Patients with fifth metatarsal fractures typically have tenderness with palpation over the area of injury, with edema and ecchymosis when the injury is acute. Evidence-based guidelines recommend x-rays of the foot, including anteroposterior (AP), lateral, and oblique views.2-4 One study supports the use of an additional x-ray—an AP view of the ankle, including the base of the fifth metatarsal—if clinical suspicion is high and initial radiographs are negative or inconclusive.10
Shaft fractures may not be seen on x-rays in the first 3 weeks, but a periosteal reaction or linear lucency near the symptomatic area may be noticeable on radiographs taken at a later date.11 If this overuse injury seems likely but does not show up on the initial x-rays, however, magnetic resonance imaging (MRI) or a technetium bone scan can reliably identify a stress fracture.9
How to treat, when to refer
Treatment of fifth metatarsal fractures range from conservative to surgical, depending on the type (and extent) of injury (TABLE 2).1,5,6,12-14
TABLE 2
Nondisplaced avulsion fractures can be treated conservatively, with relative immobilization. In one prospective study, the use of a stiff-soled shoe, with weight-bearing as tolerated, was associated with excellent long-term outcomes.11 Orthopedic referral for probable reduction and fixation is indicated for avulsion fractures that are comminuted or >2 mm displaced, or have >30% involvement of the cubometatarsal joint.15,16
Jones fractures are known for prolonged healing and nonunion, as well as a high rate of complications. If the fracture is nondisplaced, start with conservative treatment, consisting of nonweight-bearing immobilization for 6 to 8 weeks, with additional immobilization dependent on radiographs. One randomized controlled trial of patients with Jones fractures showed a relatively high failure rate (44%) with casting; patients for whom casting was successful still had a median time to bony union of 15 weeks.17 Specialty consultation may be needed when there is fracture displacement, absence of bony union, or high clinical concern.6,17
Is your patient an athlete? Surgical fixation is favored for injured athletes with Jones fractures because failure rates are lower and both clinical union and return to play are shorter.18,19 In a case series involving 23 athletic patients with Jones fractures, the success rate for immediate surgical screw fixation approached 100% within 6 to 8 weeks.18
Nondisplaced shaft fractures may be treated conservatively, with 6 to 8 weeks of immobilization with a protective orthosis. An orthopedic referral is recommended for patients whose fractures have >3 mm displacement or >10 degree angulation.15
Navicular fractures are overuse injuries
The navicular is predisposed to stress injury because the central third of the bone is relatively avascular. In addition, the navicular is the area of greatest stress and impingement between the talus and cuneiform bones during repetitive foot strikes.12,20 Navicular fractures occur predominantly in track and field athletes.12
Patients presenting with a navicular stress fracture often report a gradual onset of vague dorsal midfoot pain associated with their workout.17 Examination typically reveals tenderness on palpation over the dorsal aspect of the navicular; passive eversion and active inversion may be painful, but edema and ecchymosis are usually absent.21
When pain is elicited by palpation of the navicular, radiographs are recommended.2,6 X-rays have a relatively low sensitivity (33%), however, for detecting acute navicular stress fractures. If initial radiographs are negative but there is a high clinical suspicion, advanced studies—with either MRI or a technetium bone scan—are recommended for a definitive diagnosis.12,22 While both are highly sensitive for navicular stress fractures, MRI provides greater specificity and anatomic detail.23
Most navicular fractures are nondisplaced
Nondisplaced navicular fractures can be treated conservatively, with nonweight-bearing immobilization for 6 to 8 weeks followed by progressive activity.24 Prospective studies have found that conservative treatment has a high success rate, with athletes usually able to return to play within 6 months.22,24,25 If tenderness remains after 6 to 8 weeks of immobilization, treatment choices are continued immobilization with no weight-bearing or orthopedic referral.26
Referral is indicated for navicular fractures that are comminuted or displaced, or involve more than one bone cortex.26 Surgical screw fixation may be recommended for navicular stress fractures in selected athletes because of its high success rate—and likelihood of an earlier return to play.27
Talar injuries are characterized by persistent pain
Injuries to the talus commonly occur at the same time as ankle sprains and may cause persistent pain, even after the sprain has healed.28 Evidence suggests that up to 90% of residual pain is related to an underlying cartilage injury.29,30 Most talar injuries are associated with the disruption of the cartilage overlaying the talar dome, which may lead to osteochondritis dissecans.29 Subtle talus fractures are also a concern after an acute ankle injury.