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Fifth Metatarsal Fracture

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Other Names

  • Jones Fracture
  • Pseudo Jones Fracture
  • Fifth metatarsal base fracture
  • 5th Metatarsal fracture
  • Proximal fifth metatarsal fractures
  • Dancers Fracture

Background

History

  • Sir Robert Jones was the first to describe a fracture of the proximal 5th metatarsal in 1902[1]

Epidemiology

  • Prevalence
    • All metatarsal fractures make up 5-6% of fractures encountered in the primary care setting[2]
    • 5th metatarsal fractures account for 68% of all metatarsal fractures[2]
  • Incidence
    • Peak incidence second to fifth decades of life

Pathophysiology

Location

Lawrence and Botte Classification of fracture zones
  • Proximal metatarsal fractures divided into 3 zones[3]
    • The term 'Jones fracture' is no longer used to avoid confusion
    • Zone 1: 93% fractures
    • Zone 2: 4% fractures
    • Zone 3: 3% fractures
  • Zone 1
    • Alternatively referred to as a Pseudo-Jones fracture
    • Defined as a styloid or tuberosity avulsion fracture
  • Zone 2
    • Historically, referred to as a Jones fracture
    • Defined by fracture at the metaphyseal-diaphyseal junction fracture
  • Zone 3 fracture
    • Defined as a proximal diaphyseal fracture, distal to the 4th/5th articulation
    • Generally considered to be a metatarsal stress fracture
  • Dancers Fracture
    • Fracture of the distal metatarsal shaft or neck

Mechanism

  • Zone 1
    • Due to forefoot supination with plantar flexion[4] or plantarflexion and hindfoot inversion
    • Results in pull from the lateral band of the plantar fascia and peroneus brevis[5]
    • Fracture pattern is transverse to slightly oblique
    • Occasional: comminuted, significantly displaced or disrupt the cuboid-base of fifth metatarsal joint
  • Zone 2
    • Thought to result from a large adduction force applied to the forefoot with the ankle plantar flexed

Associated Conditions

Pathoanatomy

  • 5th Metatarsal
    • Divided into tuberosity, base, metadiaphysis, diaphysis, neck, and head
    • Watershed blood supply about 1.5 cm distal to tuberosity makes it particularly susceptible to non-union

Risk Factors

  • Unknown

Differential Diagnosis


Clinical Features

  • History
    • Acute mechanism
    • Pain with weight bearing
    • Swelling/bruising
  • Physical Exam: Physical Exam Foot And Ankle
    • Skin tenting, deformity are rare
    • Point tenderness over lateral forefoot
  • Special Tests

Evaluation

Ankle XR: Nondisplaced avulsion fracture of the base of the 5th metatarsal (zone 1)

Radiographs

  • Standard Radiographs Foot
    • Strongly consider imaging ankle as well
  • Up to 23% of fractures may not be visible on standard 3 view[6]
    • Consider additionl fifth metatarsal base projection: AP radiograph of the ankle which includes the 5th metatarsal
  • Stress fracture
    • Poor sensitivity for stress fracture, if concern remains can repeat imaging in 10-14 days
    • Look for reabsoption gap around fracture site

CT

  • May consider CT for complex cases

MRI

  • MRI for high suspicion of stress fracture

Classification System

Classification system created by Mehlhorn et al[18] based on risk of displacement with more medial joint entry of the fracture line. Type I, type II, type III are defined as fracture line entry in the lateral one-third, middle one-third and medial one-third, respectively[7]

Torg Anatomic Classification

  • Zone 1 (Pseudo-Jones fracture)
    • Proximal tubercle avulsion
  • Zone 2 (Jones fracture)
    • Metaphyseal-diaphyseal junction, involving 4th/5th metatarsal articulation
  • Zone 3
    • Proximal diaphyseal fracture, distal to 4th/5th articulation

Torg Radiographic Classification

  • 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

Melhorn Classification

  • Description (see thumbnail)
    • Divides joint surface of 5th metatarsal base into three equal parts (Type I, II, III)
    • Adds risk of displacement (A or B)

Management

Nonoperative treatment

Operative treatment

  • Indications
    • Irreducible zone 1 fracture or zone 1 fracture involving the joint
    • Displaced zone 2
    • Nondisplaced zone 2 fracture in competitive athlete
    • > than 4 mm displacement, > 10° plantar angulation
    • Avulsion fractures > 3 mm displacement or comminution
    • Involves more than 30% of the cubometatarsal joint
    • Mehlhorn type IIIA
    • Delayed or nonunion zone 2 iinjuries
  • Technique
    • Open reduction, internal fixation

Rehab and Return to Play

Rehabilitation

  • Needs to be updated

Return to Play

  • Nondisplaced zone 1
    • Treated with progressive weight-bearing and protective shoe or cast
    • Return to play dictated by pain level
  • After surgical intervention
    • 1-2 weeks of immobilization and non-weight bearing
    • Followed progressive weight-bearing in short leg cast or walking boot for 4-6 weeks
    • Functional braces/orthotics can be used in cases of athletes for expedited return to play as tolerated

Complications and Prognosis

Prognosis

  • Nondisplaced zone 2 (Jones) Fractures with early surgical fixation
    • Many studies advocate for early surgical management in active population
    • Porter et al: quicker return to sport, clinical healing in competitive athletes[12]
    • Mindrebo et al: return to sport by 8.5 weeks, radiographic union at about 6 weeks[13]
    • Quill et al: 1 in 3 nonoperative fractures re-fractured, required surgery, recommends early surgery[14]
    • Mologne et al: compared nonoperative (non weight bearing cast) to operative (early IM screw)[15]
      • Operative group had reduced time to return to sport, faster clinical union by almost 50%
      • Incidence of treatment failure in conservative group was 44%
  • Nondisplaced 5th metatarsal shaft, neck fractures
    • O'Malley et al: 31/35 dancers treated conservatively returned to dance without limitations or pain[16]
  • Predictors of adverse outcomes[17]

Complications

  • Delayed union
    • One study of all metatarsal fractures estimated it as high as 27%[19]
  • Nonunion
    • Nondisplaced zone 1 fractures have low nonunion rates (0.5%-1%)[19]
  • Failure of fixation
  • Refracture
  • Painful hardware
  • Sural Nerve Injury
  • Persistent or chronic pain
    • 25% of patients with styloid avulsion fractures experience pain one year post-injury (need citation)

See Also


References


  1. Jones R. I. Fracture of the Base of the Fifth Metatarsal Bone by Indirect Violence. Ann Surg. 1902;35:697–700.2.
  2. 2.0 2.1 Petrisor BA, Ekrol I, Court-Brown C. The epidemiology of metatarsal fractures. Foot Ankle Int. 2006;27:172–174.
  3. Thomas JL, Davis BC. Three-wire fixation technique for displaced fifth metatarsal base fractures. J Foot Ankle Surg. 2011;50:776–779.
  4. Fetzer GB, Wright RW. Metatarsal shaft fractures and fractures of the proximal fifth metatarsal. Clin Sports Med. 2006;25:139–150, x.
  5. Chuckpaiwong B, Queen RM, Easley ME, Nunley JA. Distinguishing Jones and proximal diaphyseal fractures of the fifth metatarsal. Clin Orthop Relat Res. 2008;466:1966–1970.
  6. Pao D, Keats T and Dussault R. Avulsion fracture of the base of the fifth metatarsal not seen on conventional radiography of the foot: the need for an additional projection. Am J Roentgenol 2000; 175: 549–552.
  7. Mehlhorn AT, Zwingmann J, Hirschmüller A, Südkamp NP, Schmal H. Radiographic classification for fractures of the fifth metatarsal base. Skeletal Radiol. 2014;43:467–474.
  8. Shahid MK, Punwar S, Boulind C, Bannister G. Aircast walking boot and below-knee walking cast for avulsion fractures of the base of the fifth metatarsal: a comparative cohort study. Foot Ankle Int. 2013;34:75–79.
  9. Clapper MF, O’Brien TJ, Lyons PM. Fractures of the fifth metatarsal. Analysis of a fracture registry. Clin Orthop Relat Res. 1995:238–241.
  10. Gray AC, Rooney BP, Ingram R. A prospective comparison of two treatment options for tuberosity fractures of the proximal fifth metatarsal. Foot (Edinb) 2008;18:156–158.
  11. Wiener BD, Linder JF, Giattini JF. Treatment of fractures of the fifth metatarsal: a prospective study. Foot Ankle Int. 1997;18:267–269.
  12. Porter DA, Duncan M, Meyer SJ. Fifth metatarsal Jones fracture fixation with a 4.5-mm cannulated stainless steel screw in the competitive and recreational athlete: a clinical and radiographic evaluation. Am J Sports Med. 2005;33:726–733.
  13. Mindrebo N, Shelbourne KD, Van Meter CD, Rettig AC. Outpatient percutaneous screw fixation of the acute Jones fracture. Am J Sports Med. 1993;21:720–723.
  14. Quill GE. Fractures of the proximal fifth metatarsal. Orthop Clin North Am. 1995;26:353–361.M
  15. Mologne TS, Lundeen JM, Clapper MF, O’Brien TJ. Early screw fixation versus casting in the treatment of acute Jones fractures. Am J Sports Med. 2005;33:970–975.
  16. O’Malley MJ, Hamilton WG, Munyak J. Fractures of the distal shaft of the fifth metatarsal. “Dancer’s fracture” Am J Sports Med. 1996;24:240–243.
  17. Cakir H, Van Vliet-Koppert ST, Van Lieshout EM, De Vries MR, Van Der Elst M, Schepers T. Demographics and outcome of metatarsal fractures. Arch Orthop Trauma Surg. 2011;131:241–245.
  18. Tahririan MA, Momeni A, Moayednia A, Yousefi E. Designing a prognostic scoring system for predicting the outcomes of proximal fifth metatarsal fractures at 20 weeks. Iran J Med Sci. 2015;40:104–109.
  19. 19.0 19.1 Konkel KF, Menger AG, Retzlaff SA. Nonoperative treatment of fifth metatarsal fractures in an orthopaedic suburban private multispeciality practice. Foot Ankle Int. 2005;26:704–707.
Created by:
Parker.young on 17 December 2020 17:44:24
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Last edited:
4 October 2022 12:35:59
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