Metatarsal Fracture Fixation

Why this approach — at MOS

The Jones fracture is one of the most underestimated injuries I see. Patients are often initially told by emergency physicians to wear a boot and follow up — appropriate initial management — but then not clearly informed that an active person with a Jones fracture has a real risk of this fracture failing to heal with a boot alone. I discuss this with every Jones fracture patient: the option is boot versus surgery, and for athletes and active adults, the evidence favors surgery. Published healing rates for surgically treated Jones fractures exceed 90% in active patients, compared to substantially lower and more variable rates with casting alone.

Screw sizing is critical. The intramedullary canal of the fifth metatarsal is variable in width. I measure the canal on CT or careful X-ray review before surgery to select the largest screw that fits — a well-fitting screw compresses the fracture more effectively and is less likely to fail than a screw that is too small for the canal.

For Lisfranc injuries — where multiple metatarsals fracture or the tarsometatarsal ligaments rupture — surgical stabilization of the Lisfranc joint complex is required. Patients from Germantown and surrounding communities sometimes present with a missed Lisfranc injury initially diagnosed as a midfoot sprain; these patients need prompt evaluation to avoid permanent midfoot instability.

Who is a candidate?

Indications

• Jones fracture in an active or athletic patient (high non-healing rate without fixation)
• Jones fracture nonunion — failed healing after non-operative treatment
• Displaced first metatarsal fracture with significant angulation or shortening
• Multiple metatarsal fractures or Lisfranc injury pattern (associated tarsometatarsal instability)
• Second or third metatarsal stress fracture nonunion after 3–4 months of conservative treatment
• Significantly displaced shaft fractures of any metatarsal with plantar angulation > 10° or dorsal displacement

Contraindications

• Non-displaced, isolated metatarsal shaft fractures of the lesser metatarsals — these heal reliably with a boot
• Fifth metatarsal avulsion fracture at the styloid (different from Jones fracture) — this is a ligamentous avulsion that heals well non-operatively in most cases
• Active local infection or skin compromise at the operative site

Conservative Treatment First

The majority of metatarsal fractures do not require surgery. Non-displaced shaft fractures of the second, third, and fourth metatarsals are treated with a walking boot or stiff-soled shoe for 4–6 weeks. Weight-bearing is typically allowed as tolerated. Healing rates with conservative management for these fractures are excellent.

Fifth metatarsal avulsion fractures (at the very tip of the styloid process — a different location than Jones fractures) heal non-operatively in almost all patients with a boot or supportive shoe. The key decision point is distinguishing the avulsion fracture from the Jones fracture — they have very different locations on X-ray and very different treatment requirements.

Stress fractures of the metatarsals are initially treated with activity modification, boot immobilization, and sometimes bone stimulation. Surgery is considered after 3–4 months of failed non-operative treatment or for high-risk stress fracture locations.

The procedure

What Is Metatarsal Fracture Fixation?

Metatarsal fracture fixation is surgery to stabilize a broken metatarsal bone in the foot using a screw, plate, or pin. Surgery is needed for displaced fractures, Jones fractures (a specific break at the base of the fifth metatarsal with a high non-healing rate), and stress fractures that have failed conservative management.

The foot has five metatarsal bones, running from the midfoot (tarsal bones) to the bases of the toes. Each metatarsal can fracture from direct impact, twisting injuries, or repetitive stress (stress fractures). Most metatarsal fractures — including simple, non-displaced shaft fractures — heal reliably without surgery in a boot or cast. However, specific fracture types in specific locations require surgery because the blood supply is poor, the forces across the fracture prevent healing, or displacement would cause a permanent deformity.

Jones fracture is the most commonly surgically treated metatarsal fracture. It occurs at the metaphyseal-diaphyseal junction of the fifth metatarsal — approximately 1.5 cm from the base — in a region of poor blood supply. Without surgical fixation, Jones fractures have a high rate of delayed healing (malunion) or non-healing (nonunion) in active patients. The standard treatment for Jones fractures in athletes or active individuals is intramedullary screw fixation.

Other metatarsal fractures requiring surgery include displaced fractures of the first metatarsal (which bears significant weight-bearing load), multiple metatarsal fractures (which suggest a Lisfranc injury pattern), and metatarsal stress fractures that have failed non-operative management.

What Happens During Metatarsal Fracture Fixation?

Surgery is performed at an ambulatory surgery center as an outpatient procedure.

Anesthesia: A regional ankle block provides anesthesia for the foot. Light sedation is added for patient comfort during block placement. No general anesthesia is required for most cases.

Jones Fracture — Intramedullary Screw Fixation: A small (1–2 cm) incision is made over the lateral base of the fifth metatarsal. The fracture site is identified under fluoroscopy. A guide wire is placed under fluoroscopy from the base of the fifth metatarsal down the medullary canal, passing through and across the fracture site into the metatarsal shaft. The canal is over-reamed to the appropriate screw size. A cannulated partially threaded lag screw (typically 4.5–6.5 mm) is advanced over the guide wire, with the threads crossing the fracture — the screw compresses the two fracture ends together. Fluoroscopy confirms screw length, position, and fracture reduction.

Displaced Shaft Fractures — Plate or Pin Fixation: For displaced first metatarsal fractures, a dorsal incision over the fracture is made. The fracture is reduced and held with a small locking plate and screws. For lesser metatarsal fractures with plantar displacement, a small K-wire or plate may be used depending on fracture pattern.

Stress Fracture Fixation: Technique is the same as for Jones fracture fixation when the stress fracture is at the same location. For diaphyseal stress fractures, intramedullary screw or plate fixation is used based on fracture anatomy.

Closure: Small incision closed with sutures. Compressive dressing and non-weight-bearing instructions.

Recovery timeline

Frequently Asked Questions