Metatarsal fractures (1st-5th)MANAGEMENT

FOOT · 12 SECTIONS

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469 items

☷ Legend

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

›Trend after splint

›Sensation

›Deep peroneal distribution

›Superficial peroneal distribution

›Motor

›Great toe extension

›Great toe flexion

Key concepts

›Pattern recognition and associated injury mapping

›Multiple metatarsal fractures as midfoot instability marker

›Lisfranc injury consideration

›Forefoot splay widening

›5th metatarsal base region as distinct entities

›Tuberosity avulsion

›Jones fracture

›Proximal diaphyseal stress fracture

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

›5th metatarsal nonunion risk

›Bone health risk

›Prior fragility fracture

›Chronic glucocorticoids

›Anticoagulants

›Expanding hematoma concern

›Procedural bleeding risk

›Symptom red flags

›Numbness or tingling

›Worsening after splint

›New onset after swelling

›Severe escalating pain

›Pain with passive toe stretch

›Tight compartments sensation

›Midfoot pain or plantar ecchymosis

›Lisfranc concern

›Weight-bearing intolerance

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

›Plantar sensation

›Motor exam

›Toe extensors

›Toe flexors

›Compartment syndrome indicators

›Pain out of proportion

›Escalating opioid requirement

›Pain with passive stretch

›Tense forefoot compartments

›Firm swelling

›Worsening paresthesia

PITFALLS

›Common miss patterns

›Lisfranc injury with normal non-weight-bearing radiographs

›Persistent midfoot pain as trigger for weight-bearing views

›Plantar ecchymosis as high-risk sign

›Stress fracture with initial negative radiographs

›Localized focal tenderness

›Pain with activity progression pattern

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

›Toe deviation or instability

›Infection and inflammatory mimics

›Cellulitis

›Diffuse erythema and warmth

›No focal bony tenderness

›Gout

›First MTP involvement

›Episodic flares pattern

Coding alignment

›ICD-10 and SNOMED CT mapping examples

›ICD-10 S92.3

›Fracture of metatarsal bone

›Laterality and encounter modifiers required

›ICD-10 S92.35

›Fracture of fifth metatarsal bone

›Subclassification by specific site in documentation

›SNOMED CT concept families

›Metatarsal fracture disorder

›Fifth metatarsal fracture disorder

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

›Alignment red flags

›Widening between 1st and 2nd metatarsal bases

›Fleck sign at Lisfranc region

MRI

›Indications

›Suspected stress fracture with negative X-ray

›Focal tenderness with activity pain

›High-risk athlete

›Suspected Lisfranc ligament injury without clear X-ray findings

›Midfoot pain and plantar ecchymosis

›Persistent inability to bear weight

›Utility notes

›Early marrow edema detection

›Stress reaction identification

›Earlier diagnosis than radiographs

›Soft tissue detail

›Ligament disruption assessment

›Tendon injury assessment

›Indications

›Suspected Lisfranc injury needing surgical planning detail

›Subtle diastasis assessment

›Small avulsion fragments detection

›Intra-articular extension concern

›Metatarsal head fracture pattern

›Base fracture with tarsometatarsal joint involvement

›Protocol pearls

›Thin-slice midfoot CT

›Multiplanar reconstructions

›Joint surface congruity review

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

›Early follow-up within 3-7 days

›Midfoot injury reassessment

›Stable nondisplaced central metatarsal fracture

›Follow-up within 7-14 days

›Repeat imaging consideration if pain persists

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

›Threatened dorsal skin tenting

›Gentle longitudinal traction

›Restore forefoot alignment

›Gross deformity affecting neurovascular status

›Immediate traction and alignment

›Post-reduction neurovascular reassessment

›Analgesia and anesthesia options

›Oral and parenteral analgesia ladder

›Acetaminophen PO 1000 mg

›Ibuprofen PO 400 mg

›Opioid for severe pain

›Morphine IV 0.05 mg/kg

›Re-dose every 10-15 minutes to effect

›Procedural sedation when required

›Monitoring and airway readiness

›Continuous pulse oximetry

›Capnography

›Resuscitation equipment at bedside

›Post-reduction requirements

›Post-reduction radiographs

›Confirm alignment

›Document displacement change

›Immobilization in stable position

›Splint or boot selection

›Elevation plan

Open fracture medications and timing

›Antibiotics and tetanus bundle

›Antibiotics timing goal

›As early as possible after recognition

›Do not delay for imaging if obvious open injury

›First-line antibiotics by contamination risk

›Cefazolin IV 2 g

›Repeat dosing per local protocol if prolonged transfer

›Severe beta-lactam allergy alternative

›Clindamycin IV 900 mg

›Add gram-negative coverage per local protocol for high-grade injuries

›Tetanus prophylaxis

›If unknown or incomplete immunization, tetanus vaccine

›If dirty wound and uncertain immunization, add tetanus immune globulin per protocol

DVT prophylaxis when relevant

›Lower limb immobilization thrombosis risk assessment

›High-risk features

›Prior VTE history

›Active cancer

›Contraindications

›Active bleeding

›High bleeding risk anticoagulation interaction

›Plan alignment with local protocol

›Document risk-benefit rationale

›Follow-up for reassessment

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

›Splint padding for skin protection

›Weight-bearing guidance with caregiver support

›Nonaccidental trauma consideration when appropriate

›Mechanism-history mismatch

›Multiple injuries pattern

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

›Higher functional load role

›Lower tolerance for displacement

›5th metatarsal zone 2 and zone 3

›Higher delayed union and nonunion risk

›Early ortho involvement and fixation discussion in athletes

›Alignment consequences

›Plantarflexed metatarsal head

›Transfer metatarsalgia risk

›Callus formation risk

›Dorsal angulation at neck

›Altered forefoot loading

›Shoe wear intolerance

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

›Class IIa recommendation

›Benefit probably outweighs risk

›Apply to early ortho follow-up for high-risk 5th metatarsal patterns

›Class IIb recommendation

›Benefit may outweigh risk

›Apply to advanced imaging selection when radiographs equivocal

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed March 6, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.