Distal extraarticular fractures of the 1st to 4th metatarsal

These fractures are classified by the AO/OTA as 87.1–4.3A fractures, and they may be simple or multifragmentary.

The numbers 1–4 indicate which metatarsal is injured.

The following clinical presentation is typical:

• The patient describes an acute trauma with immediate pain and difficulty in weight-bearing
• The foot progressively exhibits swelling and ecchymosis
• The damaged area is very painful to palpation and weight-bearing
• Deformities may not be appreciated. The sensation can be disrupted, particularly plantar
• Crepitation may be appreciated with palpation of the affected area (this will be very painful for the patient)
• The level of soft-tissue swelling increases proportionally with the number of fractured metatarsals
• Open fractures will have draining wounds
• Vascular compromise is uncommon

Conventional radiographs of the foot (AP and lateral oblique views) are sufficient for diagnosis and treatment.

CT scans are invaluable for clarification of the fracture pattern and assessing additional fractures of the midfoot.

Fractures may be created with multiple mechanisms:

• Axial
• Bending
• Torsion
• Combined trauma

They may involve either high or low energy mechanisms.

High energy mechanism injuries are often associated with midfoot instability (Lisfranc instability).

Compartment syndrome and Lisfranc injuries should always be suspected.