Zone 1(pseudo Jones fx)
Zone 2(Jones fx)
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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?
Weight-bearing as tolerated and immediate return to competitive dancing
Resection of the proximal fifth metatarsal base with advancement of the peroneus brevis tendon
Non-weight-bearing in a short-leg cast
Intramedullary screw fixation with return to play after signs of radiographic healing
Protected weight-bearing in a stiff soled shoe with gradual return to activity
Select Answer to see Preferred Response
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.
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.
Porter DA, Duncan M, Meyer SJ.
Am J Sports Med. 2005 May;33(5):726-33. Epub 2005 Feb 16. PMID: 15722272 (Link to Abstract)
Mindrebo N, Shelbourne KD, Van Meter CD, Rettig AC.
Am J Sports Med. 1993 Sep-Oct;21(5):720-3. PMID: 8238714 (Link to Abstract)
Shahid MK, Punwar S, Boulind C, Bannister G
Foot Ankle Int. 2013 Jan;34(1):75-9. PMID: 23386764 (Link to Abstract)
HPI - a car hit her foot -20 days ago - and caused this fracture and a wound at the dorsum of the foot and between the fingers ( not in continuity with the fracture )
What would be your treatment for this injury ?
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Average 3.0 of 19 Ratings
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?
Modified Brostrom procedure
Intramedullary screw fixation
Operative repair of the Lisfranc fracture
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.
Lehman RC, Torg JS, Pavlov H, DeLee JC.
Foot Ankle. 1987 Feb;7(4):245-52. PMID: 3817669 (Link to Abstract)
Average 4.0 of 13 Ratings
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?
Age less than 20-years-old
Return to sport prior to radiographic union
Use of a solid screw as opposed to a cannulated screw
Use of a 4.5mm screw
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.
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.
Dameron TB Jr.
J Am Acad Orthop Surg. 1995 Mar;3(2):110-114. PMID: 10790659 (Link to Abstract)
Average 4.0 of 8 Ratings
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?
short leg cast and non weight bearing
long leg cast and non weight bearing
intramedullary screw fixation
plate and screw fixation
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.
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.
Kelly IP, Glisson RR, Fink C, Easley ME, Nunley JA.
Foot Ankle Int. 2001 Jul;22(7):585-9. PMID: 11503985 (Link to Abstract)
Rosenberg GA, Sferra JJ.
J Am Acad Orthop Surg. 2000 Sep-Oct;8(5):332-8. PMID: 11029561 (Link to Abstract)
Average 4.0 of 3 Ratings
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?
Use of a partially threaded screw
Use of cannulated screw
Absence of adjunctive ultrasound stimulator use
Return to play prior to radiographic union
Use of a 4.0mm diameter screw
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).
Larson CM, Almekinders LC, Taft TN, Garrett WE
Am J Sports Med. 2002 Jan-Feb;30(1):55-60. PMID: 11798997 (Link to Abstract)
Average 2.0 of 24 Ratings
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?
Protected weightbearing in a short leg cast with gradual return to sport
Intramedullary screw fixation
Foot and ankle taping with immediate return to sport
Open reduction internal fixation with a precontoured plate
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
Portland G, Kelikian A, Kodros S.
Foot Ankle Int. 2003 Nov;24(11):829-33. PMID: 14655886 (Link to Abstract)
HPI - pain on right foot. can not stand. sudden swelling after bike accident. no other issues. can bend leg, toes. He is on cast NWB.
What zone is this fracture in?
Average 3.0 of 12 Ratings
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 surgical technique incase you prefer operation??
HPI - s/p injury playing soccer. denies previous pain/trauma. was treated in non-weightbearing short-leg cast for the last 8 weeks.
What implant do you use?
HPI - 29 yo F twisted foot stepping off bleachers at a youth baseball game.
Would you fix this Jones fx?
This video gives brief description about fracture of the bast of the 5th metatar...
Intramedullary screw fixation of a Jones fracture