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Introduction
  • Epidemiology
    • incidence
      • fairly common injury
  • Pathophysiology
    • mechanism
      • depends on zone of injury
        • zone 1: hindfoot inversion
        • zone 2: forefoot adduction
        • zone 3: repetitive microtrauma
  • Associated injuries
    • midfoot (Lisfranc injury)
    • lateral ankle ligamentous complex
    • rule out associated foot deformities
      • cavus foot or varus hindfoot
Anatomy
  • Osteology and Insertions
    • divided into tubercle (tuberosity), base, shaft, head and neck 
    • peroneus brevis and lateral band of plantar fascia insert on base 
    • peroneus tertius inserts on dorsal metadiaphysis 
  • Blood supply
    • blood supply provided by metaphyseal vessels and diaphyseal nutrient artery
    • Zone 2 (Jones fx) represents a vascular watershed area, making these fracture prone to nonunion
    • Nonunion rates for Zone 2 injuries are as high as 15-30% 
Classification
 
Classification
Class
Description
Images

Zone 1
(pseudo Jones fx)

  • Proximal tubercle (rarely enters 5th tarsometatarsal joint)
  • Due to long plantar ligament, lateral band of the plantar fascia, or contraction of the peroneus brevis
  • Nonunions uncommon

Zone 2
(Jones fx)

  • Metaphyseal-diaphyseal junction 
  • Involves the 4th-5th metatarsal articulation
  • Vascular watershed area 
  • Acute injury
  • Increased risk of nonunion (15-30%)
Zone 3
  • Proximal diaphyseal fracture
  • Distal to the 4th-5th metatarsal articulation
  • Stress fracture in athletes
  • Associated with cavovarus foot deformities or sensory neuropathies 
  • Increased risk of nonunion
 
Presentation
  • Symptoms
    • pain over lateral border of forefoot, especially with weight bearing
    • look for antecedent pain in setting of stress fracture
  • Physical Exam
    • manual palpation of area of concern
    • resisted foot eversion
Imaging
  • Radiographs
    • AP, lateral and oblique foot images
  • CT
    • not routinely obtained
    • consider in setting of delayed healing or nonunion 
  • MRI
    • not routinely obtained
    • consider in setting of delayed healing or nonunion
Treatment
  • Nonoperative
    • protected weight bearing in stiff soled shoe, boot or cast 
      • indications
        • Zone 1 
      • technique
        • advance as tolerated by pain
        • early return to work but symptoms may persist for up to 6 months
    • non weight bearing short leg cast for 6-8 weeks 
      • indications
        • Zone 2 (Jones fx) in recreational athlete 
        • Zone 3
      • technique
        • advance with signs of radiographic healing
  • Operative
    • intramedullary screw fixation      
      • indications
        • zone 2 (Jones fx) in elite or competitive athletes  
          • minimizes possibility of nonunion or prolonged restriction from activity
        • zone 3 fx with sclerosis/nonunion or in athletic individual

 

Complications
  • Nonunion
    • increased risk in Zone 2 (Jones fx) and Zone 3 due to vascular supply 
    • smaller diameter screws (<4.5mm) associated with delayed union or nonunion 
  • Failure of fixation
    • higher failure rate in 
      • elite athletes
      • return to sports prior to radiographic union
      • fracture distraction or malreduction due to screw length 
        • screws that are too long will straighten the curved metatarsal shaft or perforate the medial cortex
 

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