01Approach to the Critical Patient/attcp41

Immediate priorities

›Triage and limb threat screen

›Open fracture concern

›Wound over metatarsals

›Contamination

›Neurovascular compromise

›Cool foot

›Absent dorsalis pedis pulse

›Compartment syndrome concern

›Pain out of proportion

›Pain with passive toe stretch

›Skin threat

›Dorsal skin tenting

›Rapidly expanding swelling

›Time-critical escalation triggers

›If pulseless or hard signs of vascular injury, immediate ortho and vascular consult

›If suspected compartment syndrome, immediate ortho consult

›If open fracture, antibiotics and tetanus pathway before transfer when feasible

Limb threat documentation

›Neurovascular status

›Dorsalis pedis pulse

›Doppler signal if nonpalpable

›Compare contralateral

›Posterior tibial pulse

›Doppler signal if nonpalpable

›Compare contralateral

›Capillary refill

›Toes 1-5

02History/hx43

Mechanism and timeline

›Injury context

›Direct crush injury

›Industrial or heavy object

›High swelling risk

›Axial load with twisting

›Fall from height

›Lisfranc risk

›Inversion injury

›5th tuberosity avulsion risk

›Ankle sprain co-injury

›Repetitive overuse

›March fracture pattern

›Stress fracture risk factors

›Timing and course

›Time since injury

›Immediate pain and inability to bear weight

›Delayed swelling

›Prior self-management

›Continued sports participation

›NSAID use and masking pain

Risk modifiers and red flags

›Patient factors

›Diabetes with neuropathy

›Reduced pain reliability

›Skin breakdown risk

›Smoking or nicotine use

›Delayed union risk

03Physical Exam/exam44

Focused foot exam

›Inspection and palpation zones

›Skin integrity

›Dorsal blistering

›Laceration over fracture site

›Deformity

›Forefoot abduction

›Metatarsal head depression

›Swelling distribution

›Dorsal forefoot swelling

›Midfoot swelling

›Point tenderness mapping

›Metatarsal base

›Metatarsal neck

›Functional and stability cues

›Weight-bearing ability

›Four-step weight-bearing attempt

›Antalgic pattern

›Midfoot stability

›Plantar ecchymosis

›Pain with forefoot abduction stress

Neurovascular and compartment assessment

›Neurovascular findings

›Pulses

›Dorsalis pedis

›Posterior tibial

›Sensory exam

›Dorsal webspace sensation

04Differential Diagnosis/ddx44

Fracture and fracture-equivalent patterns

›Bony injury alternatives

›Phalangeal fracture

›Toe pain maximal at phalanx

›Pain with toe motion dominant

›Tarsal fracture

›Cuboid fracture

›Navicular fracture

›Calcaneal fracture

›Heel pain dominant

›Axial load mechanism

›Stress injury spectrum

›Metatarsal stress reaction

›Activity-related pain

›Normal initial X-ray

›Metatarsal stress fracture

›Focal bony tenderness

›Pain with hopping test

Soft tissue and joint mimics

›Ligament and tendon injuries

›Lisfranc ligament sprain or rupture

›Midfoot tenderness at tarsometatarsal joints

›Plantar ecchymosis

›Peroneus brevis tendon injury

›Lateral foot pain at 5th base region

›Pain with resisted eversion

›Plantar plate injury

›Metatarsophalangeal pain

05Laboratory Tests/lt17

When labs matter

›Selective labs only

›Open fracture or deep laceration

›CBC for infection risk context

›Basic metabolic panel for operative planning context

›Significant crush injury

›Creatine kinase for rhabdomyolysis concern

›Creatinine and potassium for renal risk

›Anticoagulation or bleeding concern

›INR for warfarin

›Platelet count for thrombocytopenia concern

Interpretation and pitfalls

›Lab limitations

›Normal CBC does not exclude open fracture infection risk

›Early infection labs may be normal

›Clinical wound assessment drives antibiotics

›CK trends

›Rising CK supports muscle injury burden

›CK level alone does not diagnose compartment syndrome

06Diagnostic Tests/dt54

Scoring Systems

›Classification and decision relevance

›5th metatarsal proximal zone classification

›Zone 1 tuberosity avulsion

›Zone 2 metaphyseal-diaphyseal junction

›Zone 3 proximal diaphysis stress fracture region

›Salter-Harris for pediatric physeal injury

›Type I-V framework

›Growth disturbance risk increases with higher type

›Gustilo-Anderson for open fractures

›Type I-IIIA low to moderate soft tissue damage

›Type IIIB-IIIC severe soft tissue or vascular injury

Radiographs

›Standard imaging

›Foot radiographs

›AP view

›Lateral view

›Oblique view

›Weight-bearing views when safe

›Suspected Lisfranc injury

›Comparison to contralateral if unclear

›Radiograph interpretation targets

›Displacement

›Shaft translation

›Articular step-off at metatarsal head or base

›Angulation

›Dorsal angulation at neck

›Plantar angulation at neck

07Disposition/dispo31

Discharge vs admission vs transfer

›Discharge suitability

›Stable isolated fracture

›Neurovascularly intact

›Pain controlled with oral regimen

›Safe mobility plan

›Crutches or walker instruction

›Weight-bearing status understood

›Admission or observation triggers

›Pain control failure

›Persistent severe pain despite ED regimen

›Inability to mobilize safely

›Significant comorbidity

›Diabetic neuropathy with skin risk

›Frailty with fall risk

›Transfer or urgent specialty triggers

›Open fracture

›Antibiotics and tetanus initiated

›Ortho capability required

›Suspected Lisfranc injury with instability

›Weight-bearing radiograph abnormality

›Plantar ecchymosis with midfoot instability

Follow-up timing

›Ortho or fracture clinic follow-up targets

›5th metatarsal zone 2 or zone 3 patterns

›Early ortho follow-up within 3-7 days

›Nonunion risk counseling

›Multiple metatarsal fractures

08Treatment/t73

Immediate life-saving interventions

›Limb-threatening complications pathway

›If hard signs of vascular injury, immediate specialist involvement

›No prolonged splint-only delay

›Emergent imaging and revascularization planning

›If suspected compartment syndrome, immediate escalation

›Remove constrictive dressings

›Ortho consult for fasciotomy decision

›If open fracture, immediate open fracture bundle

›Cover wound with sterile dressing

›Antibiotics as early as possible

Immobilization and Splinting

›Immobilization selection by pattern

›Nondisplaced central metatarsal shaft or neck fracture

›Hard-sole shoe or CAM boot

›Weight-bearing as tolerated if pain-limited and stable

›Displaced fracture or multiple metatarsals

›Posterior short leg splint

›Non-weight bearing until reassessment

›Suspected Lisfranc injury

›Posterior short leg splint plus stirrup

›Strict non-weight bearing

›Application principles

›Swelling-phase splinting preferred over circumferential cast

›Neurovascular recheck after application

›Two-finger tightness check

Reduction

›Indications for reduction attempt

09Special Populations/sp30

Pregnancy

›Pregnancy-specific considerations

›Imaging safety

›Foot radiographs with shielding when feasible

›Lowest necessary imaging set

›Analgesia selection

›Acetaminophen preferred baseline

›NSAID avoidance in later pregnancy per obstetric guidance

›Mobility and fall risk

›Crutch safety assessment

›Alternate assist devices consideration

Geriatric

›Older adult considerations

›Frailty and mobility risk

›Walker preference over crutches

›Home safety and supports

›Bone health evaluation triggers

›Fragility mechanism

›Osteoporosis workup referral

›Pain medication risk

›Delirium risk with opioids

›Renal function consideration with NSAIDs

Pediatrics

›Pediatric-specific issues

›Physeal injury concern

›Salter-Harris classification use

›Lower threshold for ortho follow-up

›Immobilization adaptation

10Background/b37

Epidemiology

›Pattern frequency highlights

›Metatarsal fractures as common forefoot injury

›Central metatarsals commonly injured with direct trauma

›5th metatarsal common with inversion mechanisms

›Stress fracture epidemiology

›Overuse sports and military training association

›Bone health and energy availability influence

Pathophysiology

›Force vector to pattern mapping

›Direct blow or crush

›Comminution risk

›Soft tissue swelling burden

›Twisting with axial load

›Tarsometatarsal ligament disruption risk

›Midfoot instability risk

›Inversion traction at 5th base

›Peroneus brevis avulsion mechanism

›Tuberosity fragment pattern

›Metaphyseal-diaphyseal junction vulnerability

›Relative hypovascular watershed region concept

›Nonunion risk in zone 2 and zone 3 patterns

Therapeutic Considerations

›Nonoperative vs operative rationale

›Central metatarsal nondisplaced patterns

›Functional immobilization and protected weight bearing

›Goal of maintaining metatarsal parabola

›First metatarsal importance

11Patient Discharge Instructions/pdi23

Copy discharge instructions

›Discharge instruction set

›Immobilization care

›Splint or boot kept clean and dry

›Do not insert objects into splint for itching

›Swelling control

›Elevation above heart as much as possible for 48-72 hours

›Ice 15-20 minutes at a time with skin protection

›Weight-bearing and activity

›Follow the instructed weight-bearing status

›Avoid sports and running until cleared

›Pain plan

›Acetaminophen as directed

›NSAID use only if safe for patient and approved

›Return to ED immediately for

›Increasing pain not controlled with medication

›New numbness or tingling in toes

›Toes becoming pale, blue, or cold

›Splint feeling too tight with worsening swelling

›Fever or spreading redness

›Drainage or foul smell from wound

›Follow-up

›Fracture clinic or orthopedics appointment timing as arranged

›Bring imaging reports if seen outside network

12References/r32

Clinical guidelines and key sources

›Reference set for metatarsal fracture management

›Orthopedic trauma texts and society guidance

›AAOS foot and ankle educational resources

›Orthopaedic Trauma Association teaching materials

›5th metatarsal base fracture literature

›Zone-based classification sources

›Nonunion and fixation outcome studies

›Midfoot and Lisfranc injury references

›Weight-bearing radiograph diagnostic approach sources

›CT and MRI utility studies

›Procedural sedation guidance

›ACEP procedural sedation clinical policy alignment

›Monitoring and safety standards references

Evidence grading notes

›Evidence interpretation conventions

›ACEP Level A

›High-quality evidence supporting recommendation

›Rare for fracture-specific ED immobilization choices

›ACEP Level B

›Moderate evidence or consistent lower-quality evidence

›Often applies to sedation and analgesia guidance

›ACEP Level C

›Consensus or expert opinion

›Common for immobilization choice specifics

›Class I recommendation

›Benefit clearly outweighs risk

›Apply to antibiotics for open fracture conceptually

Evidence & Review

Evidence & Review