The structure of the foot is complex, consisting of bones, muscles, tendons and other soft tissues. Of the 28 bones in the foot, 19 are toe bones (phalanges) and metatarsal bones (the long bones in the midfoot). Fractures of the toe and metatarsal bones are common and require evaluation by a specialist. A foot and ankle surgeon should be seen for proper diagnosis and treatment, even if initial treatment has been received in an emergency room.
What Is a Fracture?
A fracture is a break in the bone. Fractures can be divided into two categories: traumatic fractures and stress fractures.
Traumatic fractures (also called acute fractures) are caused by a direct blow or impact, such as seriously stubbing your toe. Traumatic fractures can be displaced or nondisplaced. If the fracture is displaced, the bone is broken in such a way that it has changed in position (malpositioned).
Signs and symptoms of a traumatic fracture include:
- You may hear a sound at the time of the break.
- Pinpoint pain (pain at the place of impact) at the time the fracture occurs and perhaps for a few hours later, but often the pain goes away after several hours.
- Crooked or abnormal appearance of the toe.
- Bruising and swelling the next day.
It is not true that “if you can walk on it, it’s not broken.” Evaluation by a foot and ankle surgeon is always recommended.
Stress fractures are tiny hairline breaks usually caused by repetitive stress. Stress fractures often afflict athletes who, for example, too rapidly increase their running mileage. They can also be caused by an abnormal foot structure, deformities or osteoporosis. Improper footwear may also lead to stress fractures. Stress fractures should not be ignored. They require proper medical attention to heal correctly.
Symptoms of stress fractures include:
- Pain with or after normal activity
- Pain that goes away when resting and then returns when standing or during activity
- Pinpoint pain (pain at the site of the fracture) when touched
- Swelling but no bruising
Consequences of Improper Treatment
Some people say that “the doctor can’t do anything for a broken bone in the foot.” This is usually not true. In fact, if a fractured toe or metatarsal bone is not treated correctly, serious complications may develop. For example:
- A deformity in the bony architecture, which may limit the ability to move the foot or cause difficulty in fitting shoes.
- Arthritis, which may be caused by a fracture in a joint (the juncture where two bones meet), or may be a result of angular deformities that develop when a displaced fracture is severe or has not been properly corrected.
- Chronic pain and deformity.
- Nonunion, or failure to heal, can lead to subsequent surgery or chronic pain.
Treatment of Toe Fractures
Fractures of the toe bones are almost always traumatic fractures. Treatment for traumatic fractures depends on the break itself and may include these options:
- Rest. Sometimes rest is all that is needed to treat a traumatic fracture of the toe.
- Splinting. The toe may be fitted with a splint to keep it in a fixed position.
- Rigid or stiff-soled shoe. Wearing a stiff-soled shoe protects the toe and helps keep it properly positioned. Use of a postoperative shoe or bootwalker is also helpful.
- Buddy taping the fractured toe to another toe is sometimes appropriate, but in other cases, it may be harmful.
- Surgery. If the break is badly displaced or if the joint is affected, surgery may be necessary. Surgery often involves the use of fixation devices, such as pins.
Treatment of Metatarsal Fractures
Breaks in the metatarsal bones may be either stress or traumatic fractures. Certain kinds of fractures of the metatarsal bones present unique challenges.
For example, sometimes a fracture of the first metatarsal bone (behind the big toe) can lead to arthritis. Since the big toe is used so frequently and bears more weight than other toes, arthritis in that area can make it painful to walk, bend or even stand.
Another type of break, called a Jones fracture, occurs at the base of the fifth metatarsal bone (behind the little toe). It is often misdiagnosed as an ankle sprain, and misdiagnosis can have serious consequences since sprains and fractures require different treatments. Your foot and ankle surgeon is an expert in correctly identifying these conditions as well as other problems of the foot.
Treatment of metatarsal fractures depends on the type and extent of the fracture and may include:
- Rest. Sometimes rest is the only treatment needed to promote healing of a stress or traumatic fracture of a metatarsal bone.
- Avoid the offending activity. Because stress fractures result from repetitive stress, it is important to avoid the activity that led to the fracture. Crutches or a wheelchair are sometimes required to offload weight from the foot to give it time to heal.
- Immobilization, casting or rigid shoe. A stiff-soled shoe or other form of immobilization may be used to protect the fractured bone while it is healing. Use of a postoperative shoe or bootwalker is also helpful.
- Surgery. Some traumatic fractures of the metatarsal bones require surgery, especially if the break is badly displaced.
- Follow-up care. Your foot and ankle surgeon will provide instructions for care following surgical or nonsurgical treatment. Physical therapy, exercises and rehabilitation may be included in a schedule for return to normal activities.
There are 26 bones in the foot. These bones support our weight and allow us to walk and run. Certain activities or injuries can cause a fracture, or break, in one or more of these bones. Pain, swelling, redness and even bruising are signs of a possible fracture. Fractures of the foot can be diagnosed by x-rays or other studies. A foot and ankle surgeon can determine the best treatment course. Rest, icing and immobilization are often the treatments; however, surgery is sometimes necessary to repair the fracture.
What Is a Fifth Metatarsal Fracture?
Fractures (breaks) are common in the fifth metatarsal—the long bone on the outside of the foot that connects to the little toe. Two types of fractures that often occur in the fifth metatarsal are:
- Avulsion fracture. In an avulsion fracture, a small piece of bone is pulled off the main portion of the bone by a tendon or ligament. This type of fracture is the result of an injury in which the ankle rolls. Avulsion fractures are often overlooked when they occur with an ankle sprain.
- Jones fracture. Jones fractures occur in a small area of the fifth metatarsal that receives less blood and is therefore more prone to difficulties in healing. A Jones fracture can be either a stress fracture (a tiny hairline break that occurs over time) or an acute (sudden) break. Jones fractures are caused by overuse, repetitive stress or trauma. They are less common and more difficult to treat than avulsion fractures. Other types of fractures can occur in the fifth metatarsal. Examples include midshaft fractures, which usually result from trauma or twisting, and fractures of the metatarsal head and neck.
Avulsion and Jones fractures have the same signs and symptoms. These include:
- Pain, swelling and tenderness on the outside of the foot
- Difficulty walking
Anyone who has symptoms of a fifth metatarsal fracture should see a foot and ankle surgeon as soon as possible for proper diagnosis and treatment. To arrive at a diagnosis, the surgeon will ask how the injury occurred or when the pain started. The foot will be examined, with the doctor gently pressing on different areas of the foot to determine where there is pain. The surgeon will also order x-rays. Because a Jones fracture sometimes does not show up on initial x-rays, additional imaging studies may be needed.
Until you are able to see a foot and ankle surgeon, the RICE method of care should be performed:
- Rest: Stay off the injured foot. Walking may cause further injury.
- Ice: Apply an ice pack to the injured area, placing a thin towel between the ice and the skin. Use ice for 20 minutes and then wait at least 40 minutes before icing again.
- Compression: An elastic wrap should be used to control swelling.
- Elevation: The foot should be raised slightly above the level of your heart to reduce swelling.
The foot and ankle surgeon may use one of these nonsurgical options for treatment of a fifth metatarsal fracture:
- Immobilization. Depending on the severity of the injury, the foot is kept immobile with a cast, cast boot or stiff-soled shoe. Crutches may also be needed to avoid placing weight on the injured foot.
- Bone stimulation. A pain-free external device is used to speed the healing of some fractures. Bone stimulation, most commonly used for Jones fractures, may be used as part of the treatment or following an inadequate response to immobilization.
When Is Surgery Needed?
If the injury involves a displaced bone, multiple breaks or has failed to adequately heal, surgery may be required. The foot and ankle surgeon will determine the type of procedure that is best suited to the individual patient.