Metatarsal Fracture ORIF - Central Rays

Indication. A displaced fracture of a central metatarsal (2nd, 3rd or 4th) shaft, neck or head that meets an operative threshold — displacement greater than 3-4mm in any plane, angulation greater than 10 degrees (plantar angulation is the least tolerated), multiple metatarsal fractures with loss of transverse arch stability, open fractures requiring debridement and stabilization, irreducible fractures with soft-tissue interposition, or a fracture with an associated Lisfranc (tarsometatarsal) component. Minimally displaced fractures that meet none of these thresholds are managed non-operatively. Assess the whole forefoot, not just the one line on the X-ray. Before committing, obtain AP, lateral and oblique foot radiographs — all three are essential — and on them measure displacement, angulation, rotation and look for adjacent metatarsal and tarsometatarsal injury:

• Weight-bearing views (if the patient can stand) reveal true displacement and arch disruption that non-standing films underestimate.
• CT for base fractures — a central-ray base fracture must be screened for a Lisfranc injury pattern; weight-bearing CT improves detection of subtle tarsometatarsal injuries.
• Compare rotation to the contralateral foot — rotational malreduction is invisible on plain X-ray but causes crossed toes. The fixation decision. The exposure is the same regardless of implant; the choice of fixation follows the fracture pattern and the soft tissues:

Consent specifically for nonunion, malunion (particularly rotational malunion and transfer metatarsalgia from plantar angulation), hardware prominence and shoe irritation, wound infection, superficial peroneal nerve injury with dorsal numbness or a painful neuroma, MTP stiffness, and — in high-energy patterns — compartment syndrome. Setup. Supine with a bump under the ipsilateral hip, thigh tourniquet (280-300mmHg), foot at the end of the table or on a radiolucent arm board so fluoroscopy reaches the foot easily. Loupe magnification helps identify and protect the dorsal cutaneous nerves.

The goal is to restore length, alignment and rotation of the central metatarsal through the dorsal intermetatarsal interval — protecting the dorsalis pedis artery, the superficial and deep peroneal nerves and the extensor tendons — and to hold that reduction with a low-profile dorsal plate (or an intramedullary screw / K-wires where the pattern demands) so the metatarsal parabola is preserved and metatarsalgia avoided. The exposure is laid out in full below (and in depth on the dorsal approach to the lesser metatarsals page).

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Rehabilitation | Phase | Timing | Immobilisation | Therapy | |-------|--------|-----------------|---------| | 1 | Day 0-1 | Soft dressing or posterior splint | Neurovascular check; strict elevation; begin gentle toe range of motion immediately | | 2 | Weeks 0-6 | Non-weight-bearing in a CAM boot or cast | Continue toe ROM; wound check and suture removal at 2 weeks; serial X-rays at 2, 4 and 6 weeks | | 3 | Weeks 6-8 | Transition to protected weight-bearing | Progressive weight-bearing as radiographic healing allows; physiotherapy for gait re-education | | 4 | Weeks 8-12 | Supportive athletic shoe | Advance to full weight-bearing; return to normal activities as tolerated | Hardware removal is rarely needed unless prominent and symptomatic, and then only after 12-16 weeks. Intramedullary screws and buried hardware can remain permanently. Most patients return to normal activities around 10-12 weeks and to sport at 3-4 months. Complications

Epidemiology. Metatarsal fractures are common, and the central rays are frequently injured together. In a prospective series of 355 patients with 411 metatarsal fractures (mean age 42 years), the fifth metatarsal was the most commonly fractured ray with a female predominance in older age groups — critically, multiple fractures occur in contiguous rays: 63 percent of third metatarsal fractures had an associated second or fourth metatarsal fracture. The practical implication is that a central-ray fracture should prompt a deliberate search for adjacent metatarsal injury, because contiguous multi-ray patterns are the rule rather than the exception and they change fixation sequencing. Pathoanatomy — the metatarsal parabola. The metatarsals form a parabola in which the 2nd metatarsal is the longest, then the 1st and 3rd are progressively shorter. During gait the metatarsal bends apex-dorsal under ground-reaction load, so the plantar cortex is the tension side and the dorsal cortex is loaded in compression. This is why a dorsally applied plate functions as a neutralization or bridge plate over a reconstructed plantar cortex, and why plantar angulation is so poorly tolerated: it functionally shortens the ray (pseudo-shortening), drives the head plantarward and produces metatarsalgia under that head, while dorsal angulation radiographically shortens the ray and transfers load to the adjacent metatarsal (a transfer lesion). Restoring length and sagittal alignment preserves the parabola and is the whole point of fixation. Key evidence. Low-profile dorsal plating is the well-supported default: in 45 patients with 75 first-to-fourth metatarsal shaft and neck fractures treated with dorsal plates (Bryant, 2018), union was 100 percent at a mean 10.9 weeks with full weight-bearing at 7.5 weeks, low residual angulation, and no patient requesting plate removal. Minimally invasive intramedullary fixation is a valid alternative for short shaft and neck fractures — titanium elastic nailing of 22 such fractures (Hettchen, 2015) gave a mean AOFAS midfoot score of 93.9 with no nonunion, secondary displacement or nail breakage. Contemporary technique (Kamin, 2021) emphasises restoration of length, axis, rotation and joint position with 2.0-2.4mm interlocking plates and lag-screw compression where the pattern permits, preserving the metatarsal index. Finally, because base fractures accompany Lisfranc injuries, they must be screened with weight-bearing imaging or CT: a missed tarsometatarsal injury and non-anatomic reduction are the dominant drivers of poor outcome (Ahluwalia, 2022).