SUMMARY
Metatarsal fractures represent a broad spectrum of forefoot injuries arising from either acute trauma or repetitive mechanical loading. They constitute a significant proportion of foot fractures encountered in clinical practice. Standard foot radiographs are usually sufficient to establish the diagnosis. Treatment strategies vary from conservative functional management to surgical fixation and are primarily determined by the involved metatarsal, the number of fractures, fracture stability, and displacement.
EPIDEMIOLOGY
Incidence
In adults, the fifth metatarsal is the most frequently fractured ray
In children younger than four years, fractures most commonly involve the first metatarsal
Fractures of the third metatarsal rarely occur in isolation and are commonly associated with injuries of adjacent rays
Approximately two-thirds are accompanied by fractures of the second or fourth metatarsal
Demographics
Peak incidence is observed between the second and fifth decades of life
ETIOLOGY
Mechanisms of Injury
Direct trauma, such as crush injuries, often results in comminution and may be associated with significant soft-tissue damage
Indirect mechanisms, which are more common, occur when the forefoot is fixed while rotational forces are applied through the hindfoot or leg
Associated Conditions
Lisfranc injuries should always be excluded, particularly in patients with multiple proximal metatarsal fractures
Stress fractures may occur in the setting of repetitive loading and should prompt evaluation for:
metabolic bone disease in fragility patterns
underlying foot deformities
Stress fractures at the base of the second metatarsal are frequently observed in ballet dancers and may be associated with menstrual irregularities or low energy availability
ANATOMY
Osteology
Metatarsals share structural and functional similarities with the metacarpals of the hand.
The first metatarsal is the shortest and widest, characterized by a plantar crista that articulates with the sesamoid complex
It bears approximately 30–50% of body weight during gait
The second metatarsal is the longest and is the most common site of stress fractures
Musculature
Metatarsal alignment and loading are influenced by the balance between extrinsic and intrinsic musculature:
Extrinsic muscles include the extensor and flexor digitorum longus
Intrinsic muscles include the interossei and lumbricals
Ligamentous Support
Dense ligamentous attachments at the proximal and distal ends provide stability.
Intermetatarsal ligaments between the second and fifth rays help preserve length and alignment in isolated fractures
Loss of this ligamentous support in multiple fractures increases the risk of displacement
Blood Supply
Vascularity is provided by dorsal and plantar metatarsal arteries
Biomechanics
The metatarsals play a critical role in load transmission and propulsion during gait. Disruption of length or alignment alters plantar pressure distribution and may result in transfer metatarsalgia.
CLASSIFICATION
Metatarsal fractures are best described rather than rigidly classified. A comprehensive description should include:
fracture location
fracture pattern
degree of displacement
angulation
articular involvement
CLINICAL PRESENTATION
History
Antecedent forefoot pain should raise suspicion for stress-related injury
Symptoms
Forefoot pain and difficulty with weight bearing are common presenting complaints
Physical Examination
Assessment of overall foot alignment, including cavovarus or planovalgus deformities
Identification of focal versus diffuse tenderness
Careful evaluation of soft tissues, particularly following high-energy or crush mechanisms
Motion and Neurovascular Assessment
Active and passive motion should be evaluated for malrotation or overlap of the toes
Sensory testing is recommended when peripheral neuropathy is suspected
IMAGING
Radiographs
Standard anteroposterior, lateral, and oblique views of the foot are required
Comparison views or weight-bearing radiographs may be useful in selected cases
Advanced Imaging
CT is not routinely indicated but may assist in periarticular injuries or suspected Lisfranc involvement
MRI or bone scintigraphy is valuable for detecting occult fractures or stress reactions
TREATMENT
Nonoperative Management
Functional treatment with a stiff-soled shoe or walking boot and weight bearing as tolerated is appropriate for:
nondisplaced fractures of the first metatarsal
isolated, minimally displaced fractures of the second through fourth metatarsals
stress fractures, most commonly involving the second metatarsal
Recurrent stress fractures should prompt evaluation for cavovarus alignment and metabolic abnormalities.
Operative Management
Indications
Open fractures
Any displacement of the first metatarsal due to its load-bearing role and lack of intermetatarsal ligament support
Central metatarsal fractures with:
sagittal plane angulation exceeding 10 degrees
translation greater than 4 mm
Multiple metatarsal fractures with loss of alignment
Surgical Principles
Restoration of length, alignment, and rotation to ensure normal load transmission across the metatarsal heads
Fixation options include:
antegrade or retrograde pinning
lag screw fixation
mini-fragment plating for length-unstable patterns
Maintaining appropriate length is essential to minimize the risk of transfer metatarsalgia.
COMPLICATIONS
Malunion, which may result in plantar keratosis or transfer metatarsalgia
Corrective osteotomy may be required for symptomatic deformity
PROGNOSIS
The majority of isolated metatarsal fractures heal successfully with conservative treatment. Long-term morbidity is uncommon but may occur in cases of malunion or unrecognized associated injuries.