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5th Met (Jones) Fracture

Discussion in 'General Issues and Discussion Forum' started by Steve Jackson, May 12, 2008.

  1. Steve Jackson

    Steve Jackson Member


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    I would appreciate feedback on management for a patient I was referred recently. A 64 year old female was referred to me with a fracture at the base of her left fifth metatarsal. On presentation the fracture had been untreated for almost 8 weeks as the patient recalled having a minor fall and expected the lateral foot pain to resolve naturally. She had a current xray with her on presentation but I wasn't able to get a digital copy of it and it wouldn't scan in.

    Her history involves fibromyalgia and she wears orthoses for Mortons Neuroma which have been successful.

    I initially placed her in a below knee cam walker (8 weeks post injury) and I reviewed her 4 weeks later with a follow up xray to assess healing. I have attached this xray and is much the same as the one from 4 weeks earlier (although the radiologist reports "new bone formation has commenced but there remains a clear lucency with approximately 2-3mm separation at the fracture site")

    In my limited experience with these fractures (mainly athletes) they are notoriously poor healers and have nearly always required Intramedullary screw fixation and even then have a poor healing rate.

    So my question is:

    Given there is only a small amount of healing taking place should I wait another 4-6 weeks and see if healing progresses and risk delaying the inevitable (that being a surgical opinion) or should I refer for surgery earlier.

    My feeling is surgery will be required but naturally the patient is keen to avoid this.

    Any help would be appreciated.
     

    Attached Files:

  2. drsarbes

    drsarbes Well-Known Member

    Hi Steve:

    12 weeks out; not ready to schedule ORIF;

    I would suggest a bone stimulator. I have had very good results with these fractures (symptomatically) although the radiographic changes are not impressive.

    I would try it for 4 weeks, if her symptoms have not at least decreased, then you can revisit the indications for surgery..

    Good luck.

    Steve
     
  3. Steve:

    You need to block out the name of your patient on this radiograph, Steve. Patient privacy issues require this.

    Is the patient having any pain or symptoms? 95% of these fractures heal uneventfully, in my experience, even though they appear "still fractured" when they are asymptomatic. How much pain does she have when she walks? I have never had to perform a surgery on an avulsion fracture of the styloid process of the 5th metatarsal.
     
  4. Steve Jackson

    Steve Jackson Member

    Thanks for your replies so far.

    I did crop the name from the x-rays but I must have then attached the uncropped image by mistake.. The patient has consented to having her case and x-rays posted though.

    Prior to wearing the cam walker the patient's pain was increasing with walking and she was unable to perform normal daily walking. As a normally active person she had stopped all exercise.

    After 4 weeks in the boot (12 weeks post injury) she noted she is painfree while wearing the boot. She has not done any walking without the boot.

    Given your post Kevin do you think I would be better off treating her via symptoms and not being to concerned by the lack of "radiographic" healing?

    Your help is much appreciated.
     
  5. Admin2

    Admin2 Administrator Staff Member

  6. If this were my patient, I would allow her to weightbear to tolerance in the boot-brace walker until her tenderness, edema and pain with range of motion subside to the point where she can weightbear in a supportive shoe and orthosis without pain. In my experience in these types of fractures, the radiographic appearance lags behind the healing by about 4-12 weeks. In other words, when the patient is able to weightbear in a good shoe with minimal pain, it will take another 4-12 weeks for the bone to look healed. Don't get too worried about the lack of radiographic healing in these types of fractures, it is very common. However, I would continue to radiograph her every 4 weeks until the bone is nearly completely healed. I would expect that to occur within about 8 weeks.

    Please post serial radiographs of this patient in this thread along with the pain level the patient reports every time she sees you. This will create an excellent case report for those following along who do not see these types of injuries very frequently.
     
  7. Steve Jackson

    Steve Jackson Member

    Thanks Kevin your input is most valuable....

    I was planning to re-xray in 4 weeks so I will definately post these images and keep you all posted on her progress.
     
  8. drsarbes

    drsarbes Well-Known Member

    Steve:
    Just wanted to reiterate how effective bone stimulators are for these fractures. Smith & Nephew's EXOGEN is the best of these.
    Steve
     
  9. Scorpio622

    Scorpio622 Active Member

    This is NOT a Jones fracture, but rather an avulsion fracture. As such the prognosis is very good despite the xrays. I work in a very busy orthopedic practice and see 3-4 of these a week- by far the most common foot fracture I see. Over 80% are female and I suspect footwear as the culprit. As such I am doing a study analysing the shoe worn at the time on insult- many are heels, few are athletic shoes.

    Contrary to popular belief, the vast majority these fractures are caused by an avulsion of the lateral band of the plantar fascia and not the PB tendon. As such, there is no worry about dynamic gaping nor the absolute need to immobilize the ankle in every case.

    Ambulatory pain is the guide for treatment. If the patient has no pain with a supportive regular shoe (rarely the case initially), I'll keep them in it. If there is pain I will trial a post-op shoe and then a Cam Boot if need. I try to avoid the Cam boot in the elderly.

    Many patients will "clinically heal" before the "radiographic healing" occurs. Treat the patient not the xray. Your finger is the only diagnostic tool needed- along with accessing for pain free gait. When there is no palpable tenderness and the patient can ambulate pain free- discharge the patient.

    I had a patient with a similar fracture that did not radiographically heal over 20 months. She came to me in a Cam boot requesting a second opinion. The DPM scheduled her for surgery and she was cancelling a cruise vacation because of this. She had no pain and only generalized stiffness and weakness due to prolonged and unnecessary immobilization. She had a fibrous union. I ordered physical therapy and in three weeks she was dancing on the cruise ship without a problem and has had no problems ever since.
     
  10. drsarbes

    drsarbes Well-Known Member

    Hi Scorpio:

    Avulsion - I agree although it definitely looks intra-articular, not really the run of the mill PB avulsion.
    Do you agree?

    Steve
     
  11. Nick:

    Your clinical experiences are nearly identical to mine. Thanks for the posting.:good:
     
  12. Steve Jackson

    Steve Jackson Member

    Thanks scorpio.. I agree that the fracture appears a little proximal to be classified as a true jones fracture but I would have thought it was not really a true avulsion fracture either...

    Going by the attached diagram (which is from http://www.wheelessonline.com) I would say the fracture appears atypical of either fracture and on the border of an avulsion and Jones fracture.

    Either way your information on treatment is most useful. I reviewed the patient yesterday and she now has only minor generalised swelling in the area and is only mildly tender to palpation. She has been in the cam walker for 5 weeks so I have advised her to now return to her walking shoes with her orthoses. She was able to do this in the clinic yesterday quite comfortably.

    I have arranged to review her in 3 weeks with a follow up x-ray. (4weeks since her last one) I will post this xray when I see it.
     

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  13. Dean Hartley

    Dean Hartley Active Member

    Scorpio could you please explain this a little further in regards to the mechanism of injury and involved structures? I was under the belief of the PB tendon being the main offender due to its attachment and 'usual' mechanism of injury. Could you explain the relationship of the lateral band of the plantar fascia and the mechanism of injury.
    That would be much appreciated.
     
  14. Dean and Colleagues:

    The lateral component of the plantar aponeurosis inserts onto the styloid process of the 5th metatarsal along with the peroneus brevis tendon. However, the lateral component of the plantar aponeurosis is absent in 7% of feet (Sarrafian SK.: Anatomy of the Foot and Ankle, J.B. Lippincott Co., Philadelphia, 1983, p. 136) so it is probably not the cause of avulsion fractures of the 5th metarsals in all cases.

    A Jones fracture is, by definition, not in the cancellous bone of the 5th metatarsal, but rather occurs within the proximal shaft of the 5th metatarsal where there is more cortical (i.e. tubular) bone, and less cancellous bone.

    The radiographs presented by Steve are not a Jones fracture but are best considered an avulsion fracture of the styloid process of the 5th metatarsal. Jones fractures have a high incidence of delayed or non-union, probably due either to low blood flow, high metatarsal bending moments or due to being in cortical bone, and are much more likely to require surgical intervention to achieve healing than are avulsion fractures of the styloid process of the 5th metatarsal.

    Dr. Karl Landorf wrote a nice paper on the subject 9 years ago in JAPMA which I have attached below (Landorf KB: Clarifying proximal diaphyseal fifth metatarsal fractures. The acute fracture versus the stress fracture. JAPMA, 89:398-404, 1999.)

    Hope this helps.
     
  15. drsarbes

    drsarbes Well-Known Member

    Hi Kevin (et al)

    This thread is getting more interesting.

    Re; Avulsion vs Jones......

    The avulsions are a little more variable than your diagram illustrates (as I'm sure you know).
    In my experience the true avulsions are just that, a section of the styloid avulses - NOT entering the joint. These are often small enough to merely excise en toto if needed. Some are not.

    When these proximal fractures involve the joint space (as the original radiograph here shows) they often DO NOT heal quickly and are in fact quite painful. Case in point, this patient we are discussing has apparently been in a CAM walker for 5 weeks and is 13 weeks post injury and is still somewhat symptomatic. I find this the rule rather than the exception. Whether one feels the PB or a fascia effect is the causative agent (or direct trauma from inversion/ground force) the fact remains that the PB is actively distracting the fragment. Symptoms vary, and I must point out here that my patient population is quite young and active, but all things being equal, 13 weeks is a rather long time to be limited, even for a 64 year old. That's 3+ months.

    We all know that certain areas of the foot/ankle are more sensitive than others. I have always found the 5th meta base area to be very painful when pathology presents itself.

    Quick note: The bone stimulators work so well for many of these that most insurance carriers in our area do not even require a waiting period or proof of delayed healing/psuedoarthoses.

    Steve
     
  16. Steve Jackson

    Steve Jackson Member

    Just an update on this case.

    I reviewed the lady today 13 weeks post injury. She has now been wearing the cam walking boot for 8 weeks. After trying walking in shoes and orthoses her symptoms increased so she has returned to wearing the boot.

    I haven't posted her x-ray today as it shows no change from the last x-ray I posted. The report confirms non-union of the fracture with a 3mm seperation at the fracture site.

    As she is still symptomatic and there is no sign of healing I have referred her for a surgical opinion.

    I will endeavour to post the results of the consult if anyone is interested.
     
  17. Scorpio622

    Scorpio622 Active Member

    Steve,

    The picture you posted from Wheeless is completely inaccurate and without reference. First off, the Jones fracture is distal to all the pretty colours- as it involves only cortical bone. Furthermore, the "stress fracture" is a variant of the Jones fracture. The current thought is that Jones fractures are either completely traumatic or have a prodromal weakening of the bone (ie stress fracture) and the fracture occurs like an insufficiency type. The way you tell the difference is that the latter has narrowing of the medullary canal, and the purely traumatic does not.

    With respects to the case- I would continue with conservative care since it is the path chosen. I have had several cases such as this and they ALL resolved with time and patience. Sometimes the immobilization needs to be prolonged and a Exogen bone stim (ultrasonic) works great. I question if a foot orthotic will put more force through the fracture if it is posted in varus? The injury was no doubt caused by a varus mechanism so that is probably not the best position of function while healing. I've used valgus wedges in the situation, but usually progress improved but still symptomatic patients to a rocker bottom post op shoe after the cam boot.

    No doubt surgery will fix this, but will require more time in the boot anyway and it is not without potential complications.

    Nick
     
  18. Steve Jackson

    Steve Jackson Member

    Hi Nick,

    Point taken regarding the diagram.. When I reviewed this patient yesterday she was understandably frustrated given her symptoms have not reduced and the radiograph shows no change since her initial radiograph.

    Wearing the boot is causing other problems given this lady has fibromyalgia. This is mainly related to her having to use a walking stick and the obvious changes in her gait. I have explained to her that given time the fracture should heal conservatively.

    Our sports physician also came in and had a look yesterday, and together we decided that a surgical opinion would be warrented given persistant symptoms and non-union of the fracture.

    I would stress that this doesn't mean the patient will definately progress to surgery but will get the opinion of a surgeon. In my letter to the surgeon I have suggested the possibility of a bone stimulator but as I have no access to one of these I will let the surgeon decide on this. (I am not sure how available these are in Western Australia)

    Naturally the patients concern is how long will she have to wear to boot if she continues conservative treatment... and will this be shorter if she progresses to surgery sooner rather than later.

    Happy to update when I hear the outcome of the consultation.
     
  19. Steve Jackson

    Steve Jackson Member

    Here is an update on this case, I saw this lady recently whom is now 9 weeks post op involving internal fixation of the fracture. She is now walking reasonably comfortably and reports great improvement since undergoing surgery.

    She returned to me, as she has been unable to wear her orthoses since returning to walking, as she couldn't tolerate pressure beneath the fracture site. As a result of not wearing her orthoses her original symptoms from her Mortons Neuroma had returned. I have therefore modified the orthoses by cutting away the poly beneath the fifth met and putting a cushioned cover over them. This was much more comfortable and she is happily wearing them. On a side note she was experiencing some irritation from the scar within her shoe so I have given her a silicone sleeve to wear and this has resolved that issue.

    Her surgeon plans to remove the pin and plate in approximately 3 weeks.

    I have attached the latest x-rays that indicate good healing. My apologies for the scanning quality but it was the best I could do.

    Many thanks for those who provided advice on this case. I understand that I didn't really follow much of it given this patients circumstances but it was very much appreciated all the same...
     

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