summary Metatarsal fractures are among the most common injuries of the foot that may occur due to trauma or repetitive microstress. Diagnosis is made with plain radiographs of the foot. Treatment may be nonoperative or operative depending on the specific metatarsal involved, number of metatarsals involved, and fracture displacement. Epidemiology Incidence 5th metatarsal most commonly fractured in adults 1st metatarsal most commonly fractured in children less than 4 years old 3rd metatarsal fractures rarely occur in isolation 68% associated with fracture of 2nd or 4th metatarsal Demographics peak incidence between 2nd and 5th decade of life Etiology Mechanism direct crush injury may have significant associated soft tissue injury indirect mechanism (most common) occurs with forefoot fixed and hindfoot or leg rotating Associated conditions Lisfranc injury Lisfranc equivalent injuries seen with multiple proximal metatarsal fractures stress fracture consider metabolic evaluation for fragility fracture look for associated foot deformity seen at base of 2nd metatarsal in ballet dancers may have history of amenorrhea Anatomy Osteology shape and function similar to metacarpals of the hand first metatarsal has plantar crista that articulates with sesamoids widest and shortest bears 30-50% of weight during gait second metatarsal is longest most common location of stress fracture Muscles muscular balance between extrinsic and intrinsic muscles extrinsics include Extensor digitorum longus (EDL) Flexor digitorum longus (FDL) intrinsics include Interossei Lumbricals see Layers of the Plantar Foot Ligaments Metatarsals have dense proximal and distal ligamentous attachments 2nd-5th metatarsal have distal intermetatarsal ligaments that maintain length and alignment with isolated fractures implicated in formation of interdigital (Morton's) neuromas multiple metatarsal fractures lose the stability of intermetatarsal ligaments leading to increased displacement Blood supply dorsal and plantar metatarsal arteries Biomechanics see Foot and Ankle Biomechanics Classification Classification of metatarsal fractures is descriptive and should include location fracture pattern displacement angulation articular involvement Presentation History look for antecedent pain when suspicious for stress fracture Symptoms pain, inability to bear weight Physical Exam inspection foot alignment (neutral, cavovarus, planovalgus) focal areas or diffuse areas of tenderness careful soft tissue evaluation with crush or high-energy injuries motion evaluate for overlapping or malrotation with motion neurovascular semmes weinstein monofilament testing if suspicious for peripheral neuropathy Imaging Radiographs recommended views required AP, lateral and oblique views of the foot optional contralateral foot views stress or weight bearing radiographs CT not routinely obtained may be of use in periarticular injuries or to rule out Lisfranc injury MRI or bone scan useful in detection of occult or stress fractures Treatment Nonoperative stiff soled shoe or walking boot with weight bearing as tolerated indications first metatarsal non-displaced fractures second through fourth (central) metatarsals isolated fractures non-displaced or minimally displaced fractures stress fractures second metatarsal most common look for metabolic bone disease evaluate for cavovarus foot with recurrent stress fractures Operative percutaneous vs open reduction and fixation indications open fractures first metatarsal any displacement no intermetatarsal ligament support 30-50% of weight bearing with gait central metatarsals sagittal plane deformity more than 10 degrees >4mm translation multiple fractures techniques restore alignment to allow for normal force transmission across metatarsal heads antegrade or retrograde pinning lag screws or mini fragment plates in length unstable fracture patterns maintain proper length to minimize risk of transfer metatarsalgia outcomes limited information available in literature Complications Malunion may lead to transfer metatarsalgia or plantar keratosis treat with osteotomy to correct deformity Prognosis Majority of isolated metatarsal fractures heal with conservative management Malunion may lead to transfer metatarsalgia