Which type of therapy is most appropriate always depends on the type and severity of the fracture. When deciding on a therapy, the localization of the fracture, i.e. which metatarsal bones are affected and how many are affected, must always be considered. In the fifth metatarsal, the risk of developing a “false joint”, a so-called pseudarthrosis, is higher than for fractures of the other metatarsals, so that surgery is often necessary here.
Even if several bones of the metatarsus are fractured, surgery is often necessary. However, there is also the possibility of conservative therapy. This requires that the individual fracture pieces are not too much displaced from each other.
In the case of a displacement, an attempt can first be made to manually bring the bone pieces into their correct position (so-called reduction). However, this is often not possible satisfactorily, so that a shift usually requires surgery. Otherwise, a plaster cast is used in conservative therapy, which immobilizes the foot for a certain time and also leads to relief.
Alternatively, a special shoe or tape can be used to achieve the same effects. To ensure relief, the patient must walk with crutches. Immobilization is usually maintained for six weeks.
In addition, thrombosis prophylaxis is recommended due to immobility and the associated risk of blood clots forming in the lower leg veins. If swelling is present, it can be counteracted by elevating the leg and cooling it. In individual cases, lymph drainage may also be useful.
In most cases, physiotherapy is prescribed afterwards to prevent other muscle groups from regressing. Within the six weeks the load can be slowly increased. If the affected person’s bone healing slows down or does not heal at all, low-frequency ultrasound can be used. This stimulates the process of bone healing. This procedure is often used when surgery cannot be performed.
Surgical therapy
If the decision to undergo surgery is made, there are several treatment options available. During surgery, the bone is brought back into its correct anatomical position to ensure optimal healing and future full weight bearing. If the base of the fifth metatarsal bone is broken, a so-called “Jones fracture” (fracture of the Os metatarsal V), a screw can be implanted, which can be inserted during a minor operation.
First, a small wire is inserted into the metatarsal bone so that it can be brought back into its normal position. Using this wire, also known as a Kirschner wire, as a guide rail, the screw can now be inserted into a previously prepared canal. The screw directs the force from the tendon of the short fibula muscle across the fracture, allowing the bone to heal better.
Due to the very small skin incision, the risk of later wound infection is very low. However, if a comminuted fracture with many small fracture fragments is present, it is not possible to insert a screw alone, but a so-called open plate osteosynthesis must be performed. In this procedure, the small bone parts are brought back into their correct position and then a plate with screws is inserted to hold the individual fragments in the correct position.
In the case of a joint fracture, the individual joints are brought back into their original anatomical position, also by means of screws. If one has very complicated fractures, such as a dislocation fracture, an early operation is recommended. In this case, the access route is via the back of the foot, and screws and wires are also inserted to restore the original joint position.
In this case, the foot must be immobilized for at least eight weeks. After the period of immobilization, the screws and wires can be removed again in a second surgical procedure and a slow loading can be started. When full weight bearing can be achieved again depends on the degree of joint destruction and cannot be said in general terms.
In individual cases it is also necessary to insert a holding system through the skin from the outside for stabilization, which immobilizes the joint or fracture. This procedure is also called external fixator.This will be removed after several weeks, but it may be followed by further surgical treatment. The operations can be performed under local or general anesthesia.
This is decided individually depending on the patient and the respective previous illnesses. Possible complications during or after the various operations include bleeding or secondary bleeding, infection of the wound with disturbances in wound healing or injuries to neighboring structures (nerves, vessels, tendons, etc.) within the surgical area. However, when a decision on surgery is made by a physician, the benefits are usually far greater than the possible risks, since the fracture results in an incorrect load with sometimes great pain and also tissue damage due to the anatomically incorrect fracture fragments themselves.
