Review Question - QID 217414

5th Metatarsal Base Fracture TREATMENT Operative QID: 217414 (OBQ21.95)

QID 217414 (Type "217414" in App Search)

A 21-year-old football lineman sustains an inversion injury to his right foot and states he heard a pop. He is unable to continue practice and has significant pain with attempts at weight-bearing. Radiographs of the right foot are seen in Figure A. When discussing treatment options, which of the following are true?

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Short leg casting results in >95% union rates in this fracture pattern

59/1377

Short leg casting results in high rates of asymptomatic fibrous nonunion in this fracture pattern

61/1377

Intramedullary screw fixation is expected to improve pain but not increase union rates compared to short leg cast

33/1377

Intramedullary screw fixation should always be augmented with bone graft

3/1377

Intramedullary screw fixation is expected to decrease time to union compared to casting

88%

1213/1377

Select Answer to see Preferred Response

Intramedullary screw fixation for zone 2 (Jones) 5th metatarsal fractures has demonstrated quicker time to union than nonoperative measures.

Jones fractures represent a difficult subset of 5th metatarsal fractures to manage, given the poor blood supply in the metadiaphyseal region. This vascular watershed area makes these zone 2 fractures prone to nonunion, with rates of nonunion >30% in some studies with nonoperative management in a boot or cast. In elite athletes or those at high risk of nonunion who have a Jones fracture, intramedullary screw fixation is recommended. Screw size is important, with screws <4.5mm showing a higher rate of nonunion as well. Bone graft can be used, and may be particularly helpful in cases of revision fixation but is not necessary in all primary Jones fracture fixation.

Yates et al. performed a review comparing the outcomes of surgical vs. conservative management in Jones fractures. With a total of 237 patients, they noted the non-operative group had a 5.74x higher risk of nonunion. They also describe delayed time to union and prolonged return to sport in the conservative group, therefore they recommend operative fixation.

Roche et al. evaluated the management and return to sport after Jones fractures in athletes. They noted that fractures treated nonoperatively had a union rate of 76%, with fractures treated operatively having a 96% union rate. Therefore, they recommend intramedullary screw fixation for these patients, with the understanding that they are more likely to go on to union and an earlier return to play.

Figure A demonstrates an oblique right foot radiograph which shows a zone 2 Jones fracture.

Incorrect Answers:
Answer 1: Short leg casting for Jones fractures results in nonunion rates >30% in some studies and can delay union in other cases.
Answer 2: Short leg casting can lead to nonunion which is usually symptomatic. Zone 1 fractures may have an asymptomatic fibrous nonunion more commonly.
Answer 3: Intramedullary screw fixation has been shown to increase union rates of Jones fractures.
Answer 4: Bone graft is not necessary in all cases of intramedullary screw fixation.