5th Metatarsal Base Fracture

Author: Brian Weatherford

Topic updated on 03/01/13 8:15pm

Introduction

Common injury
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

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 Involvies the 4th-5th metatarsal articulation Vascular watershed area Acute injury Increased risk of nonunion
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
  - indications
    - Zone 1
  - technique
    - protected weight bearing in stiff soled shoe, boot or cast
    - advance as tolerated by pain
    - early return to work but symptoms may persist for up to 6 months
- non weight bearing
  - indications
    - Zone 2 (Jones fx) in recreational athlete
    - Zone 3
  - technique
    - non weight bearing short leg cast for 6-8 weeks
    - 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
- higher failure rate if return to sports prior to radiographic union
- fracture distraction or malreduction due to screw length
  - screws that are too long will straigthen the curved metatarsal shaft or perforate the medial cortex

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Qbank (4 Questions)

TAG

(SBQ07.41) A 19-year-old college soccer player has been experiencing pain along the lateral border of her foot since the beginning of the season 6 weeks ago. A current radiograph is seen in Figure A. Which of the following would be a risk factor for failure after operative fixation? Topic

Review Topic

FIGURES: A

1. Female gender
2. Age less than 20-years-old
3. Return to sport prior to radiographic union
4. Use of a solid screw as opposed to a cannulated screw
5. Use of a 4.5mm screw

PREFERRED RESPONSE ▶

DISCUSSION: The radiograph seen in Figure A demonstrates a metadiaphyseal fracture of the fifth metatarsal that involves the 4th-5th intermetatarsal joint, otherwise known as a Jones fracture. A Jones fracture in a high performance athlete is a relative indication for operative intervention, however increased rates of failure are seen if the athlete returns to athletic participation prior to radiographic union.

Dameron reviews the presentation and treatment of fractures of the fifth metarsal. He states that internal fixation, usually with an intramedullary screw, will allow for more rapid return to sport than nonoperative management. The author cautions, however, that return to sport prior to radiographic union leads to higher rates of failure of fixation.

Illustration A shows an example of intramedullary screw fixation.

Incorrect Answers:
Answer 1: Female gender has not been associate with failure of fixation
Answer 2: Patient age has not been shown to affect outcomes with these fractures
Answer 4: No clinical difference has been shown with solid screw fixation and some advocate for use a solid screw given the increased strength
Answer 5: Increased rates of failure are seen with 3.5mm screws, not 4.5 mm screws

Illustrations: A

REFERENCES:

1. Dameron TB Jr. Fractures of the Proximal Fifth Metatarsal: Selecting the Best Treatment Option. J Am Acad Orthop Surg. 1995 Mar;3(2):110-114. PMID:10790659 (Link to Abstract)

Question Authors:

Brian Weatherford MD, John Badylak MD, Michael Hughes MD,

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TAG

(OBQ11.40) A 21-year old college lacrosse player injures her left foot while walking down a flight of stairs. She has pain and inability to bear weight on her injured foot. She has no plantar ecchymosis but does have tenderness over her lateral foot. A radiograph of her foot is found in Figure A. What is the best form of management? Topic

Review Topic

FIGURES: A

1. Hard-soled shoe
2. Cast immobilization
3. Modified Brostrom procedure
4. Intramedullary screw fixation
5. Operative repair of the lisfranc fracture

PREFERRED RESPONSE ▶

DISCUSSION: The clinical scenario and radiographs are consistent with a fracture of the base of the fifth metatarsal. In young athletes, operative screw fixation is the treatment of choice. The 5th metatarsal is divided into 3 zones. Zone I is an avulsion fracture, zone II is described as a jones fracture and zone III is proximal diaphyseal fracture (Illustration A). Nonunions are more common with fractures in zones II and III.

Lehman et al reviewed fractures of the base of the fifth metatarsal. They describe the current controversies regarding nomenclature and treatment. They recommend NWB immobilization for acute fractures and delayed unions. The active patient and non-unions are treated operatively.

Illustrations: A

REFERENCES:

1. Lehman RC, Torg JS, Pavlov H, DeLee JC. Fractures of the base of the fifth metatarsal distal to the tuberosity: a review. Foot Ankle. 1987 Feb;7(4):245-52. PMID:3817669 (Link to Abstract)

2. Sanders RW, Papp S. Fractures of the midfoot and forefoot. In: Coughlin MJ, Mann RA, Saltzman CL, eds. Surgery of the Foot and Ankle. 8th ed. St Louis, MO: Mosby Elsevier; 2007:133-149.

Question Authors:

Terrill Julien MD, Ben Taylor MD, Ben Taylor MD, Mark Miller MD,

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(OBQ06.173) A 20-year-old male collegiate basketball player presents with a 1 day history of left foot pain. He developed severe pain on the lateral border of his left foot after landing from a jump. The pain is worsened with weightbearing and walking. The patient reports that 12 weeks ago he sustained a similar injury and underwent surgery on his foot by a different surgeon. He reports that his physician released him to full activity 8 weeks ago because he had no pain. He is currently tender to palpation on the lateral border of the foot. Radiographs and CT scan are shown in Figures A-D. What is the most likely etiology for the new injury? Topic

Review Topic

FIGURES: A

1. Use of a partially threaded screw
2. Use of cannulated screw
3. Absence of adjunctive ultrasound stimulator use
4. Return to play prior to radiographic union
5. Use of a 4.0mm diameter screw

PREFERRED RESPONSE ▶

DISCUSSION: Radiographic views demonstrate a bent 4.0 mm cannulated intramedullary screw along with incomplete healing of the left proximal 5th metatarsal fracture. It is important to note that return to full activity prior to radiographic union is directly related to the risk of potential treatment failure.

The study by Larson et al examined 15 patients (mean age 21.7 years) who underwent cannulated screw fixation of a Jones fracture between 1993 and 1999. There were 6 failures: four refractures and two symptomatic nonunions. The mean time to full activity was 6.8 weeks for the patients with failure, compared with 9 weeks for patients who did not have complications. Although all patients were asymptomatic and radiographically progressing to union before return to full activity, only one of 6 patients with failures had complete radiographic union, compared with 6 of 7 patients with no complications. There was a higher proportion of elite athletes among the failure group (83%) compared with those without complications (11%). This study showed no significant differences in age, sex, screw diameter, use of bone graft, or age of fracture between patients with failures and those without complications. However, it should be noted that other studies have reported that smaller sized and cannulated screws may be risk factors for treatment failure.

An appropriate treatment for the bent, failed hardware is removal of the hardware and placement of a larger intramedullary screw (Illustrations A and B).

Illustrations: A

REFERENCES:

1. Larson CM, Almekinders LC, Taft TN, Garrett WE. Intramedullary screw fixation of Jones fractures. Analysis of failure. Am J Sports Med. 2002 Jan-Feb;30(1):55-60. PMID:11798997 (Link to Abstract)

Question Authors:

Michael Hughes MD, Ben Taylor MD,

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TAG

(OBQ05.211) A 25-year-old professional basketball player sustains a twisting injury to his foot. He complains of immediate pain and is unable to finish the game. Two days following the injury, he has continued tenderness with palpation of the base of the 5th metatarsal. A radiograph is provided in Figure A. Which of the following is the best management of this patient? Topic

Review Topic

FIGURES: A

1. Protected weightbearing in a short leg cast with gradual return to sport
2. Intramedullary screw fixation
3. MRI evaluation
4. Foot and ankle taping with immediate return to sport
5. Open reduction internal fixation with a precontoured plate

PREFERRED RESPONSE ▶

DISCUSSION: The fifth metatarsal base fracture that occurs at the metaphyseal-diaphyseal junction should be treated with placement of an intramedullary screw for high performance athletes, which allows for quicker return to play and time to union.

Type II, fifth metatarsal base fractures (Jones Fracture) occur at the metaphyseal-diaphyseal junction approximately 2.5 cm distal to the base. The acute Jones fracture can also be treated with a non-weight bearing cast for 6-8 weeks in patients that are not athletes. This is a circulatory watershed region that is subject to nonunion secondary to poor blood supply. Clinically, failure of fixation has been noted in athletes who returned to full activities before radiographic evidence of complete radiographic union.

Portland et al performed a Level 4 study of 22 patients that underwent intramedullary screw fixation for 5th metatarsal fractures. They report 100% rate of union and 9% incidence of complications

REFERENCES:

1. Portland G. Kelikian A. Kodros S: Acute management of Jones’ fractures. Foot Ankle Int.2003;24:829-833 PMID:14655886 (Link to Abstract)

2. Griffin LY (ed): Orthopaedic Knowledge Update: Sports Medicine Rosemont, IL, American Academy of Orthopaedic Surgeons, 1994, pp 261-268

Question Authors:

John Badylak MD, Michael Hughes MD, John Badylak MD,

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Cases

	Jones fx (C1051) Anatomy - - 5th Metatarsal Base Fracture HPI - 29 yo F twisted foot stepping off bleachers at a youth baseball game. Would you fix this Jones fx with an intramedullary screw or treat with cast...	8/17/2011 34 responses
	Jones Fracture (C1134) Foot & Ankle - - 5th Metatarsal Base Fracture HPI - s/p injury playing soccer. denies previous pain/trauma. was treated in non-wei... What implant do you use?	1/20/2012 63 responses
	closed comminuted fracture left base 5th metatarsal (C1321) Foot & Ankle - Treatment Consult - 5th Metatarsal Base Fracture HPI - 41 yo Male twisted his left foot stepping off stair and could not bear weight 1)what should we management ,cast VS. operation ? 2) which choices of s...	11/15/2012 183 responses 5

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Intramedullary screw fixation of Jones fractures. Analysis of failure. Includes Poll

Larson CM, Almekinders LC, Taft TN, Garrett WE
Am J Sports Med. 30(1):55-60. PMID: 11798997 (Link to Pubmed)

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Evidence & References Show References

Level of Evidence 4 (Case Series)

Larson CM, Almekinders LC, Taft TN, Garrett WE. Intramedullary screw fixation of Jones fractures. Analysis of failure. Am J Sports Med. 2002 Jan-Feb;30(1):55-60. PMID:11798997 (Link to Abstract)
Lehman RC, Torg JS, Pavlov H, DeLee JC. Fractures of the base of the fifth metatarsal distal to the tuberosity: a review. Foot Ankle. 1987 Feb;7(4):245-52. PMID:3817669 (Link to Abstract)
Portland G. Kelikian A. Kodros S: Acute management of Jones’ fractures. Foot Ankle Int.2003;24:829-833 PMID:14655886 (Link to Abstract)

Level of Evidence 5 and Other Journal Articles (includes Case Reports, Expert Opinions, Personal Observations, and Biomechanic Studies)

Dameron TB Jr. Fractures of the Proximal Fifth Metatarsal: Selecting the Best Treatment Option. J Am Acad Orthop Surg. 1995 Mar;3(2):110-114. PMID:10790659 (Link to Abstract)
Griffin LY (ed): Orthopaedic Knowledge Update: Sports Medicine Rosemont, IL, American Academy of Orthopaedic Surgeons, 1994, pp 261-268

Textbooks

Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Sanders RW, Papp S. Fractures of the midfoot and forefoot. In: Coughlin MJ, Mann RA, Saltzman CL, eds. Surgery of the Foot and Ankle. 8th ed. St Louis, MO: Mosby Elsevier; 2007:133-149.

Undefined

Porter DA, Duncan M, Meyer SJ: Fifth metatarsal Jones fracture fixation with a 4.5 mm cannulated stainless steel screw in the competitve and recreational athlete: A clinical and radiographic evaluation. Am J Sports Med 2005;33:726-733.
Kelly IP, Glisson RR, Fink C, et al: Intramedullary screw fixation of Jones fractures. Foot Ankle Int 2001; 22:585-589.
Rosenberg GA, Sferra JJ: Treatment strategies for acute fractures and nonunions of the proximal fifth metatarsal. J Am Acad Orthop Surg 2000;8:332-338.

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5th Metatarsal Base Fracture

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