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Fifth Metatarsal Fracture
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Contents
Other Names
- Jones Fracture
- Pseudo Jones Fracture
- Fifth metatarsal base fracture
- 5th Metatarsal fracture
- Proximal fifth metatarsal fractures
- Dancers Fracture
Background
- This page refers to acute, traumatic fractures of the 5th Metatarsal
- Fractures of the 1st to 4th metatarsal are discussed separately
- Metatarsal stress fractures are also discussed separately
History
- Sir Robert Jones was the first to describe a fracture of the proximal 5th metatarsal in 1902[1]
Epidemiology
- Prevalence
- Incidence
- Peak incidence second to fifth decades of life
Pathophysiology
Location
- 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
- Fractures & Osseous Disease
- Traumatic/ Acute
- Stress Fractures
- Other Osseous
- Dislocations & Subluxations
- Muscle and Tendon Injuries
- Ligament Injuries
- Plantar Fasciopathy (Plantar Fasciitis)
- Turf Toe
- Plantar Plate Tear
- Spring Ligament Injury
- Neuropathies
- Mortons Neuroma
- Tarsal Tunnel Syndrome
- Joggers Foot (Medial Plantar Nerve)
- Baxters Neuropathy (Lateral Plantar Nerve)
- Arthropathies
- Hallux Rigidus (1st MTPJ OA)
- Gout
- Toenail
- Pediatrics
- Fifth Metatarsal Apophysitis (Iselin's Disease)
- Calcaneal Apophysitis (Sever's Disease)
- Freibergs Disease (Avascular Necrosis of the Metatarsal Head)
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
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
- Indications
- Zone 1 fracture
- Can consider in non-displaced zone 2 in recreational athlete
- Nondisplaced 5th metatarsal shaft, neck
- Immobilization
- Consider Hard sole shoe, walking boot, cast with weight-bearing as tolerated
- Zone 1: Compared to Below Knee Walking Cast, Airboot[8], Hard Soled Shoe[9], Plastic Slipper[10], Tubi Grip Support, Bulky Jones Dressing[11] may all be just as effective
- Nondisplaced zone 2: Short Leg Cast for 6-8 weeks
- Weight bearing status
- Zone 1: Protected weight bearing
- Nondisplaced zone 2: Non weightbearing for duration of cast
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]
- Female gender
- Diabetes Mellitus
- Obesity
- Torg type III: displacement, weight[18]
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
- Internal
- External
- https://www.sportsmedreview.com/blog/case-report-fifth-metatarsal-fracture/
- Sports Medicine Review Foot Pain: https://www.sportsmedreview.com/by-joint/foot/
References
- ↑ Jones R. I. Fracture of the Base of the Fifth Metatarsal Bone by Indirect Violence. Ann Surg. 1902;35:697–700.2.
- ↑ 2.0 2.1 Petrisor BA, Ekrol I, Court-Brown C. The epidemiology of metatarsal fractures. Foot Ankle Int. 2006;27:172–174.
- ↑ Thomas JL, Davis BC. Three-wire fixation technique for displaced fifth metatarsal base fractures. J Foot Ankle Surg. 2011;50:776–779.
- ↑ Fetzer GB, Wright RW. Metatarsal shaft fractures and fractures of the proximal fifth metatarsal. Clin Sports Med. 2006;25:139–150, x.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ Clapper MF, O’Brien TJ, Lyons PM. Fractures of the fifth metatarsal. Analysis of a fracture registry. Clin Orthop Relat Res. 1995:238–241.
- ↑ 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.
- ↑ Wiener BD, Linder JF, Giattini JF. Treatment of fractures of the fifth metatarsal: a prospective study. Foot Ankle Int. 1997;18:267–269.
- ↑ 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.
- ↑ 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.
- ↑ Quill GE. Fractures of the proximal fifth metatarsal. Orthop Clin North Am. 1995;26:353–361.M
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 19.0 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:
John Kiel, User on 17 December 2020 17:44:24
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Last edited:
4 October 2022 12:35:59
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