What are Metatarsal Fractures?
There are 5 metatarsals in your foot. These bones join your midfoot bones and the toe bones. Fractures of the metatarsals are quite common. They occur with a direct injury or a twisting injury to the foot. Sometimes however metatarsal fractures can be due to overuse, which are commonly known as a “stress fracture”.
Although fracturing a metatarsal can be quite painful—it rarely requires surgery. In most cases, a fracture will heal with rest and a change in activities.
Types of Metatarsal Fractures
Fractures may either be “non-displaced,” where the bone shows a crack but the ends of the bone are together, or “displaced,” where the end of the broken bones have partially or completely separated. Fractures can also be divided into “closed fractures” where the skin is not broken and “open fractures” where the skin is broken, and the wound extends down to the bone. Open fractures are serious as once the skin is broken, bacteria can enter the wound and cause infection in the bone. Immediate treatment is required to prevent infection.
Some metatarsal fractures are “stress fractures”. Stress fractures are small cracks in the surface of the bone that may extend and become larger over time. Stress fractures are typically caused by repetitive activity or pressure on the forefoot. They are common in runners and athletes who participate in high-impact sports such as soccer and basketball. High-impact activities like running can lead to stress fractures in the metatarsals. A stress fracture can also come from a sudden increase in physical activity or a change in your exercise routine.
Fifth metatarsal fractures most commonly arise through the base of the bone. This usually occurs from an injury where the foot and ankle are twisted downward and inward. In this type of injury, the tendon that attaches to the base of the fifth metatarsal may stretch and avulse a fragment of bone away from the base, also called an avulsion fracture. This is also sometimes called a “ballerina fracture” or “dancer’s fracture” because of the “pointe” position that ballet dancers assume when they are up on their toes.
How are Metatarsal Fractures Diagnosed?
Your specialist will take a history to find out how your foot was injured and ask about your symptoms. They will then examine your foot and may compare it to the foot on the opposite side. During the exam, your specialist will look for swelling, bruising, discoloration, any deformity and the integrity of the skin.
It is likely your specialist will request an X-ray, as most fractures are visible on this routine scan. A stress fracture, however, may start as a tiny crack in the bone and may not be visible on a first x-ray. If your doctor suspects a stress fracture but cannot see it, they may recommend an MRI scan. An MRI can detect changes in the bone that may indicate a fracture. Unlike an x-ray, there is no radiation with an MRI.
What are the treatment options?
Treatment of metatarsal fractures depends on their location and type.
Most metatarsal fractures can be treated non-surgically, with an initial period of elevation and limited weight bearing and following the RICE (Rest, Ice, Compression, Elevate) protocol. This is followed by gradual weight bearing, as tolerated, in a walking boot. Surgery is not often required. You will need to wear the boot for about 4 weeks and your specialist will then request follow up X-rays. You may have to wean from the boot into a trainer and you may need a period of physiotherapy and rehabilitation.
If you have fractured several metatarsals at the same time and your foot is deformed or unstable, surgery may be necessary.
During the procedure, under an anesthetic your surgeon will make an incision in your foot, then insert pins or plates and screws to hold the bones in place while they heal. You will be immobilized in a plaster cast for 4 weeks and then allowed to bear weight in a boot. It will take about 6 weeks for the bones to heal and about 3 months for the swelling to settle. Even with proper healing, your foot may be swollen for several months and it may be hard to find a comfortable shoe. Your specialist will tell you when it is safe to resume activities and return to sports. If you experience any pain, however, you should stop your activity and notify your doctor. Returning to activities too soon can put you at risk for re-injury.
Although not done routinely, you may need your metal plates or screws removed later.