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Metatarsal fractures

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Excluding toe fractures, metatarsal fractures are the most common foot fracture and represent about 5% of all fractures. In children, the most commonly injured metatarsals are the first and fifth simply due to their anatomical exposure. In adults, high forces are required to fracture the larger and stronger first metatarsal so these are much less common. In industrial injuries, the fifth metatarsal is most commonly injured.

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A metatarsal fracture must be suspected in all patients with direct trauma to the forefoot and pain with ambulation. Maintain a high index of suspicion for an associated Lisfranc injury at the tarsometatarsal joint, especially with the involvement of the proximal first through fourth metatarsals and if the patient has plantar ecchymosis on exam. The metatarsophalangeal joint and phalanges should also be assessed for injury.

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In some sense, a metatarsal fracture is itself a red flag, calling attention to the need to exclude a more serious injury. In particular, fractures of the 2nd, 3rd or 4th metatarsal should raise suspicion of a ligament (Lisfranc) injury; a 5th metatarsal fracture must be scrutinized to make sure a zone 2 (Jones) fracture (which needs more protection) is identified; and a 1st metatarsal fracture must be examined closely to ensure there is no displacement. In short, Lisfranc injuries, zone 2 5th metatarsal fractures and displacement of  1st metatarsal fractures must be detected, and the presence of any fracture near their regions is a red flag alerting the examiner to their possible presence as well.

Pain that seems to worsen even persists or even worsens after immobilization may be a sign of a (rare) compartment syndrome )of the foot.  Late signs include pallor, paresthesias, and tense swelling–but don't wait for them to appear.

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