Metatarsal and Phalangeal Fractures Metatarsal and phalangeal fractures are common in children, with fifth metatarsal fractures occurring most frequently Radiographic evaluation should include anteroposterior, lateral, and oblique views of the foot For nondisplaced or minimally displaced fractures, a splint can be applied and crutches given for ambulation Phalangeal fractures can be managed with buddy taping and/or a hard sole shoe for stabilization Intraarticular fractures of the first toe or significantly displaced fractures of the other phalanges require orthopedic referral for possible pinning Fractures at the base of the fifth metatarsal may be confused with accessory ossification centers that occur at this site, which are parallel to the long axis of the metatarsal shaft and are nontender to palpation The base of the fifth metatarsal is the site of two common fractures: avulsion fractures and fractures of the proximal fifth metatarsal diaphysis, which is called a Jones fracture The avulsion fracture of the base of the fifth metatarsal, also called a pseudo-Jones fracture, occurs from the pull of the peroneus brevis, the abductor digiti minimi quinti tendon, or lateral cord of the plantar aponeurosis Typically, the fracture line is perpendicular to the long axis of the metatarsal shaft, and there is minimal displacement Treatment is with a short leg weight-bearing cast for weeks This fracture is more proximal and has a better prognosis than the Jones fracture, which is associated with delayed union and nonunion The Jones fracture occurs at the metaphyseal–diaphyseal junction at the base of the fifth metatarsal, which is a watershed area with a tenuous blood supply Due to complications in healing, this injury should be splinted, the patient should be made non-weight-bearing, and referred to the orthopedist for possible operative management Tarsometatarsal injuries of the foot, referred to as a Lisfranc injury, can be caused by a direct blow to the foot or when there is forced plantar flexion of the forefoot combined with a rotational force This is more commonly seen in the skeletally mature patient and may be difficult to diagnose as the injuries are subtle and will present with minor pain and swelling at the base of the first and second metatarsals Weight-bearing radiographs (AP, lateral, oblique views of the foot) are recommended to stress the joint complex Fracture at the base of the second metatarsal should raise suspicion for a possible tarsometatarsal dislocation ( Fig 111.55 ) Further imaging with CT or MRI may be required to fully visualize the injury The foot should be immobilized and the patient should follow up with outpatient orthopedics