Acute Fifth Metatarsal Tuberosity Fractures: A Systematic Review of Nonoperative Treatment

Abstract

Objective: Acute metatarsal fractures are a common lower extremity injury. Although surgery may be recommended in specific cases, most are treated nonoperatively. Treatment protocols vary significantly among practitioners, with no consensus on the most efficacious approach. This systematic review aims to identify the effect of treatment protocols on union rate and functional outcome after an acute fifth metatarsal tuberosity fracture. Literature Survey: Multiple databases, including CINAHL, EMBASE, MEDLINE, and the Cochrane CEntral Register of Controlled Trials (CENTRAL) were searched from database inception to March 4, 2018 to identify clinical studies addressing nonoperative management of metatarsal fractures reporting nonunion, pain, and/or length of recovery. Methodology: Two reviewers independently completed title, abstract, and full-text screening. Data abstraction was completed in duplicate. Outcome measures and complications were descriptively analyzed. Synthesis: A total of 1941 studies were eligible for screening. Seven studies (four randomized controlled trials and three prospective cohort studies) satisfied inclusion criteria. This resulted in a total of 388 patient with acute fifth metatarsal tuberosity fractures in 12 different treatment arms, with the most common treatment including plaster casting (7). The mean age was 42 years (27 to 56 years), and the overall nonunion rate was low (1.1%). Four unique functional scores were reported across all studies, and all showed good to excellent short-term results. The overall qualities of studies were moderate, with particular limitations in randomization and concealment allocation. Conclusion: Most acute fifth metatarsal tuberosity fractures heal well, with good-to-excellent functional outcomes with nonoperative treatment, regardless of technique. We recommend a conservative rehabilitation framework, including 2 to 3 weeks of immobilization in a walking cast, followed by gradual increase in activity and strengthening until clinical union is achieved.

Fifth metatarsal fractures: an update on management, complications, and outcomes

“…Historically, surgery was recommended for a displacement greater than 2 mm, or comminution in Zone 1 fractures and various operative interventions have been described (76,77,78,79,80,81). A prospective study showed no benefit of immobilization vs symptomatic treatment for avulsion fractures of the base of the fifth metatarsal (48), while a recent systematic review opted for non-operative treatment, regardless of technique (82). Involvement of more than one-third of the cubometatarsal joint may require open reduction and screw fixation using tension band wiring or a small fragment screw (2.0-2.7 mm) (40,83,84); however, the latter is found to be superior (83).…”

Proximal Fifth Metatarsal Fractures: A Retrospective Study of 834 Fractures With a Minimum Follow-up of 5 Years

“…10,13,14,22,35,36 In accordance with other authors' findings, our results support a nonoperative treatment approach for nondisplaced zone 1 fractures. 1,3,5,8,10,18 Previous studies have indicated better results for WBAT strategy regarding pain, function, and time to fracture union compared with NWB. 7,14,29,36 Our findings show no differences between these strategies, supporting WBAT to be the treatment of choice for these fractures.…”

“…3,19 Nonoperative treatment of nondisplaced zone 1 fractures yields good outcomes with both symptomatic treatment and cast immobilization, whereas displaced zone 1 fractures could benefit from operative treatment. 1,3,4,8,10,18 Zone 2 and zone 3 fractures usually are nondisplaced, and both operative and nonoperative treatment have been advocated. Several studies argue for operative fixation to be the treatment of choice in young and athletic patients because of anticipated higher union rates and a shorter time to union.…”

Fractures of the Base of the Fifth Metatarsal Bone

“…Avulsion fractures of the tuberosity have good healing potential, and nonoperative treatment is generally recommended 53 . This is particularly true for extra-articular and nondisplaced fractures 2,12,51,85-97 . In the nonathletic population, excellent results with union rates of 100% have been reported for displaced fractures and fractures involving the articular facet to the cuboid 13,52,94,98-100 .…”