Managing Metatarsal Fractures: Surgical vs. Conservative Treatment Options

Metatarsal fracture of the foot?

Hello Doctor, my mother was in a car accident today.
The doctor diagnosed her with fractures of the second, third, and fourth metatarsals (the bones are separated) through an X-ray.
The orthopedic surgeon in the emergency room recommended surgery to fix it with a steel plate, which is not covered by insurance and would cost around 80,000 to 90,000 NTD.
However, since my mother is 68 years old, we are considering a conservative treatment with a cast for gradual recovery.
What would you recommend as the best approach? With the cast treatment, how long is the recovery time? How long until she can walk normally? Will there be any long-term complications? Thank you!

Ms. K, 40~49 year old female. Ask Date: 2023/12/12

Dr. Chen Yongxue reply Orthopedics

Hello, whether a metatarsal fracture requires surgery depends on several factors, including the location of the fracture (near the joint surface or in the diaphysis), the degree of comminution, and the separation of the fracture fragments.
If the fracture is near the joint surface and the angulation is not significant, surgery may not be necessary.
However, if the angulation is considerable, it is recommended to undergo surgery with a self-paid plate.
For fractures located in the midshaft (diaphysis), if the bone quality is adequate, a National Health Insurance (NHI) plate can be used.
If there is osteoporosis, it is advisable to opt for a self-paid plate for surgery.
Regardless, this is not an emergency surgery; you can initially use a splint for immobilization, apply ice, and elevate the limb above the heart to reduce swelling, then seek opinions from other physicians at different hospitals.
Thank you.

Reply Date: 2023/12/12

More Info

Managing metatarsal fractures, particularly in older adults, requires careful consideration of various factors, including the type of fracture, the patient's age, overall health, and the potential for complications. In your mother's case, she has sustained fractures in the second, third, and fourth metatarsals, which can be treated either surgically or conservatively.

Surgical Treatment
Surgical intervention, such as the use of plates and screws to stabilize the fractures, is often recommended for displaced fractures, especially in older patients. The advantages of surgical treatment include:
1. Immediate Stability: Surgery can provide immediate stabilization of the fractured bones, which may lead to a quicker return to normal function.

2. Reduced Risk of Malunion: Proper alignment and fixation can minimize the risk of the bones healing in a misaligned position, which can lead to long-term complications.

3. Faster Rehabilitation: Patients may experience a shorter rehabilitation period, allowing them to return to their daily activities sooner.

However, surgery also comes with risks, including infection, complications from anesthesia, and the need for a longer recovery period post-surgery.

Conservative Treatment
On the other hand, conservative treatment, such as immobilization with a cast or walking boot, is a viable option, especially for non-displaced fractures or in patients who may not tolerate surgery well due to age or comorbidities. The benefits of conservative treatment include:
1. Lower Risk: Non-surgical treatment generally carries fewer risks compared to surgery.

2. Cost-Effective: It avoids the high costs associated with surgical procedures and hospitalization.

3. Simplicity: It is a straightforward approach that requires less medical intervention.

Recovery Time and Prognosis
If your mother opts for conservative treatment with a cast, the typical recovery time for metatarsal fractures can range from 6 to 8 weeks, depending on the severity of the fractures and her overall health. During this time, she will need to avoid putting weight on the affected foot, which may require the use of crutches or a walker.

After the cast is removed, physical therapy may be recommended to regain strength and mobility. Most patients can expect to return to normal walking within 2 to 3 months, but this can vary based on individual healing rates and adherence to rehabilitation protocols.

Potential Complications
While many patients recover well from metatarsal fractures, there are potential complications to consider, including:
1. Malunion or Nonunion: If the bones do not heal properly, it can lead to chronic pain or deformity.

2. Post-Traumatic Arthritis: Joint stiffness or arthritis can develop in the affected area, particularly if the fractures were severe.

3. Decreased Mobility: Older adults may experience a longer recovery time and may not regain their pre-injury level of activity.

Conclusion
Given your mother's age and the nature of her fractures, a conservative approach with a cast may be appropriate, especially if she is hesitant about surgery. However, it is crucial to have a detailed discussion with her orthopedic surgeon to weigh the risks and benefits of both options. The surgeon can provide insights based on the specific characteristics of her fractures and her overall health status.

Ultimately, the decision should be made collaboratively, considering her preferences, lifestyle, and the potential impact on her quality of life. Regular follow-up appointments will be essential to monitor her healing progress, regardless of the treatment chosen.

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