Treatment strategies for acute fractures and nonunions of the proximal fifth metatarsal

There are at least three distinct fracture patterns that occur in the proximal fifth metatarsal: tuberosity avulsion fractures, acute Jones fractures, and diaphyseal stress fractures. Each of these fracture patterns has its own mechanism of injury, location, treatment options, and prognosis regarding delayed union and nonunion. Tuberosity avulsion fractures are the most common in this region of the foot. The majority heal with symptomatic care in a hard-soled shoe. The true Jones fracture is an acute injury involving the fourth-fifth intermetatarsal facet. These injuries are best treated with non-weight-bearing cast immobilization for 6 to 8 weeks. The rate of successful union with this treatment has been reported to be between 72% and 93%. For the high-performance athlete with an acute Jones fracture, early intramedullary-screw fixation is an accepted treatment option. Nonacute diaphyseal stress fractures of the proximal fifth metatarsal and Jones fractures that develop into delayed unions and nonunions can both be managed with operative fixation with either closed axial intramedullary-screw fixation or autogenous corticocancellous grafting. Early results with the use of electrical stimulation are promising; however, prospective studies are needed to better define the role of this modality in managing these injuries.     

Functional outcome of fifth metatarsal fractures

IntroductionFifth metatarsal fractures are common and the outcome has been reported; however, prospective studies reporting the functional outcome using validated questionnaires are lacking in the literature. The aims of this study were to determine whether fifth metatarsal fractures remain symptomatic in the medium term and whether the fracture type influences outcome.MethodsOver the course of a year, 117 patients (62 avulsion fractures, 26 Jones fractures, 29 shaft fractures) were followed up (1 month, 4 months, 12 months), with functional outcome assessed using the Foot Function Index (FFI)- and Short Form 36 (SF36)-validated questionnaires.ResultsThe FFI reduced (function improved) over the course of the year from 22.0 (8.4–38.5) at 1 month to 0.0 (0.0–4.2) at 4 months, to 0.0 (0.0–1.3) at 1 year. There was no significant difference in the FFI scores with regard to gender or fracture type.Pain scores were also observed to decline over the year, with no significant differences between fracture types. However, while the severity of pain was low, the numbers of people reporting pain were relatively high. At 1 month, >80% of patients reported ongoing pain (83% avulsion, 88% Jones and 83% shaft), reducing to 38% at 4 months and 28% at 1 year. At final follow-up, 25% with an avulsion fracture, 28% with a Jones fracture and 33% with a shaft fracture reported pain.ConclusionsWhile 25–33% of patients continue to experience pain at 1 year, <10% experience any limitation of their activities. At the final follow-up at 1 year, there were no significant differences in functional outcome by fracture type, gender or patient age. Patients should be advised about the likelihood of ongoing low-level symptoms, even after a year from injury in this previously presumed innocuous injury.     

The Jones fracture—transverse proximal diaphyseal fractures of the fifth metatarsal: frequency by radiology

1477 consecutive foot X-rays were reviewed over an 11-month period from the Lehigh Valley Hospital Center Emergency Services. 49 fifth metatarsal fractures were identified. Two transverse proximal diaphyseal fractures 3.0 cm distal from the fifth metatarsal tuberosity, the Jones fracture, were identified. The frequency of the Jones fracture in this group of fifth metatarsal fractures (n = 49) is 4%.     

Metatarsal fractures

Generally nondisplaced metatarsal fractures can be treated nonoperatively. Fracture angulation of more than 10 degrees or fracture displacement of more than 3-4 mm are a valid indication for open or closed reduction. Fractures of the metatarsal bases are often associated with Lisfranc injury. Special attention must be paid to proximal fractures of the fifth metatarsal (avulsion, Jones, proximal diaphyseal fracture). Dislocated midshaft fractures of the first and fifth metatarsals should be treated operatively to realign foot geometry. Subcapital fracture malalignment causes post-traumatic metatarsalgias. Stress and children's fractures are treated most times nonoperatively.     

Metatarsale Frakturen

Generally nondisplaced metatarsal fractures can be treated nonoperatively. Fracture angulation of more than 10° or fracture displacement of more than 3–4 mm are a valid indication for open or closed reduction. Fractures of the metatarsal bases are often associated with Lisfranc injury. Special attention must be paid to proximal fractures of the fifth metatarsal (avulsion, Jones, proximal diaphyseal fracture). Dislocated midshaft fractures of the first and fifth metatarsals should be treated operatively to realign foot geometry. Subcapital fracture malalignment causes post-traumatic metatarsalgias. Stress and children’s fractures are treated most times nonoperatively.     

Effects of Foot Posture on Fifth Metatarsal Fracture Healing: A Finite Element Study

The goal of this study was to evaluate the effects of maintaining different foot postures during healing of proximal fifth metatarsal fractures for each of 3 common fracture types. A 3-dimensional (3D) finite element model of a human foot was developed and 3 loading situations were evaluated, including the following: (1) normal weightbearing, (2) standing with the affected foot in dorsiflexion at the ankle, and (3) standing with the affected foot in eversion. Three different stages of the fracture-healing process were studied, including: stage 1, wherein the material interposed between the fractured edges was the initial connective tissue; stage 2, wherein connective tissue had been replaced by soft callus; and stage 3, wherein soft callus was replaced by mature bone. Thus, 30 3D finite element models were analyzed that took into account fracture type, foot posture, and healing stage. Different foot postures did not statistically significantly affect the peak-developed strains on the fracture site. When the fractured foot was everted or dorsiflexed, it developed a slightly higher strain within the fracture than when it was in the normal weightbearing position. In Jones fractures, eversion of the foot caused further torsional strain and we believe that this position should be avoided during foot immobilization during the treatment of fifth metatarsal base fractures. Tuberosity avulsion fractures and Jones fractures seem to be biomechanically stable fractures, as compared with shaft fractures. Our understanding of the literature and experience indicate that current clinical observations and standard therapeutic options are in accordance with the results that we observed in this investigation, with the exception of Jones fractures.     

LCP distal ulna hook plate as alternative fixation for fifth metatarsal base fracture

Intramedullary screw fixation is the most common treatment for fifth metatarsal base fractures. Screw application does not achieve accurate reduction in fracture with small fragments, osteoporotic bone, or Lawrence zone 1 fractures, however. On the basis of similar anatomical architectures between the distal ulna and the fifth metatarsal base, the purpose of this study was to assess the results of a locking compression plate (LCP) distal ulna hook plate in stabilizing displaced zone 1 or 2 fifth metatarsal base fractures. Nineteen patients with Lawrence zone 1 (n = 12) or 2 (n = 7) fractures of the fifth metatarsal base were treated surgically with an LCP distal ulna hook plate. The patients were evaluated clinically and radiographically, and functional outcomes were graded by using the American Orthopaedic Foot and Ankle Society (AOFAS) midfoot scoring system. Radiographic bony union was obtained in all patients, at an average of 7.4 weeks. The mean AOFAS midfoot score improved from 26 (range, 0–45) preoperatively to 94 (range, 72–100) points at the final follow-up. There were three patients with post-traumatic cubometatarsal arthrosis and one patient with sural nerve neuropraxia. In our experience, the distal ulna hook plate achieves a high rate of bony consolidation and anatomically suitable fixation in zone 1 or 2 fifth metatarsal base fractures. We also suggest that the LCP distal ulna hook plate should be considered as an alternative treatment in multifragmentary, osteoporotic, and tuberosity avulsion (zone 1) fifth metatarsal base fractures.     

Fractures of the fifth metatarsal; diagnosis and treatment

Of all foot fractures the fifth metatarsal fracture is the most common. A complete clinical and radiological assessment is required to select the best treatment option. Nondisplaced tuberosity avulsion fractures can be treated non-operatively. Surgical treatment is indicated when the fracture is displaced more than 2 mm or when more than 30% of the cubometatarsal joint is involved. Non or minimally displaced shaft fractures can be treated non-operatively. If the dislocation is more than 3-4 mm or the angulation is more than 10°, percutaneous K-wires, plate or screw fixation is indicated. The Jones fracture is known for prolonged healing time and non-union. The indication for surgical treatment of Jones’ fractures depends on activity level and Torg classification: type I fractures are treated non-operatively. Type II fractures can be treated non-operatively or operatively, depending on patient activity level. Type III fractures have more complications and should be treated operatively. Several operation techniques have been described.     

The outcome of conservative treatment of fifth metatarsal diaphyseal fractures

IntroductionThe fifth metatarsal diaphyseal fracture is a common fracture. However, clear consensus about the treatment is lacking. Unlike the avulsion fracture or Jones’ fracture, literature available on the treatment and long-term outcome of the diaphyseal fracture is scarce.The purpose of this study is to demonstrate a substantial number of conservatively treated patients with persistent pain and to evaluate metatarsal shortening and displacement within this group.MethodsIn this retrospective study, 106 patients who had experienced a fifth metatarsal diaphyseal fracture were included and evaluated. The minimum follow-up period was three months. FAAM, AOFAS and NRS scores were used as outcome measurements for function and pain. Length and displacement were analysed on plain X-rays.ResultsAt least 11% of the patients who received conservative treatment for their fifth metatarsal diaphyseal fracture had persistent pain at least 3 months after initiation of conservative treatment. No relationship has been found between the length of the fifth metatarsal and the FAAM (r( Petrisor et al., 2006) 2 = 0,051), AOFAS (r( Petrisor et al., 2006) 2 = 0,009) and NRS (r( Petrisor et al., 2006) 2 = 0,001). Furthermore, there was no association between patients with a shorter fifth metatarsal and FAAM, AOFAS, NRS, displacement and BMI.Discussion and conclusionThe finding of persistent pain in at least 11% of all patients at long-term follow-up confirms our hypothesis on long-term symptoms. However, the results suggest that these persistent symptoms are not related to metatarsal shortening or displacement.     

Endoscopic bone grafting for management of nonunion of the tuberosity avulsion fracture of the fifth metatarsal

The most common fracture of the proximal fifth metatarsal is the tuberosity avulsion fracture. Most of the time, the fracture is relatively undisplaced and it can be treated conservatively with a hard-soled shoe or walking cast. For painful intra-articular nonunion, internal fixation with or without bone graft is the treatment of choice. We describe an endoscopic approach to treat nonunions of the tuberosity avulsion fracture. Under endoscopic guidance, the nonunion site can be debrided thoroughly and bone grafted without the need of extensive soft tissue dissection. Moreover, the condition of the fifth metatarsal cuboid articulation can be assessed and intra-articular pathology can be dealed with arthroscopically. Finally, the desired position of the screw can be guided by the arthroscopic aiming device.     

Conservative Versus Surgical Management of Fifth Metatarsal Avulsion Fractures

Fifth metatarsal avulsion fractures are among the most common fractures seen by foot and ankle surgeons. Studies have centered around classification systems, but debate continues regarding surgical versus conservative treatment modalities. The present study focused on quantifying the time for healing fifth metatarsal base avulsion fractures. Specifically, we compared healing time, displacement, and incidence of nonunion among surgically managed and conservatively managed avulsion fractures. Surgically managed patients underwent either open reduction with internal fixation or closed reduction with percutaneous fixation. Conservatively managed fractures were immobilized with a below-knee cast or pneumatic walking boot. Fifty-one patient records (51 feet) were retrospectively compared for basic demographics, smoking, and diabetes status, presence of peripheral neuropathy, Stewart classification, amount of displacement, rate of nonunion, and radiographic healing time. The groups did not differ significantly based on age, sex, or the remaining clinical characteristics including time to consolidation. However, among the 31 conservatively managed patients, 11 (35.5%) developed an asymptomatic nonunion versus none among the 20 patients treated surgically (p = .004). All patients were asymptomatic at 1 year. This study provides insight into the time required for fifth metatarsal avulsion fractures to heal or become asymptomatic. The surgical management of these fractures helped to eliminate the risk of nonunion and helped ensure a timely return to preinjury activity. We recommend surgical management of any fifth metatarsal avulsion fracture displaced >2 mm. Both patients and physicians should have realistic expectations when making decisions regarding treatment modalities for fifth metatarsal avulsion fractures.     

Fractures of the fifth metatarsal in children and adolescents

OBJECTIVE: Fractures of the fifth metatarsal are the most common metatarsal fractures in children. Their treatment is based on the adult literature. The purpose of our study was to identify the different types of fifth metatarsal fractures, to determine the mean time to healing, and to examine whether current adult recommendations can be extrapolated to children and adolescents. METHODS: A total of 103 patients met the inclusion criteria. The fractures were classified according to location. Type I represented an apophyseal injury. Type II represented tubercle fractures with intra-articular extension. Type III injuries represented Jones fracture. Metatarsal neck and shaft fractures were included separately. RESULTS: Apophyseal fractures did well with a short-leg walking cast for 3 to 6 weeks. Displaced intraarticular fractures had a significant delay in healing versus nondisplaced ones. Jones fractures had delays in healing if not treated surgically. Neck and shaft fractures did well with casting. CONCLUSIONS: Most fractures of the fifth metatarsal in the pediatric population do well clinically after a course of walking cast, unless the fracture is an intra-articular displaced fracture type or the fracture occurs in the proximal diaphyseal area. Fixation of Jones fractures in active adolescents should be considered to allow faster return to regular activities and prevent refracture. We recommend non-weight bearing casts for all angulated or displaced intra-articular injuries to avoid delays in healing and angulation. From our series, it is evident that most pediatric fifth metatarsal fractures behave as those found in adults and can be treated similarly.     

Short leg cast versus orthotic removable support for the management of pseudo-Jones avulsion fracture: A systematic review and meta-analysis

BackgroundThe fifth metatarsal base avulsion fracture (i.e., Pseudo-Jones fracture) is one of the most common foot fractures. The management of pseudo-Jones fractures could be carried out surgically or conservatively. This systematic review and meta-analysis aimed to provide an update about the efficacy of orthotic removable support compared to short-leg casting for individuals with pseudo-Jones fracture.MethodsWe searched Embase, Medline, and Cochrane Central register of Controlled Trials (CENTRAL) for randomized controlled trials (RCTs) that compared the clinical outcomes of orthotic removable support and short-leg cast for adult individuals with a fifth metatarsal base avulsion fracture. We used 95% as a confidence level and P <0.05 as a threshold. The standardized mean difference (SMD) was used for the continuous outcomes, and the risk ratio (RR) was used for the dichotomous outcomes.ResultsA total of 6 RCTs incorporating 403 individuals out were deemed eligible. There was no significant difference between orthotic removable support and short-leg casting regarding AOFAS score (standardized mean difference (SMD)= 0.31, 95% CI -0.17 to 0.8), pain on VAS score (SMD= -0.08, 95% CI -0.39 to 0.22), VAS-FA score (SMD= 0.22, 95% CI -0.19 to 0.62) EQ-5D VAS score, and non-union rate (RR=0.37, 95% CI 0.05 to 2.74).ConclusionThe current meta-analysis reveals that there is no difference between orthotic removable support and short-leg casting for the conservative management of individuals sustaining pseudo-Jones fracture.     

Effects of wearing foot orthosis with medial arch support on the fifth metatarsal loading and ankle inversion angle in selected basketball tasks

STUDY DESIGN: Preintervention and post-intervention, repeated-measures experimental design. OBJECTIVES: The objective was to investigate the effects of foot orthoses with medial arch support on ankle inversion angle and plantar forces and pressures on the fifth metatarsal during landing for a basketball lay-up and during the stance phase of a shuttle run. BACKGROUND: Proximal fractures of the fifth metatarsal, specifically the Jones fracture, are common in sports. Wearing foot orthoses with medial arch support could increase the ankle inversion angle and the plantar forces and pressure on the fifth metatarsal that may increase the risk for fifth metatarsal fracture, METHODS AND MEASURES: Three-dimensional (3-D) videographic, force plate, and in-shoe plantar force and pressure data were collected during landing after a basketball lay-up and during the stance phase of a shuttle run with and without foot orthoses with medial arch support for 14 male subjects. Two-way ANOVAs with repeated measures were performed to compare ankle inversion angle, maximum forces, and pressure on the fifth metatarsal head and base between conditions and between tasks. RESULTS: The maximum ankle inversion angle and maximum plantar force and pressure on the base of the fifth metatarsal during both tasks as well as the maximum plantar force and pressure on the head of the fifth metatarsal during the stance of the shuttle run were significantly increased (P< or =026) when wearing foot orthoses. No significant differences were found in the maximum vertical ground reaction forces between foot orthotic conditions. CONCLUSION: Generic use of off-the-shelf foot orthoses with medial arch support causes increased plantar forces and pressures on the fifth metatarsal and may increase the risk for proximal fracture of the fifth metatarsal. Future studies are needed to investigate this risk, acknowledging that the differences noted in our study were small in magnitude and the foot type was not measured.     

Existing fixation modalities for Jones type fifth metatarsal fracture fixation pose high rates of complications and nonunion

Jones type fifth metatarsal fractures pose a challenge to the foot and ankle surgeon, given documented high nonunion rates as well as high complication rates including hardware prominence, nerve injury, and screw breakage for existing treatment modalities including screw and plantar plate fixation. We call for the design of innovative Jones-fracture specific implants which contour to the natural curve of the fifth metatarsal. Future research should aim to expand upon existing literature for Jones fracture fixation and evaluate efficacy of novel implants which are designed to address unacceptably high complication rates for existing treatment modalities.     

Locking Compression Plate Distal Ulna Hook Plate as Alternative Fixation for Fifth Metatarsal Base Fracture

Intramedullary screw fixation has been the most common treatment for fifth metatarsal base fractures. However, screw application will not achieve accurate reduction in fractures with small fragments, osteoporotic bone, or Lawrence zone 1 fractures. Because of the similar anatomic architecture between the distal ulna and the fifth metatarsal base, the purpose of the present study was to assess the results of a locking compression plate distal ulna hook plate in stabilizing displaced zone 1 or 2 fifth metatarsal base fractures. A total of 19 patients with Lawrence zone 1 (n = 12) or 2 (n = 7) fractures of the fifth metatarsal base were treated surgically with a locking compression plate distal ulna hook plate. The patients were evaluated clinically and radiographically, and the functional outcomes were graded using the American Orthopaedic Foot and Ankle Society midfoot scoring system. Radiographic bony union was obtained in all patients, at an average of 7.4 weeks. The mean American Orthopaedic Foot and Ankle Society midfoot score improved from 26 (range 0 to 45) points preoperatively to 94 (range 72 to 100) points at the final follow-up visit. Three patients developed post-traumatic cubometatarsal arthrosis, and 1 patient developed sural nerve neurapraxia. In our experience, the distal ulna hook plate achieved a high rate of bony consolidation and anatomically suitable fixation in zone 1 or 2 fifth metatarsal base fractures. We suggest that the locking compression plate distal ulna hook plate should be considered as an alternative treatment of multifragmentary, osteoporotic, and tuberosity avulsion (zone 1) fifth metatarsal base fractures.     

Conservative management of Jones fractures with immediate weight-bearing in a walking boot demonstrates healing

Jones fractures, or proximal metatarsal fractures at the level of the fourth and fifth intermetatarsal junction, have a high risk for nonunion due to a vascular watershed region. Classically, treatment consists of weight bearing restrictions in a cast or surgical fixation. Some studies have assessed immediate weight bearing following a Jones fracture. Due to conflicting results, the most appropriate treatment method remains unclear. This study analyzes outcomes after treating adults with acute Jones fractures non-operatively without weight bearing restrictions in a walking boot. This study hypothesizes that patients will not require future operative intervention following functional treatment.A retrospective review of 55 adult patients who sustained acute, closed Jones fractures was conducted. 47 were treated weight bearing as tolerated (WBAT) in a walking boot and eight were treated non-weight bearing (NWB) in a cast. They were followed radiographically by an orthopedic surgeon for an average of 6.4 and 15.5 months, respectively.Three patients in each group (6.4% WBAT, 37.5% NWB) developed painful nonunion leading to surgical fixation. Thirty (66.7%) patients in the WBAT group demonstrated radiographic union on final radiographs. Only two (13.3%) of the 15 patients with partial union were seen at least six months from time of injury, one of whom had ongoing pain but declined surgery. The remaining 13 patients were asymptomatic at their final clinic appointment.Controversy still exists as to the best treatment methodology for acute Jones fractures. Due to a lack of clear guidelines, it can be difficult for the multiple medical specialties involved to evaluate and treat this injury. Our study suggests that non-operative management of minimally displaced Jones fractures, in the adult, low demand population, without weight bearing restrictions in a walking boot offers similar outcomes to cast immobilization with weight bearing restrictions, resulting in bony union or asymptomatic fibrous nonunion.     

Jones type fifth metatarsal fracture fixation in athletes: A review and current concept

Jones type fifth metatarsal fracture is a common occurrence among athletes at all levels. These fractures may occur due to several mechanisms, but inversions and twisting injuries are considered some of the leading causes in sports. However, while Jones fracture incidences are frequent in the sporting world, there is still a lack of consensus on how such fractures should be effectively managed. There are numerous treatment options for patients with fifth metatarsal Jones fractures. The role of nonoperative treatment remains controversial, with concerns about delayed union and nonunion. Surgical stabilization of metatarsal Jones fractures is therefore often recommended for athletes, as it is often associated with a low number of complications and a higher rate of union than nonoperative management. This review will focus on literature regarding the prevalence of Jones type fifth metatarsal fracture, alongside the efficacy of both conservative and surgical treatment within this population.     

Interventions for treating proximal fifth metatarsal fractures in adults: A meta-analysis of the current evidence-base

Background

This study assessed the clinical and radiological outcomes of different non-surgical interventions, surgical versus non-surgical interventions, and different surgical interventions used in the management of proximal fifth metatarsal fractures.

Methods

A systematic review of published and unpublished literature was undertaken.

Results

Six studies, assessing 330 patients and 333 fractures of the proximal fifth metatarsal were reviewed. Four studies assessed outcomes following tuberosity fractures, whilst 2 studies recruited patients following proximal diaphyseal or Jones fractures. The findings suggested that bandage is superior to below knee cast immobilisation for patient-reported functional and pain scores, with no difference in fracture union or re-fracture, and a shorter duration to return to work. There was no significant difference in complication rates or functional outcomes for patients managed in a plaster slipper compared to a bandage post-injury. When comparing surgical and non-surgical management, intramedullary screw fixation results in a shorter time to fracture union, reduced complication rates and earlier return to pre-injury activities compared to non-surgical cast immobilisation. However, the evidence-base is limited in it size and presented with a number of methodological limitations.

Conclusions

Further well-conducted randomised controlled trials are required to determine the optimal management strategy for the different types of proximal fifth metatarsal fractures.