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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
    • Nonunion rates for Zone 2 injuries are as high as 15-30% 
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 (15-30%)
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 (19)
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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%

(73/2150)

2

Use of cannulated screw

7%

(159/2150)

3

Absence of adjunctive ultrasound stimulator use

1%

(23/2150)

4

Return to play prior to radiographic union

83%

(1778/2150)

5

Use of a 5.0mm diameter screw

5%

(112/2150)

Select Answer to see Preferred Response

PREFERRED RESPONSE 4
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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

2%

(14/729)

2

long leg cast and non weight bearing

1%

(6/729)

3

intramedullary screw fixation

85%

(620/729)

4

k-wire fixation

3%

(22/729)

5

plate and screw fixation

8%

(58/729)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

(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%

(45/3545)

2

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

1%

(21/3545)

3

Non-weight-bearing in a short-leg cast

11%

(403/3545)

4

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

31%

(1098/3545)

5

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

55%

(1952/3545)

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

(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

7%

(38/584)

2

Intramedullary screw fixation

85%

(495/584)

3

MRI evaluation

1%

(6/584)

4

Foot and ankle taping with immediate return to sport

1%

(4/584)

5

Open reduction internal fixation with a precontoured plate

6%

(35/584)

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

(SBQ07SM.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%

(35/1430)

2

Age less than 20-years-old

0%

(4/1430)

3

Return to sport prior to radiographic union

92%

(1313/1430)

4

Use of a solid screw as opposed to a cannulated screw

1%

(10/1430)

5

Use of a 4.5mm screw

4%

(62/1430)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

(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%

(62/3204)

2

Cast immobilization

6%

(203/3204)

3

Modified Brostrom procedure

0%

(6/3204)

4

Intramedullary screw fixation

91%

(2900/3204)

5

Operative repair of the Lisfranc fracture

1%

(17/3204)

Select Answer to see Preferred Response

PREFERRED RESPONSE 4
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