In this section
Metatarsal fractures are common in the paediatric population and rarely require operative management.
Care should be taken in differentiating an avulsion fracture of the fifth metatarsal from a Jones fracture, due to the risk of nonunion in the latter.
Metatarsal fracture are classified by the following:
Fractures of the metatarsals are common injuries in children.
Children 5 year or younger are more likely to fracture 1st metatarsal, whereas children older than 5yrs are more likely to injure 5th metatarsal
Common mechanisms of injury include:
Fractures of the 2nd, 3rd and 4th metatarsals rarely occur in isolation and commonly result in fracture/s of the adjacent metatarsals. Occasionally, this is part of a LisFranc injury (tarso-metatarsal fracture-dislocation)
The forefoot will usually appear swollen with bruising, and the patient may be unwilling or unable to bear weight.
Children with pain, swelling and/or deformity to forefoot require foot radiographs.
Plain film – anterior-posterior, oblique and lateral views
CT is seldom necessary. The exception is a suspected Lisfranc injuries, where it should be arranged in consultation with orthopaedics.
Operative management is required for:
- Significantly angulated or displaced fractures
- Multiple metatarsal fractures that are unstable
- Jones fractures. These are associated with a high incidence of non-union and re-fracture post cast removal due to the tenuous blood supply of this area. They may subsequently require fixation.
Consultation on the day of presentation is required for:
- Open fractures
- Displaced fractures (>20 degrees of angulation or significant displacement)
- Multiple metatarsal fractures
- Suspected Lisfranc injury
- Jones fractures
- Neurovascular compromise
Avulsion fracture at the base of the 5th metatarsal tubercle
Firm soled shoe or walking boot (CAM) if more support is required. Wear until able to walk without symptoms. This is usually 2-3 weeks.
No follow up required.
(If there in ongoing pain at the site at 2 weeks, see GP).
Jones Fracture of the proximal diaphyseal region
Refer to orthopaedics
Prone to non-union due to tenuous vascular supply
Children >13yrs prone to re fracture
Follow up in fracture clinic in 7-14 days
Early operative fixation will be considered at this appointment.
Metatarsal diaphysis- Undisplaced
Firm soled shoe or walking cast (CAM)
Refer to orthopaedics if 20degress or more of angulation
No follow up required if undisplaced single metatarsal
Metatarsal diaphysis- Displaced
Minimally displaced- Below knee backslab
If completely displaced and / or 20degress or more of angulation, refer to orthopaedics
Follow up in fracture clinic within 7 days
Fractures involving the physeal plate (Salter Harris I-IV)
Below knee backslab
(consult orthopaedics if displaced)
May appear on X-ray as subtle fracture of first proximal metatarsal as described earlier
CT foot; specialised orthopaedic management and follow-up.
Boutis, K., 2018. Metatarsal and toe fractures in children, UpTodate
Fox, S.M., 2018. Metatarsal fractures in children, PEM
Mahan, S., Hoellwarth, J., Spencer, S., Kramer, D., Hedequist, D., and Kasser, J. 2015 Journal of pediatric orthopaedics, 35, 3 296-302
Singer, G., Cichocki, M., Schalamon, J., Eberl, R., and Hollwarth, M. 2008 A study of metatarsal fractures in children. The journal of bone and joint surgery 90:772-6