SUMMARY 5th Metatarsal Base Fractures are among the most common fractures of the foot and are predisposed to poor healing due to the limited blood supply to the specific areas of the 5th metatarsal base. Diagnosis is made with plain radiographs of the foot. Treatment can include protected weight bearing, immobilization or surgery depending on location of fracture, degree of displacement, and athletic level of patient. Epidemiology Incidence frequent injury encountered in primary care setting base of 5th metatarsal fractures account for 25% of all metatarsal fractures 90% are zone 1 fractures Demographics athletes, military recruits, and manual laborers Etiology Pathophysiology mechanism of injury plantarflexion and hindfoot inversion leads to zone 1 fractures forefoot adduction leads to zone 2 fractures repetitive microtrauma leads to zone 3 fractures Associated conditions concomitant midfoot injuries (i.e. Lisfranc injury) lateral ankle ligamentous laxity cavus foot and varus hindfoot deformities ANATOMY Osteology divided into tuberosity, base, metadiaphysis, diaphysis, neck, and head base and tuberosity is primarily cancellous and highly vascularized tuberosity flairs from base site of peroneus brevis and lateral band of plantar fascia insertion open apophysis or os peroneum may be confused for fracture (comparison radiographs warranted) metadiaphyseal region has no tendinous attachments and is vascular watershed diaphysis has dorsal curve in distal one third peroneus tertius inserts on dorsal diaphysis neck distal metadiaphyseal region more common site of fracture head articulates with proximal phalanx to form metatarsophalangeal joint Blood supply blood supply provided by metaphyseal vessels and diaphyseal nutrient artery zone 2 (Jones fracture) represents a vascular watershed area, making these fractures prone to nonunion Biomechanics fifth metatarsal forms lateral border of forefoot functions as a lever in gait during push-off CLASSIFICATION Torg Anatomic Classification Class Description Zone 1 PseudoJones fx Proximal tubercle avulsion Due to long plantar ligament, lateral band of the plantar fascia, or contraction of the peroneus brevis May extend into cubometatarsal joint Nonunion 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 Torg Radiographic Classification Class Characteristics Fracture Age Type I Narrow fracture line without intramedullary sclerosis Acute Type II Widened fracture line with intramedullary sclerosis Delayed Union Type III Widened intramedullary canal with no callus Nonunion PRESENTATION History antecedent pain in setting of stress fracture, rapid increase in workload or change in training regimen Symptoms location pain over lateral border of forefoot, especially with weight bearing aggravating/alieving factors worse on weightbearing Physical Exam inspection rare skin tenting from zone 1 fractures tenderness to palpation along bone at fracture site varus hindfoot alignment during weightbearing cavus foot deformity excessive lateral wear pattern on shoe treads fifth metatarsal head callosity motion evaluate for lateral ligamentous instability and whether varus hindfoot is correctable provocative tests pain with resisted foot eversion (indicates peroneal tendon weakness) IMAGING Radiographs recommended views AP, lateral and oblique foot images findings details fracture pattern and location intramedullary sclerosis and lack of periosteal callus reaction indicative of chronicity callus forms medially first and progresses laterally plantar fracture gap lends poor prognosis for union with nonoperative treatment plantarflexed first metatarsal and high Meary's angle indicating cavovarus deformity Bone scan indications suspicion for stress fracture with equivocal radiographs findings uptake within diaphysis CT indications to evaluate degree of fracture healing in setting of delayed/nonunion or following surgical fixation MRI indications suspicion for stress fracture with equivocal radiographs or bone scan findings high signal stress reaction and edema TREATMENT Nonoperative protected weight bearing in stiff soled shoe, boot or cast indications zone 1 fracture without rotational displacement outcomes union achieved by 8 weeks, fibrous unions are infrequently symptomatic 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 fracture in recreational athlete zone 3 fracture outcomes high non-union rate and risk of re-fracture approaching 33% in zone 2 fractures Operative intramedullary screw fixation indications zone 1 fractures with rotational displacement or skin tenting zone 2 (Jones fracture) in elite or competitive athletes minimizes possibility of nonunion or prolonged restriction from activity zone 3 fractures in athletic individuals, cavovarus alignment, or with sclerosis/nonunion (Torg Types 2-3) outcomes bony union rates approaching 100% in most series open reduction internal fixation with plate and screws indications same as intramedullary screw fixation salvage for nonunion following intramedullary screw fixation outcomes early data show plate and screw construct has equivalent strength to intramedullary fixation TECHNIQUES Protected weight bearing in stiff soled shoe, boot, or cast technique advance weight bearing as tolerated by pain union achieved by 8 weeks, fibrous unions are infrequently symptomatic early return to work but symptoms may persist for up to 6 months Non-weight bearing short leg cast for 6-8 weeks technique advance weight bearing with signs of radiographic callus (around 4-6 weeks) zone 3 fractures often require 6-7 weeks of non-weight bearing immobilization reports of extracorpeal shock wave with similar union rates as internal fixation for zone 3 stress fractures Intramedullary screw fixation approach patient supine with bump under hip and fluoroscopy immediately available percutaneous/ limited open approach short longitudinal incision proximal to tuberosity, parallel with plantar surface soft tissue blunt dissection past sural nerve branches to tuberosity, between peroneus longus and brevis tendons using fluoroscopy, K-wire starting position superior and medial on tuberosity ("high and inside" position) k-wire does not need to be passed further than the metatarsal curvature reduction k-wire placed intramedullary, fluoroscopy to confirm location soft tissue protector placed and wire may be removed or cannulated drill used to open canal and drill pilot hole sequentially tap to be able to place screw larger than 4mm diameter instrumentation tap can be used to measure appropriate length screw 4.5mm, 5.5mm, or 6.5mm diameter partially-threaded screw placed recommended to use the largest diameter screw that can be accommodated fluoroscopy must be used to confirm all threads cross fracture site and no distal cortical perforation if fracture gap persists or in cases of nonunion/revision, bone graft material may be added at fracture site rehabilitation short period of non-weight bearing (1-3 weeks) followed by protected weightbearing and beginning therapy focusing on range of motion and non-impact aerobic exercises running and impact activities commenced at 6 weeks if surgical site pain-free and signs of radiographic callus Open reduction with plate and screw internal fixation approach longitudinal incision centered over proximal 5th metatarsal bone work typical plantar fracture gap and/or rotational displacement able to be reduced instrumentation 3mm plate bent to contour to plantar-lateral surface of bone to compress fracture COMPLICATIONS Nonunion incidence nonunion rates for Zone 2 injuries are as high as 15-30% risk factors zone 2 and zone 3 fractures due to vascular supply smaller diameter screws (<4.5mm) associated with delayed or nonunion nutritional (vitamin-D) or hormonal (thyroid) deficiencies treatment revision intramedullary screw fixation with use of bone grafting Failure of fixation risk factors 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 screw that is too short will not compress fracture treatment revision internal fixation Refracture incidence 33% of zone 2 fractures following nonoperative treatment risk factors cavovarus foot deformity, stress fractures, vitamin-D insufficiency, removal of intramedullary screw treatment internal fixation with surgical correction of cavovarus deformity if present leave screw in place until end of patient's athletic career Painful hardware incidence rare complication following intramedullary screw fixation risk factors screw head left prominent can irritate sural nerve branches treatment modified shoewear Sural nerve injury risk factors direct trauma during screw insertion prominent screw head impinging on nerve branches dorsolateral branch of sural nerve within 2-3 mm of tuberosity treatment prevented by using tissue protector during procedure and sinking screw head Chronic pain uncommon, result of zone 1 fracture nonunion after initial conservative treatment treatment fragment excision and reattachment of peroneus brevis tendon
QUESTIONS 1 of 21 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 Previous Next Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (SBQ18FA.12) A patient presents to your office with lateral midfoot pain after an inversion injury. In which of the following scenarios would early surgical intervention be indicated? QID: 211231 Type & Select Correct Answer 1 Collegiate soccer player with an acute nondisplaced zone 2 proximal 5th metatarsal fracture 35% (568/1620) 2 High school varsity lacrosse player with a subacute zone 2 proximal 5th metatarsal fracture and no evidence of bony healing after 1 month of conservative management 26% (427/1620) 3 Elite dancer with an acute zone 1 proximal 5th metatarsal fracture 4% (66/1620) 4 Recreational football player with an acute zone 2 proximal 5th metatarsal fracture 1% (19/1620) 5 All of the above 33% (533/1620) L 5 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (SBQ12FA.46) A 23-year-old professional skier presents to the orthopedic clinic with foot pain after a mechanical fall at home. He is diagnosed with a Zone II base of 5th metatarsal fracture and is recommended for internal fixation. Which of the following is the primary advantage of operative intervention for these fractures compared to non-operative treatment? QID: 3853 Type & Select Correct Answer 1 Improved union rate 94% (3189/3383) 2 Decreased pain 2% (62/3383) 3 Decreased heterotopic ossification 1% (29/3383) 4 Improved range of motion 1% (32/3383) 5 Reduced long-term cost 2% (62/3383) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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? QID: 4528 FIGURES: A Type & Select Correct Answer 1 Weight-bearing as tolerated and immediate return to competitive dancing 1% (57/4351) 2 Resection of the proximal fifth metatarsal base with advancement of the peroneus brevis tendon 1% (29/4351) 3 Non-weight-bearing in a short-leg cast 12% (507/4351) 4 Intramedullary screw fixation with return to play after signs of radiographic healing 31% (1334/4351) 5 Protected weight-bearing in a stiff soled shoe with gradual return to activity 55% (2390/4351) L 4 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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? QID: 3463 FIGURES: A Type & Select Correct Answer 1 Hard-soled shoe 2% (81/4097) 2 Cast immobilization 6% (245/4097) 3 Modified Brostrom procedure 0% (12/4097) 4 Intramedullary screw fixation 91% (3720/4097) 5 Operative repair of the Lisfranc fracture 1% (24/4097) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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? QID: 1426 FIGURES: A Type & Select Correct Answer 1 Female gender 3% (56/2201) 2 Age less than 20-years-old 0% (8/2201) 3 Return to sport prior to radiographic union 91% (2009/2201) 4 Use of a solid screw as opposed to a cannulated screw 1% (26/2201) 5 Use of a 4.5mm screw 4% (90/2201) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic (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? QID: 341 FIGURES: A Type & Select Correct Answer 1 short leg cast and non weight bearing 2% (21/1347) 2 long leg cast and non weight bearing 1% (7/1347) 3 intramedullary screw fixation 88% (1179/1347) 4 k-wire fixation 3% (37/1347) 5 plate and screw fixation 7% (91/1347) L 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic (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? QID: 359 FIGURES: A B C D Type & Select Correct Answer 1 Use of a partially threaded screw 3% (87/3068) 2 Use of cannulated screw 7% (218/3068) 3 Absence of adjunctive ultrasound stimulator use 1% (31/3068) 4 Return to play prior to radiographic union 84% (2574/3068) 5 Use of a 5.0mm diameter screw 5% (145/3068) L 1 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic (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 would most likely lead to the quickest return to play? QID: 1097 FIGURES: A Type & Select Correct Answer 1 Protected weightbearing in a short leg cast with gradual return to sport 4% (57/1326) 2 Intramedullary screw fixation 89% (1178/1326) 3 MRI evaluation 1% (15/1326) 4 Foot and ankle taping with immediate return to sport 0% (6/1326) 5 Open reduction internal fixation with a precontoured plate 5% (61/1326) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic
All Videos (5) Podcasts (1) 2022 California Orthopaedic Association Annual Meeting Jones Fractures: What's In, What's Out? - Max Michalski, MD, MSc Max Michalski Foot & Ankle - 5th Metatarsal Base Fracture 4 days ago 122 views 5.0 (1) Login to View Community Videos Login to View Community Videos 2019 Orthopaedic Summit Evolving Techniques Evolving Technique: The Ever Present Jones Fracture: Everything You Need To Know To Be Successful in 2019 - MaCalus V. Hogan, MD, MBA MaCalus Hogan Foot & Ankle - 5th Metatarsal Base Fracture C 11/20/2020 169 views 5.0 (1) 2019 Orthopaedic Summit Evolving Techniques Evolving Technique: The Ever Present Jones Fracture: Everything You Need To Know To Be Successful in 2019 - MaCalus V. Hogan, MD, MBA MaCalus Hogan Foot & Ankle - 5th Metatarsal Base Fracture A 11/9/2020 1577 views 4.0 (4) Foot & Ankle⎪5th Metatarsal Base Fracture Foot & Ankle - 5th Metatarsal Base Fracture Listen Now 21:21 min 10/15/2019 817 plays 5.0 (1) See More See Less
Fifth Metatarsal Lesion in a 28F (C2874) eslam hadhoud Foot & Ankle - 5th Metatarsal Base Fracture E 10/9/2017 255 0 0 5th Metatarsal Base Fracture in 33M (C2078) Foot & Ankle - 5th Metatarsal Base Fracture E 12/9/2014 2028 5 14 Jones fracture (C1667) Abd Elrahman Mahmoud Foot & Ankle - 5th Metatarsal Base Fracture E 10/25/2013 733 1 7 See More See Less