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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 
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 
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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Questions (6)

(OBQ12.168) An 19-year-old elite dancer falls and sustains the injury seen in Figure A. Which of the following interventions is most appropriate at this time? Review Topic

QID:4528
FIGURES:
1

Weight-bearing as tolerated and immediate return to competitive dancing

1%

(40/2870)

2

Resection of the proximal fifth metatarsal base with advancement of the peroneus brevis tendon

1%

(18/2870)

3

Non-weight-bearing in a short-leg cast

12%

(341/2870)

4

Intramedullary screw fixation with return to play after signs of radiographic healing

31%

(897/2870)

5

Protected weight-bearing in a stiff soled shoe with gradual return to activity

54%

(1556/2870)

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

The radiograph shows a base of 5th metatarsal avulsion fracture, which is initially treated with protected weight-bearing and gradual return to activity as pain allows.

Identifying the difference between "true" Jones fractures and base of 5th metatarsal avulsion fractures is important, as healing rates without surgery are much higher for those fractures proximal to the metadiaphyseal junction. While Jones fractures enter the intermetatarsal joint, avulsion fracture enter the tarsometatarsal joint. Even in the elite athelete as described above, non-surgical management with protected weight-bearing is the initial management of choice. If the patient described above had a more distal fracture located in the watershed region of the metaphyseal-diaphyseal junction, intramedullary screw fixation would be the more appropriate option.

Porter et al. review the results of 23 athletes (24 feet) who had a Jones fracture fixed with a 4.5mm cannulated screw. Clinical healing was seen in 100% of the cases with an average return to play time of 7.5 weeks.

Mindrebo et al. review the results of 9 patients with a Jones fracture who were treated with percutaneous intramedullary screw fixation. All patients achieved clinical and radiographic union with an average reterun to full competition at 8.5 weeks.

Shahid et al. compared the outcome of avulsion fractures treated with a short leg walking cast versus a CAM boot and found quicker healing and return to activity with WBAT in a CAM boot, supporting non-operative treatment of this fracture.

Figure A shows a non-displaced base of fifth metatarsal avulsion fracture. Contrast this to illustration A, which represents a "true" Jones fracture at the metadiaphyseal junction which enters the intermetatarsal joint.

Incorrect Answers:
Answer 1: Immediate return to competitive activity is not recommended.
Answer 2: This surgical technique has not been described for her fracture.
Answer 3: Non-weight-bearing would be an unnecessary limitation in her activity.
Answer 4: This would be the appropriate management of a "true" Jones fracture.

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(OBQ11.40) A 23-year-old professional 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? Review Topic

QID:3463
FIGURES:
1

Hard-soled shoe

2%

(51/2473)

2

Cast immobilization

7%

(163/2473)

3

Modified Brostrom procedure

0%

(5/2473)

4

Intramedullary screw fixation

90%

(2232/2473)

5

Operative repair of the Lisfranc fracture

1%

(13/2473)

Select Answer to see Preferred Response

PREFERRED RESPONSE 4

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.

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(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? Review Topic

QID:1426
FIGURES:
1

Female gender

2%

(29/1199)

2

Age less than 20-years-old

0%

(2/1199)

3

Return to sport prior to radiographic union

92%

(1104/1199)

4

Use of a solid screw as opposed to a cannulated screw

1%

(8/1199)

5

Use of a 4.5mm screw

5%

(54/1199)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

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: Smaller diameter screws (less than but not including 4.5mm) are associated with delayed union or nonunion.

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(OBQ06.155) a 19-year old collegiate football lineman sustains a twisting injury to his right foot 1 week ago and radiographs are shown in Figure A. He was initially treated with a short leg splint, non-weight bearing and elevation. What treatment offers the fastest time to bony union and return to sport? Review Topic

QID:341
FIGURES:
1

short leg cast and non weight bearing

1%

(3/302)

2

long leg cast and non weight bearing

1%

(2/302)

3

intramedullary screw fixation

87%

(264/302)

4

k-wire fixation

4%

(12/302)

5

plate and screw fixation

7%

(20/302)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

Figure A shows a Zone 2 base of fifth metatarsal (Jones) fracture. Elite athletes have been shown to have faster time to union with open reduction internal fixation of these fractures, as compared to non-operative management.

In the average patient with a Jones fracture, treatment is largely non-operative. These fractures are usually treated with casting and advised to be non-weightbearing for 6-8 weeks (union rates shown to be between 72% to 93%). In the athletic population, early intramedullary screw fixation has shown to improve postoperative outcomes by shortening the time to union as well as increasing the overall union rates.

Porter et al. reported on a case series of 23 athletes, followed up 22 months with 98.9% healing on radiographs with return to sport in 7.5 weeks. There were no reports of re-fracture in this series.

Kelly et al. created, in human cadavers, 23 pairs of fifth metatarsal fractures. The fractures were then fixed using either 5.0 mm or 6.5 mm screws. They found that larger diameter screws did not result in greater fracture stiffness but did result in significantly greater pull-out strengths.

Figure A shows a minimally displaced Jones fracture.

Incorrect Answers:
Answer 1,2,4,5: Internal fixation will allow for a more rapid return to sport than nonoperative management. However, return to sport prior to radiographic union may lead to high rates of hardware failure and loss of fixation.


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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? Review Topic

QID:359
FIGURES:
1

Use of a partially threaded screw

3%

(61/1771)

2

Use of cannulated screw

8%

(143/1771)

3

Absence of adjunctive ultrasound stimulator use

1%

(21/1771)

4

Return to play prior to radiographic union

82%

(1449/1771)

5

Use of a 4.0mm diameter screw

5%

(94/1771)

Select Answer to see Preferred Response

PREFERRED RESPONSE 4

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:

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(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? Review Topic

QID:1097
FIGURES:
1

Protected weightbearing in a short leg cast with gradual return to sport

5%

(17/324)

2

Intramedullary screw fixation

90%

(292/324)

3

MRI evaluation

2%

(5/324)

4

Foot and ankle taping with immediate return to sport

1%

(2/324)

5

Open reduction internal fixation with a precontoured plate

2%

(7/324)

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

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


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