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5th Metatarsal Base Fracture

Topic updated on 02/20/14 7:23pm
Introduction
  • 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 
  • 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 (5 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 ▶
TAG
(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? Topic Review Topic
FIGURES: A          

1. Weight-bearing as tolerated and immediate return to competitive dancing
2. Resection of the proximal fifth metatarsal base with advancement of the peroneus brevis tendon
3. Non-weight-bearing in a short-leg cast
4. Intramedullary screw fixation with return to play after signs of radiographic healing
5. Protected weight-bearing in a stiff soled shoe with gradual return to activity

PREFERRED RESPONSE ▶
TAG
(OBQ11.40) A 21-year-old competitive 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 ▶
TAG
(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   B   C   D    

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 ▶
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 ▶



Cases

http://upload.orthobullets.com/cases/1667/1375304_563695377019466_828134853_n.jpg
HPI - a car hit her foot -20 days ago - and caused this fracture and a wound at the do...
poll what is the suggested management ?
10/25/2013
392 responses
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http://upload.orthobullets.com/cases/1051/jones fx.jpg
HPI - 29 yo F twisted foot stepping off bleachers at a youth baseball game.
poll Would you fix this Jones fx with an intramedullary screw or treat with cast...
8/17/2011
70 responses
http://upload.orthobullets.com/cases/1134/5thmt-ap.jpg
HPI - s/p injury playing soccer. denies previous pain/trauma. was treated in non-wei...
poll What implant do you use?
1/20/2012
90 responses
http://upload.orthobullets.com/cases/1321/eeeeeeeee.jpg http://upload.orthobullets.com/cases/1321/new imageeee.jpg http://upload.orthobullets.com/cases/1321/photo[1]eee.jpg
HPI - 41 yo Male twisted his left foot stepping off stair and could not bear weight
poll 1)what should we management ,cast VS. operation ? 2) which choices of s...
11/15/2012
203 responses
3
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post
Larson CM, Almekinders LC, Taft TN, Garrett WE
Am J Sports Med. 2002 Jan-Feb;30(1):55-60. PMID: 11798997 (Link to Pubmed)
5/9/2013
58 responses
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