The metatarsal bones are the long bones in the middle of the foot. Each metatarsal bone has a base, a shaft, a neck, and a head. The fifth metatarsal is the last bone at the outside of the foot, and most breaks of the fifth metatarsal occur at the base.
The majority of fifth metatarsal fractures are treated without surgery. However, certain situations may require surgical treatment. Your foot and ankle orthopaedic surgeon can perform surgery to help the bone heal in a correct position and help you return to full function. Surgery may
reduce the time needed for immobilization and improve the chance of healing compared to non-surgical treatment.
The base of the fifth metatarsal is divided into three fracture zones.
A Zone 2 fracture at the base of the fifth metatarsal
Surgery is not indicated in a fracture where there is an infection or severely damaged soft tissue. Zone 1 fractures that are not displaced do not require surgery, and most fifth metatarsal shaft fractures without significant displacement do not
require surgery.
There are many surgical options for fifth metatarsal fractures. One popular technique (for Zone 2 and 3 fractures) is a surgery where a screw is placed lengthwise within the bone (intramedullary screw fixation). Fractures of the shaft of the metatarsal are fixed with a plate and screws. These procedures can be performed under general or regional anesthesia with the patient going home the same day.
Specific Techniques
The surgical incision for an intramedullary screw is typically no more than a stab incision at the base of the fifth metatarsal. An X-ray machine is used to guide the screw placement. The screw threads cross the fracture site and allow for the fracture ends to be squeezed together. If bone grafting is needed, such as in a chronic fracture that has failed non-surgical treatment, then a separate incision may be needed over the fracture to insert the bone graft or bone graft substitute.
A fifth metatarsal base fracture treated with screw fixation
For the first 7-14 days after surgery, you may be allowed to bear weight through your heel but typically not through the front of your foot. This could last as long as six weeks (sometimes longer based on healing and other factors such as diabetes). Weight bearing in a removable walking boot is allowed after that. You can expect to return to full activity 3-4 months after a typical fracture. This includes returning to sports. Some fractures may require bone grafting and have longer recoveries. The screw is not usually removed unless it causes discomfort.
All surgeries come with possible complications, including the risks associated with anesthesia, infection, damage to nerves and blood vessels, and bleeding or blood clots.
Some complications can result in the need for repeat surgery. The metatarsal fracture may not heal and can become a nonunion. Another rare but serious complication is a re-fracture after fixation. Some patients may be at greater risk for poor healing
or re-fracture due to the shape of their foot. A high-arched foot or a heel that turns in can put extra pressure on the fifth metatarsal and may require other surgical procedures to change the architecture of the foot.
Most Zone 2 breaks will go on to heal after 12 weeks with appropriate treatment. The nonunion rate for these fractures may still be as high as 15-20%. A fracture that fails to heal and is painful may require surgical treatment. The surgery can be more difficult at that point and may require a bone graft.
The need for surgery in these fracture types depends on the degree of deformity. Surgery may be recommended if you have rotational deformity of the little toe, angulation of the shaft of the metatarsal with a change in the shape of the foot, or shortening as a result of the fracture.
There is some evidence that electromagnetic bone stimulation may be useful in increasing healing rates and reducing time for healing in Zone 2 fractures of the base of the fifth metatarsal. However, more evidence is needed before these therapies can be recommended to all patients with such fractures.
This is a relatively new and not well researched area at this time. These injections are not typically covered by insurance and can be quite expensive without data to suggest that they improve results. You should speak with your foot and ankle orthopaedic surgeon who is best educated to evaluate the full spectrum of care including non-surgical and surgical options.
Original article by Gowreeson Thevendran, FRCS
Contributors/Reviewers: Jeffrey Feinblatt, MD; Jason Tartaglione, MD
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