Metatarsals 1

Modern Study Review (AI-Generated)

High-Yield Summary

The first metatarsal (MT1) plays a critical role in foot biomechanics, bearing significant load during gait and push-off. Accurate diagnosis and management of MT1 fractures are essential to prevent long-term deformity, plantar pressure ulcers, and functional impairment. Modern treatment emphasizes early mobilization with rigid fixation for displaced fractures, while minimally displaced injuries may be managed conservatively. Understanding fracture zones, especially in the fifth metatarsal, and associated soft tissue injuries like turf toe is vital for optimal outcomes.

Key Diagnostic Findings

Anatomy

• First Metatarsal (MT1): Largest and strongest metatarsal; critical for weight-bearing and propulsion.
• Soft Tissue Restraints at First MTP: Capsule, medial/lateral collateral ligaments, extensor hallucis longus (EHL) expansion dorsally, volar plate, flexor hallucis longus (FHL), flexor hallucis brevis (FHB), and conjoined tendons with abductor and adductor hallucis.
• Sesamoids: Medial sesamoid more commonly fractured than lateral.

Clinical Presentation

• Pain localized to the first metatarsal or great toe, swelling, and difficulty with push-off.
• Sagittal plane deformity may cause plantar pressure and ulceration.
• Turf toe presents as hyperextension injury of the first MTP joint with pain and swelling.
• Fifth metatarsal base fractures present with lateral foot pain; differentiation between zones is critical.

Imaging

• X-rays: AP, lateral, and oblique foot views to evaluate fracture displacement and alignment.
• Advanced Imaging: CT or MRI may be used for complex fractures, nonunions, or soft tissue assessment (e.g., sesamoid fractures, turf toe).
• Radiographic Signs:
• Sagittal plane displacement of MT1 is poorly tolerated.
• Sesamoid fractures may be subtle; assess medial sesamoid closely.
• Fifth metatarsal fractures classified by location (zones 1-3).

Classification Systems

Current Gold Standard Treatment

Non-operative Indications and Treatment

• Minimally displaced or nondisplaced shaft and neck fractures of MT1:
• Protected weight-bearing in a walking boot or cast for 2-4 weeks.
• Early ambulation encouraged as tolerated to prevent stiffness and muscle atrophy.
• Zone 1 fifth metatarsal avulsion fractures:
• Immobilization in a walking cast for 2-3 weeks, then transition to supportive footwear.
• Sesamoid fractures:
• Walking cast for 3-4 weeks followed by stiff-soled shoe.
• Turf toe (first MTP sprain):
• Rest, ice, NSAIDs, and stiff-soled shoe or orthotic to limit hyperextension.

Operative Indications and Treatment

• Displaced first metatarsal fractures with sagittal plane deformity:
• Open reduction and internal fixation (ORIF) with rigid fixation to restore alignment and allow early mobilization.
• Unstable fractures after closed reduction:
• Percutaneous pinning or ORIF.
• Fifth metatarsal Zone 2 and 3 fractures:
• Nonunion risk warrants early surgical fixation with intramedullary screw and possible bone grafting for Zone 3 stress fractures or established nonunions.
• Irreducible first MTP dislocations:
• Surgical reduction via dorsal approach due to soft tissue interposition (e.g., FHB tendons).
• Symptomatic sesamoid fractures refractory to conservative care:
• Surgical excision (medial sesamoid via medial approach; lateral via dorsal first web space).

Modern Complications & Outcomes

Complications

Outcomes

• Early rigid fixation of displaced MT1 fractures yields excellent functional outcomes with return to normal gait and minimal pain.
• Conservative treatment of nondisplaced fractures generally results in good healing and function.
• Fifth metatarsal fractures in Zone 2 and 3 require careful monitoring; surgical fixation improves union rates and reduces time to return to activity.
• Turf toe injuries respond well to conservative management but may cause chronic pain if untreated.
• Sesamoid fractures have good prognosis with conservative care; excision reserved for persistent symptoms.

Classic Clinical Notes

Metatarsals 1

Reference: Heckmann, James, in Rockwood and Green, 1996, Chapter 32

Main Message

• The first MT is the most important, and needs to be treated with some caution.
• Lookout for sagittal deformity – these can cause pressure problems on the sole of the foot.

Points of Interest

• Be careful to look at the entire foot!
• Nondisplaced and minimally displaced shaft and neck fractures can be treated in a walking cast 2-4 weeks, with emphasis on early ambulation as soon as tolerated.
• If walking cast is chosen, the patient should be kept in a cast for as short a time as possible (2-3 weeks) and then encouraged to ambulate in a well padded shoe.
• Displacement in the frontal plane of the 2nd, 3rd, and 4th MTs is well tolerated. In the 1st and 5th there may be bony prominences that give problems, so this needs to be watched for. Sagittal plane displacement, however, is not well tolerated.
• Reduction of sagittal plane deformity can be achieved closed with traction, and if unstable percutaneous pinning can be done.
• For 1st MT fractures, these are probably best treated with ORIF and rigid internal fixation – it is more important to get this one perfect and mobilize the patient.
• Metatarsal head fractures are often angulated plantarly, and can be fixed with K-wires after reduction.

Base of 5th MT Fractures

• The “Jones” Fracture is a fracture of the proximal shaft of the 5th, described by him to be “approximately three quarters of an inch from the fifth metatarsal base”.
• Much confusion about what actually constitutes a Jones fracture!

Dameron, Lawrence, Botte – 3 zones:

1. Avulsion fractures
2. Fracture at the metaphyseal/diaphyseal junction – these are probably representative of the Jones fracture
3. Fracture through the proximal 1.5 cm of the shaft

• Basically, the Zone 1 injuries give no long term problems; the Zone 2 injuries are similar but take longer to heal, and the Zone 3 injuries are stress fractures that are a major pain in the ass.

Zone 1 – avulsion fracture:

• Interestingly, the avulsion is from the lateral cord of the plantar aponeurosis, not the peroneus brevis, which inserts a bit more distally.
• “Regardless of size or degree of displacement, and for all nondisplaced intra-articular fractures, there are few long-term complications, and in most cases, symptomatic treatment alone is indicated.”
• Treat with 2-3 weeks immobilization in walking cast, then supportive shoe.
• If persistently symptomatic after nonunion, you can excise it.
• They do comment that if significant displacement at the cuboid-MT joint exists (in an unusually large fragment), these can be fixed.

Zone 2:

• Similar to zone 1, but take longer to heal; thus, treat with 6 weeks non-weightbearing cast.

Zone 3:

• Generally speaking, these are stress fractures.
• Treat initially with 6 weeks non-weightbearing cast if there is no sclerosis.
• Can be bone grafted and then fixed with compression screw fixation.
• For obvious nonunion with sclerosis – bone graft.

Metatarsophalangeal Joint Injuries

First MTP – significant soft tissue restraints:

• Capsule, lateral/medial collateral ligaments
• EHL expansion dorsally
• Volar plate, FHL, FHB, conjoined tendon of FHB and Abductor Hallucis, conjoined tendon of FHB and adductor.

• Sprains are “turf toe” from persistent hyperextension.
• Dislocations are rare, and may be “complex” in that the reduction is blocked by the FHB tendons and the capsule, where traction causes a “Chinese Finger Trap” scenario.
• Seeing unfractured sesamoids should alert to the potential of being irreducible.
• These can be reduced through a dorsal incision.

Sesamoid Fractures

• The medial is more commonly fractured than the lateral.
• Initial treatment is in walking cast for 3-4 weeks, then a stiff soled shoe.
• Excision only if persistently symptomatic.
• The medial one is approached from the medial aspect of the 1st ray; the lateral is excised through a dorsal first web space incision.

Fractures of the Great Toe

• Nondisplaced

Last Updated on January 25, 2026 by orthonet