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This acute diaphyseal stress fracture should be treated with non-weightbearing short leg cast for 6 to 8 weeks
7%
267/4049
This diaphyseal stress fracture delayed union should be treated with full-weightbearing short leg cast for 6 to 8 weeks
1%
54/4049
This diaphyseal stress fracture nonunion should be treated with solid intramedullary screw fixation
4%
150/4049
This meta-diaphyseal junction fracture delayed union should be treated with with intramedullary screw fixation
14%
573/4049
This acute meta-diaphyseal fracture should be treated with intramedullary screw fixation
74%
2987/4049
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This athlete has an acute meta-diaphyseal (Jones) fracture of the proximal 5th metatarsal. In an athlete, this is best managed with intramedullary screw fixation to allow rapid return to sport. A Jones fracture is located at the metadiaphyseal junction about 1.5-3 cm from the proximal tip of the 5th metatarsal. They are intra-articular and involves the 4th-5th intermetatarsal facet. It does NOT extend distal to the 4th-5th intermetatarsal articulation, or proximal to involve the metatarsocuboid joint. They are treated with non-weight-bearing cast immobilization for 6 to 8 weeks. For the high-performance athlete, acute intramedullary-screw fixation is an acceptable treatment option. Nonunion rates range from 10-30%. Porter et al. retrospectively reviewed fixation of Jones fractures in 23 athletes (24 feet) with 4.5mm cannulated screws. They obtained 100% clinical and 99% radiographic healing rates. Return to sport was at 7.5weeks. They state that cannulated 4.5mm screws may insert into the tortuous 5th metatarsal easier, and are biomechanically comparable to solid 4.5mm screws. Rosenberg et al. reviewed treatment of acute fractures and nonunion of the proximal 5th metatarsal. The mechanism of injury is forefoot adduction to a plantarflexed ankle. They recommend fixation with a 4.5-mm or a 6.5-mm partially threaded cannulated screw depending on the canal diameter. The screw length is generally between 40 and 55 mm. Time to union is 7-8 weeks. Bucknam et al. reviewed outcomes of 32 acute and subacute Jones fractures and treated with IM screw fixation by a single surgeon. Acute fractures were treated at mean 13 days after injury; subacute fractures were treated at mean 60 days after injury. The authors found no statistical difference in times to return to weight bearing (overall mean, 4 weeks), radiographic union (overall mean, 11 weeks), and high impact activities (overall mean, 13 weeks) between the two groups. 75% of patients in the series were active duty military personnel. In this cohort, the overall mean time to IM screw fixation was 26 days after injury, which is quite typical for presentation in many cases and the situation in this stem scenario. Figures A through C are AP, oblique and lateral radiographs showing a Jones fracture. Illustration A depicts radiographs along with an illustration of the the Torg classification of acute Jones and proximal diaphyseal stress fracture, delayed union, and nonunion. Illustration B is a table showing the main differences in the Torg classification. Incorrect Answers Answers 1 to 4: This patient has an acute Jones fracture. Fixation should be with solid or cannulated screw ranging from 4.5 to 6.5mm in diameter.
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