicular tenderness

›Fifth metatarsal base tenderness

›Inability to bear weight four steps immediately and in ED

›High sensitivity for clinically significant midfoot fractures in validation studies

›ACEP Level B support for use as a decision aid in low-risk trauma settings

›Limitation in high-energy trauma and intoxication

›ACEP Level C caution for exclusion use in unreliable exam

MRI

›MRI indications

›Suspected stress fracture with normal radiographs

›Bone marrow edema detection

›Early cortical injury detection

›Suspected Lisfranc ligament injury with equivocal x-ray

›Ligament disruption assessment

›Persistent pain beyond expected healing window with concern for nonunion

›Fracture line persistence and edema pattern

›MRI limitations

›Availability and time

›Metal hardware artifact

›Not first-line in uncomplicated acute fractures

CT

›CT indications

›Suspected Lisfranc injury with subtle radiograph findings

›Joint incongruity and small avulsion fragments

07Disposition/dispo29

Admission and urgent consultation

›Admission or immediate orthopedics triggers

›Open fracture

›IV antibiotics and operative irrigation and debridement pathway

›Neurovascular compromise not rapidly reversible

›Emergent reduction attempt then escalation if persistent

›Compartment syndrome concern

›Emergent surgical evaluation

›Lisfranc injury suspected

›Non-weight-bearing immobilization and urgent foot and ankle specialist follow-up

›Multiple metatarsal fractures with instability

›High risk of malalignment and arch compromise

›Marked displacement or angulation

›Reduction or operative assessment threshold

Discharge with follow-up

›Outpatient pathway criteria

›Closed fracture

›Intact neurovascular exam

›No skin threat

›Pain controlled with oral regimen

›Safe mobility plan

›Crutches or walker training

›Fall risk assessment

›Follow-up timing suggestions

›Most nondisplaced fractures

›Orthopedics or fracture clinic in 5 to 10 days

›Fifth metatarsal proximal patterns

›Zone 2 or zone 3

08Treatment/t98

Immobilization and weight bearing

›Mechanical management

›Immobilization choices

›Hard-soled shoe for stable nondisplaced shaft fractures

›Weight bearing as tolerated if pain allows and no Lisfranc concern

›Walking boot for most nondisplaced fractures with significant pain

›Protected weight bearing

›Posterior short leg splint for more painful or unstable patterns

›Non-weight-bearing if displacement risk or multiple fractures

›Reduction indications

›Significant angulation or displacement on radiograph

›If reduction performed, post-reduction radiographs

›Fifth metatarsal specifics

›Tuberosity avulsion

›Boot or hard-soled shoe

›Weight bearing as tolerated

›Junction fracture and proximal diaphyseal stress pattern

›Non-weight-bearing short leg splint or cast pathway per specialist preference

›Higher nonunion risk counseling

Analgesia

›Multimodal pain regimen

›Acetaminophen

›Adult dosing

›1000 mg PO every 6 to 8 hours as needed

›Maximum 4000 mg per day

›Maximum 3000 mg per day in chronic alcohol use or frailty

›Pediatrics dosing

›15 mg per kg PO every 6 hours as needed

›Maximum 75 mg per kg per day

›NSAID option when not contraindicated

›Ibuprofen

›Adult dosing

›400 mg PO every 6 hours as needed

›Maximum 2400 mg per day without specialist direction

›Pediatrics dosing

›10 mg per kg PO every 6 to 8 hours as needed

›Maximum 40 mg per kg per day

›Naproxen

›Adult dosing

›250 mg PO twice daily as needed

›Maximum 1000 mg per day

›Opioid for severe pain despite above

›Oxycodone immediate release

›Adult dosing

›2.5 mg PO every 6 hours as needed

›Use lowest effective dose and shortest duration

›Hydromorphone

›Adult dosing

›1 mg PO every 6 hours as needed

›Avoid in opioid-naive when alternatives adequate

›Antiemetic if opioid used

›Ondansetron

›Adult dosing

›4 mg ODT or PO every 8 hours as needed

›Pediatrics dosing

›0.15 mg per kg PO every 8 hours as needed

›Analgesia cautions

›NSAID avoidance or caution

›Active GI bleed or high-risk ulcer history

›Advanced chronic kidney disease

›Heart failure exacerbation risk

›Opioid safety

›Avoid co-prescribing sedatives when possible

›Driving and impairment counseling

Procedural options

›Reduction support

›If reduction required, sedation pathway or regional anesthesia

›Procedural sedation per local protocol

›Regional block option

›Ankle block by trained clinician

›Lidocaine 1 percent without epinephrine

›Maximum 4.5 mg per kg

›Bupivacaine 0.25 percent

›Maximum 2.5 mg per kg

›Wound care for associated lacerations

›If open fracture suspected, avoid primary closure before orthopedics direction

›Sterile dressing and splint

›Tetanus update

Antibiotics and tetanus for open fractures

›Open fracture infection prophylaxis

›First-generation cephalosporin coverage

›Cefazolin

›Adult dosing

›2 g IV once then every 8 hours until operative care

›Pediatrics dosing

›30 mg per kg IV every 8 hours

›If severe beta-lactam allergy

›Clindamycin

›Adult dosing

›600 mg IV every 8 hours

›Pediatrics dosing

›10 mg per kg IV every 8 hours

›If gross contamination or farm injury

›Add gram-negative coverage per local protocol

›Gentamicin dosing per weight and renal function with pharmacy support

›Tetanus prophylaxis

›Vaccine status review

›Booster if indicated

›Tetanus immune globulin if indicated for dirty wound and incomplete immunization

›Evidence framing

›Early antibiotics in open fractures associated with lower infection risk

›Class I recommendation by trauma and orthopedic consensus statements

09Special Populations/sp35

Pregnancy

›Pregnancy considerations

›Imaging safety

›Foot radiographs acceptable with shielding and low fetal exposure

›Avoid CT unless strong indication and benefits outweigh risks

›Analgesia adjustments

›Acetaminophen preferred

›NSAIDs avoidance especially later gestation

›Opioid short course if required with obstetric awareness

›Thromboembolism risk

›Prolonged immobilization counseling

›Obstetric follow-up if additional risk factors

Geriatric

›Older adult considerations

›Fragility fracture suspicion

›Low-energy mechanism with fracture suggests osteoporosis

›Bone health follow-up planning

›Mobility and falls

›Walker preference over crutches when balance limited

›Home safety and support assessment

›Medication risk

›NSAID renal and GI risk higher

›Opioid delirium and fall risk

›Healing risk

›Vascular disease and smoking increase delayed union

Pediatrics

›Pediatric considerations

›Growth plate involvement possibility

10Background/b34

Epidemiology

›Epidemiology highlights

›Metatarsals among the most commonly fractured foot bones

›Fifth metatarsal frequently involved in inversion injuries

›Stress fractures common in runners and military recruits

›Second and third metatarsals classic sites

›Proximal fifth metatarsal fractures carry higher nonunion risk than distal shaft fractures

›Junction region relatively hypovascular

Pathophysiology

›Injury mechanisms

›Direct trauma

›Transverse or comminuted shaft patterns

›Twisting inversion

›Fifth metatarsal tuberosity avulsion from peroneus brevis and plantar fascia tension band

›Axial load

›Metatarsal neck fractures

›Repetitive load

›Stress reaction to stress fracture continuum

›Fifth metatarsal proximal zone concepts

›Tuberosity avulsion region

›Better healing potential

›Metaphyseal-diaphyseal junction region

›Higher nonunion due to watershed blood supply

›Proximal diaphysis

›Stress fracture and delayed union patterns

Therapeutic Considerations

›Treatment rationale

›Alignment preservation prevents transfer metatarsalgia and deformity

11Patient Discharge Instructions/pdi26

copy discharge instructions

›Discharge packet

›Diagnosis summary

›Metatarsal fracture of foot bone

›Immobilization and weight bearing

›Keep boot or splint on except for hygiene if allowed

›If non-weight-bearing instructions given, no standing or walking on injured foot

›Elevation above heart as much as possible for first 48 to 72 hours

›Ice 15 to 20 minutes at a time up to every 2 to 3 hours for swelling

›Medications

›Use acetaminophen as first option unless told otherwise

›Use ibuprofen or naproxen only if safe for you and not told to avoid

›If opioid prescribed, use only for severe pain and do not drive

›Wound care if any cuts

›Keep dressing clean and dry

›Return immediately for spreading redness, pus, fever, or worsening pain

›Follow-up

›Fracture clinic or orthopedics appointment in the recommended timeframe

›Repeat x-ray may be needed to ensure alignment and healing

›Return to ED now for

›Increasing pain not controlled with medication

›New numbness or weakness in toes

›Toes turning blue, pale, or cold

›Increasing swelling with severe tightness

›Wet or tight cast or splint with worsening pain

›New wound drainage, fever, or red streaking

›Fall or re-injury with new deformity

12References/r9

Decision rules and emergency care sources

›Reference set

›Ottawa ankle and foot rules validation studies for radiography decisions

›High sensitivity for clinically significant fractures in original and subsequent validations

›Orthopedic and foot and ankle society guidance on fifth metatarsal proximal fractures

›Higher nonunion risk in metaphyseal-diaphyseal junction region

›Open fracture antibiotic timing guidance from trauma and orthopedic consensus statements

›Early IV antibiotics associated with reduced infection risk

›Emergency medicine procedural sedation guidelines for ED sedation safety

›Standard monitoring and staffing recommendations

Evidence & Review

Evidence & Review