Proximal fifth metatarsal fractures

NewsBot · Apr 4, 2012

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Acute fractures to the proximal fifth metatarsal bone: Development of classification and treatment recommendations based on the current evidence.
Polzer H, Polzer S, Mutschler W, Prall WC.
Injury. 2012 Mar 30.

Fractures to the proximal fifth metatarsal bone are among the most frequent injuries to the foot. Various classifications intend to distinguish different fracture entities in regard to prognosis and treatment. The most commonly used classification by Lawrence and Botte delineates three fracture zones and gives treatment recommendations based on retrospective case series. Aim of our study was to critically review the literature and reevaluate the classification and treatment recommendations based on the highest level of evidence available. We performed a systematic literature search in Medline, Embase and Cochrane library and identified six prospective trials either comparing the same treatment for different fracture entities or different treatment strategies for the same fracture entity. The studies reveal that all "tuberosity avulsion fractures" (Zone 1, according to Lawrence and Botte) heal well using functional treatment. Even multifragmentary, displaced and intraarticular fractures in Zone 1 give comparable good results. Treatment with a short leg cast leads to a significant delay in return to preinjury level when compared to functional treatment. "Jones' fractures" (Zone 2) also demonstrate good to excellent results and complete bone healing when treated functionally. In contrast, "diaphyseal stress fractures" (Zone 3) at the distal limit of the fourth-fifth intermetatarsal articulation and just distally feature a significantly higher rate of treatment failure when treated non-operatively in a non-weight bearing short leg cast. Early intramedullary screw fixation leads to a significantly shorter time to bone healing and return to sport. In conclusion, acute fractures to the proximal fifth metatarsal bone should be classified into two entities only: First, metaphyseal fractures not extending beyond the distal end of the fourth-fifth intermetatarsal articulation, as these fractures, regardless the number of fragments, displacement and intraarticular involvement, should be treated functionally. Second, meta-diaphyseal fractures located at the distal end of the fourth-fifth intermetatarsal articulation or just distally, as these fractures require early intramedullary screw fixation.
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Admin2 · Apr 4, 2012

Re: Proximal fifth metetarsal fractures

Related threads:
Jones Fracture Surgery
Fractured base of 5th or Os vesalianum pedis
5th Met (Jones) Fracture
Rearfoot alignment and jones fracture
Jones fracture
Avulsion fracture of the styloid process?
Screw Fixation Versus Casting Jones Fractures

NewsBot · Sep 12, 2012

Re: Proximal fifth metetarsal fractures

Treatment and return to sport following a Jones fracture of the fifth metatarsal: a systematic review.
Roche AJ, Calder JD.
Knee Surg Sports Traumatol Arthrosc. 2012 Sep 6

PURPOSE:
The aim of this study is to better inform the sports surgeon of current evidence for the treatment of Jones fractures of the base of the 5th metatarsal. The study aimed to establish what the outcomes were for different treatments modalities. By doing this, the clinician will be better prepared to institute a logical, evidence-based approach to the treatment of their patients with this injury.

METHODS:
A thorough literature search was performed from 1980 to present day. Studies were included based on set criteria and analysed for their validity, and their results were scrutinised. Jones fractures were segregated into acute fractures, delayed unions and non-unions.

RESULTS:
Twenty-six studies were included, of which 22 were level 4 evidence, with only 1 randomised controlled trial. Functional outcome data were limited to return to sports in most studies with few studies using established scoring systems. Return to sports following intra-medullary screw fixation for acute fractures ranged from 4 to 18 weeks. Acute fractures treated non-operatively had a union rate of 76 % (pooled), whereas in fractures treated with a screw it was 96 % (pooled). Delayed unions treated non-operatively had a union rate of 44 and 97 % treated operatively. Non-unions treated with screw fixation healed in 97 % of cases.

CONCLUSIONS:
Although supported by mostly level 4 evidence, intra-medullary screw fixation is more likely to lead to successful union of all types of Jones fractures compared to non-operative treatments. Early return to play in athletes prior to full radiological union is not advised in case of re-fracture.
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NewsBot · Feb 19, 2013

Re: Proximal fifth metetarsal fractures

Radiographic Factors and Effect of Fifth Metatarsal Jones and Diaphyseal Stress Fractures on Participation in the NFL.
Carreira DS, Sandilands SM.
Foot Ankle Int. 2013 Feb 15.

Introduction:Jones fracture and proximal diaphyseal stress fracture of the fifth metatarsal have been associated with prolonged healing times and nonunions. We hypothesized that the Jones fracture and proximal diaphyseal stress fracture have a high incidence in elite collegiate football players and that they lead to a decrease in participation in the NFL. Also, we hypothesized that these fractures are associated with a cavovarus foot alignment.

Materials and Methods:The database collected by a single NFL team during the 2004 to 2009 NFL Combines was reviewed to identify players with Jones and proximal diaphyseal fifth metatarsal fractures. A total of 74 fifth metatarsal fractures were identified in 68 players. Subsequent participation data also were collected through the NFL.com website and included games played and years played. Digital plain radiographs and additional imaging studies also were reviewed to determine the extent of healing, types of fixation utilized, and foot alignment.

Results:The locations of fractures in the proximal fifth metatarsal were 45 (61%) in the Jones area, 15 (20%) in the proximal diaphyseal area, and 14 (19%) of indeterminate location. The number of patients treated with intramedullary fixation was 55/74 (74%). Of 74 proximal fifth metatarsal fractures, 9 (12.2%) were nonunions at the time of the NFL Combine medical examinations. With the numbers available, the average number of games played in the NFL was not significantly different in the fifth metatarsal fracture group, 16.9, compared to the control group, 24.9 (P > .05). The average number of games started was 7.4 in the fracture group versus 12.1 in the control group (P > .05). No significant differences were noted in the number of years played in the NFL. Except for talonavicular angle measurements, all measurements of coronal plane alignment demonstrated significant differences across groups, but no differences were noted in sagittal plane alignment.

Conclusion:No statistically significant difference was noted in participation in the NFL following Jones fractures and proximal diaphyseal stress fractures of the fifth metatarsal, although a trend toward decreased participation was noted. Radiographic abnormalities were noted in the coronal plane with varus alignment, but not in the sagittal plane.
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NewsBot · Mar 12, 2013

Re: Proximal fifth metetarsal fractures

Fifth metatarsal fractures among male professional footballers: a potential career-ending disease
Jan Ekstrand, C Niek van Dijk
Br J Sports Med (online first)

Background There is little information about Metatarsal Five (MT-5) fractures for specific sports.

Objective To study the occurrence, the imaging characteristics, the lay-off times and healing problems of MT-5 fractures among male footballers.

Methods Sixty-four European elite teams were monitored from 2001 to 2012. x-Rays were collected and classified by the Torg criteria.

Results Of 13 754 injuries, 0.5% (67) proved to be MT-5 fractures. Their incidence was 0.04 injuries/1000 h of exposure. A team of 25 players might thus expect an MT-5 fracture every fifth season. Of these fractures, 67% (38) were primary and 33% were refractures. One of the 38 primary fractures was an avulsion of the tuberosity; all the others (97%) located towards the base. In total, 32% of the players with MT-5 fracture were younger than 21 years, 40% of the fractures occurred during the preseason and 45% of the players had prodromal symptoms. In total, 54% of the initial x-rays were classified as Torg type II (stress fractures), and 46% were classified as Torg type I (acute type). After surgical treatment the fractures healed faster, compared with conservative treatment (75% vs 33%, p<0.05). There was no significant difference in lay-off days between players that had been operated, and those that had not (80 vs 74 days, p=0.67).

Conclusions The majority of MT-5 fractures are stress fractures, and mainly occur among young players. There are frequent healing problems, which might be explained by the stress nature of the injury. After surgery there are less healing problems, compared with those in conservative treatment.
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NewsBot · Aug 3, 2013

Re: Proximal fifth metetarsal fractures

Outcome of Nonoperative Management of Displaced Oblique Spiral Fractures of the Fifth Metatarsal Shaft.
Aynardi M, Pedowitz DI, Saffel H, Piper C, Raikin SM.
Foot Ankle Int. 2013 Aug 1.

BACKGROUND:
Nonoperative management has been the preferred treatment for displaced oblique spiral fractures of the fifth metatarsal shaft; yet a paucity of literature supports this claim. The purpose of this investigation was to report the incidence and long-term outcome in the largest cohort of these fractures reported to date.
METHODS:
From 2006 through 2010, 2990 patients sustaining closed metatarsal fractures were seen and treated. Displaced, oblique, spiral fractures of the distal shaft of the fifth metatarsal were identified and follow-up was conducted. Only patients who were initially treated with nonoperative management were included. Patients were seen at 6 and 12 weeks, and a minimum 2-year follow-up was conducted. In addition, demographic information was obtained, and the Short Form-12 (SF-12) and Foot and Ankle Ability Measure (FAAM) were administered. Average follow-up was 3.5 years.
RESULTS:
In all, 142 acute fractures were managed for an incidence of 4.8% of all metatarsal fractures. There were 117 females and 25 males, average age was 55. FAAM activities of daily living subscale scores averaged 95.5 (±5.7), while FAAM sports subscales were 92.7 (±9.1). SF-12 physical and mental scores averaged 51.4 (±4.9) and 50.3 (±4.6), respectively. There were 2 delayed unions, 1 asymptomatic nonunion treated nonoperatively, and 2 painful nonunions that required open reduction internal fixation with bone grafting.
CONCLUSION:
This large cohort described the relative incidence and functional outcomes of displaced oblique fracture of shaft of the fifth metatarsal bone treated nonoperatively. Nonoperative management of these fractures resulted in excellent, long-term functional outcomes.
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NewsBot · Sep 2, 2013

Re: Proximal fifth metetarsal fractures

Prolonged Rehabilitation of Jones Fracture in Division I-A Collegiate American Football Player: A Case Report
Farah M. Hernandez
Florida International University

Objective: To describe the prolonged rehabilitation program for a Jones fracture in a Division I-A American football player.

Background: A 21 year old, African American, collegiate football player (body mass= 264 lb; height= 76.5 in; body fat= 16.0%) complained of a sharp pain at the dorsal aspect of the left foot. The athlete experiences a compressive force to the fifth metatarsal and upon evaluation, mild swelling was present along the lateral aspect of the foot.

Differential Diagnosis: Jones fracture, metatarsal fracture, bone contusion.

Treatment: An intramedullary fixation surgery was scheduled two weeks post injury, to correct and stabilize the fracture. Intramedullary fixation is a method of mending the bone internally with a screw, wire, or metal plate along the fractured bone length wise. Following surgery the athlete continued use of crutches for ambulation and was placed in a removable walking boot for 5 weeks.

Uniqueness: This case presented a unique challenge in the rehabilitation program, as the athlete experienced slow formation of the bone callus and therefore a prolonged rate of recovery. The athlete was in a walking boot longer than expected (2 weeks longer than anticipated) which inhibited advancement in his rehabilitation due to a slow bone callus formation. A soft callus usually begins to form at day 5 following injury, but documentation was incomplete, and a hypothesis for slow bone callus formation could be secondary to lengthened time between injury occurrence and injury reporting. The athlete may have been weight bearing during the early callus formation, but healing may have been prohibited. Also, vascularization in the area is already limited and may also have played a role in delayed bone growth.

Conclusions: Although the return to participation was longer than expected, the rehabilitation program was successful in returning the athlete to competition.
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NewsBot · Dec 18, 2013

Re: Proximal fifth metetarsal fractures

The accuracy of bedside ultrasonography as a diagnostic tool for the fifth metatarsal fractures.
Yesilaras M1, Aksay E2, Atilla OD2, Sever M2, Kalenderer O3.
Am J Emerg Med. 2013 Nov 12.

OBJECTIVES:
Musculoskeletal ultrasonography is a technique that is becoming more popular in diagnosing injuries of emergency department (ED) patients especially for the diagnosis of fractures. In this study, we determined the reliability of ultrasonography for the diagnosis of fractures of the fifth metatarsal.
METHOD:
This is a prospective blind study. Patients over 14 years old who were admitted to the ED with acute foot injury and who had tenderness on the fifth metatarsal were consecutively enrolled into the study. A bedside ultrasonography exam was performed by an emergency physician, and antero-posterior and oblique views were obtained. X-rays were blindly evaluated by an orthopedic surgeon and were considered to be the gold-standard for diagnosing fractures. In patients with noncomminuted fractures, bone displacement was measured by both radiologically and sonographically.
RESULTS:
Eighty-four patients were included in this study. Their mean age was 36.0, and 42.9% were male. Fractures were diagnosed by both x-ray and ultrasonography in 33 patients. In one patient, the x-ray was positive for fracture, while ultrasonography yielded a negative result. For the fractures of fifth metatarsal, the diagnostic sensitivity of ultrasonography was 97.1%, the specificity was 100%, the positive likelihood ratio was infinity, the negative likelihood ratio was 0.03. Mean displacement was 1.2 ± 0.7 mm with x-ray and 1.8 ± 1.5 mm with ultrasonography. The intraclass correlation coefficient of displacement measured by x-ray and ultrasonography was ĸ: 0.388.
CONCLUSION:
Ultrasonography is a reliable diagnostic tool for acute fifth metatarsal fractures.
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NewsBot · Jan 25, 2014

Re: Proximal fifth metetarsal fractures

Radiographic classification for fractures of the fifth metatarsal base
Alexander T. Mehlhorn, Jörn Zwingmann, Anja Hirschmüller, Norbert P. Südkamp, Hagen Schmal
Skeletal Radiology; January 2014

Objective
Avulsion fractures of the fifth metatarsal base (MTB5) are common fore foot injuries. Based on a radiomorphometric analysis reflecting the risk for a secondary displacement, a new classification was developed.
Materials and methods
A cohort of 95 healthy, sportive, and young patients (age ≤ 50 years) with avulsion fractures of the MTB5 was included in the study and divided into groups with non-displaced, primary-displaced, and secondary-displaced fractures. Radiomorphometric data obtained using standard oblique and dorso-plantar views were analyzed in association with secondary displacement. Based on this, a classification was developed and checked for reproducibility.
Results
Fractures with a longer distance between the lateral edge of the styloid process and the lateral fracture step-off and fractures with a more medial joint entry of the fracture line at the MTB5 are at higher risk to displace secondarily. Based on these findings, all fractures were divided into three types: type I with a fracture entry in the lateral third; type II in the middle third; and type III in the medial third of the MTB5. Additionally, the three types were subdivided into an A-type with a fracture displacement <2 mm and a B-type with a fracture displacement ≥ 2 mm. A substantial level of interobserver agreement was found in the assignment of all 95 fractures to the six fracture types (κ = 0.72). The secondary displacement of fractures was confirmed by all examiners in 100 %.
Conclusions
Radiomorphometric data may identify fractures at risk for secondary displacement of the MTB5. Based on this, a reliable classification was developed.
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NewsBot · Feb 1, 2014

Re: Proximal fifth metetarsal fractures

This clinical trial just got registered:

Hard-soled Shoe Versus Short Leg Walking Cast for a Fifth Metatarsal Avulsion Fracture: A Randomized Multicenter Noninferiority Trial

Fifth metatarsal avulsion fractures are common and can usually be treated conservatively. Symptomatic care consisting of protected weightbearing in a hard-soled shoe, air-cast walking boot, or below-knee walking cast have been successful. Several papers reported that early rehabilitation may decrease ankle stiffness, muscle and bone atrophy, and aids in early return to activities. However, early motion of the ankle joint may have the risk of displacement of the fifth metatarsal avulsion fractures. However, studies using hard-sole shoe for protected weightbearing and allowing motion of the ankle joint had successful results. Clapper et al. compared the results of hard-soled shoe and walking cast for a fifth metatarsal avulsion fracture and reported that all avulsion fractures healed uneventfully and that the results were similar between the two. However, this was not a randomized controlled trial.

Devices such as air-cast walking boot, plaster slipper, or Jone's dressing can also be used for the treatment. However, we decided to compare results of hard-soled shoe and short leg walking cast for the treatment of a fifth metatarsal avulsion fracture.

We hypothesized that the 100mm visual analogue scale (VAS) assessed on 6 months after a fifth metatarsal avulsion fracture treated with protected weightbearing in a hard-soled shoe is not inferior to protected weightbearing in a short leg walking cast but is superior to short leg walking cast with respect to time to return to normal daily life and patient's satisfaction.
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NewsBot · Jun 1, 2014

Re: Proximal fifth metetarsal fractures

Site-specific loading at the fifth metatarsal base in rehabilitative devices: Implications for Jones fracture treatment.
Hunt KJ, Goeb Y, Esparza R, Malone M, Shultz R, Matheson G.
PM R. 2014 May 28. pii: S1934-1482(14)00243-3.

BACKGROUND:
Fractures of the fifth metatarsal base are a relatively common injury. Whether treated surgically or non-surgically, injury rehabilitation typically involves immobilization in a rigid sandal or short CAM walker boot.
OBJECTIVE:
The primary objective of this study is to determine the peak pressure, contact pressure, and impulse at the base of the fifth metatarsal in three common footwear devices during common gait activities.
DESIGN:
Retrospective comparative study SETTING: Research was conducted in a sports performance laboratory at a university.
PARTICIPANTS:
Twenty subjects without a recent history of foot injuries volunteered to participate. Methods: Each subject performed three common gait activities (walking, heel walking, and pivoting) in three footwear devices (short CAM walker boot, post-op sandal, running shoe). Pressure data was sampled (100Hz) using individually sized plantar pressure insoles and software (Tekscan). Walking trials were collected at 1.0m/s +/- 5% (FusionSport Timing Gates).
OUTCOME MEASUREMENTS:
Peak pressure, contact pressure, and impulse at the fifth metatarsal base region were determined for all trials for all subjects. Mixed-effect regression models were used to compare pair-wise differences in outcome variables between footwear devices. Results: The CAM walker boot resulted in significantly lower peak pressure at the fifth metatarsal during walking and heel-walking relative to the post-op sandal (p <.01) and during heel-walking (p<.01) relative to the standard athletic shoe. The CAM walker boot significantly reduced contact pressures at the fifth metatarsal during walking and heel-walking relative to the post-op sandal (p <.01), and during heel-walking relative to the standard athletic shoe (p<.001).

Conclusions: Our results suggest that the short CAM walker boot more effectively offloads the fifth metatarsal during common gait activities than a post-operative sandal or a standard athletic shoe. A short CAM walker boot may be a beneficial rehabilitative tool for patients undergoing rehabilitation after treatment of Jones fractures and other base of fifth metatarsal fractures.
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NewsBot · Jun 21, 2014

Re: Proximal fifth metetarsal fractures

Functional outcome of fifth metatarsal fractures
E. Bigsby, R. Halliday, R.G. Middleton, R. Case, W. Harries
Injury; Articles in Press

Intro
Fifth metatarsal fractures are common and outcome has been reported, however, prospective studies reporting 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 fracture type influences outcome.
Methods
One hundred and seventeen patients (62 avulsion fractures, 26 Jones fractures, 29 shaft fractures) were followed-up over the course of a year (1 month, 4 months, 12 months), with assessment of functional outcome assessed using the FFI and SF36 validated questionnaires.
Results
The 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 over 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.
Conclusions
While 25%–33% of patients continue to experience pain at 1 year, less than 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.
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NewsBot · Aug 7, 2014

Re: Proximal fifth metetarsal fractures

The Effect Of Peroneus Brevis Tendon Anatomy On Stability Of Fractures At The Fifth Metatarsal Base
Lutul D. Farrow et al
Orthopaedic Journal of Sports Medicine July 2014 vol. 2 no. 2 suppl

Objectives: Fractures of the fifth metatarsal base are not uncommon. Both fracture management and outcomes can differ greatly depending on fracture location. The purpose of the present study is to evaluate the influence of the peroneus brevis (PB) tendon on proximal fifth metatarsal fracture stability. We hypothesize that proximal fifth metatarsal fractures distal to the PB tendon footprint are inherently less stable than more proximal fractures.

Methods: We utilized 5 matched pairs of fresh-frozen cadaveric specimens. We carefully exposed the 5th metatarsal and PB tendon. We measured the length of the PB insertion at the base of the fifth metatarsal with calipers. The PB and Achilles tendons were then whip-stitched proximally to facilitate loading. A custom leg holder was fabricated to allow loading and fluoroscopic evaluation. Two conditions were utilized for biomechanical testing; (1) a simulated fracture distal to the PB insertion (Jones equivalent) and (2) a simulated fracture within the footprint of the PB insertion (avulsion equivalent). All fractures were carefully created with a narrow osteotome. Following fracture creation, the plantar flexed foot was statically loaded through the Achilles and PB tendons. Oblique images with and without loading and digital measurements were performed to evaluate for fracture separation. We utilized a paired student T test and intraclass correlation coefficient (ICC) for all statistical analysis.

Results: The average length of the PB footprint was 15.2 mm. Compared to fractures within the PB footprint, fractures distal to the PB tendon insertion demonstrated greater fracture widening following loading of the PB tendon. Fractures within the PB footprint widened 0.4 mm on loading (Figure 1A to 1B) compared to 1.1 mm of widening in the fractures distal to the PB insertion (Figure 1C to 1D). This difference was significant (p = 0.02). Intraobserver reliability for all radiographic measurements showed substantial agreement.

Conclusion: Avulsion fractures at the base of the fifth metatarsal have much better healing potential than the so-called Jones fracture. Poor vascularity has been cited as a cause for poor healing potential following Jones fractures. The principal findings of this study demonstrate that proximal fifth metatarsal fractures distal to the PB insertion are significantly more unstable than more proximal fractures. In our study, the PB exerts a deforming force on the proximal fragment of fractures distal to the PB footprint. This deforming force was less pronounced in fractures within the PB footprint. Our findings help support the notion that a mechanical component may contribute to the poor healing potential of Jones fractures secondary to deformation exerted by the PB tendon. This would help explain why screw fixation is often recommended to address Jones fractures. Further research is needed to evaluate the biomechanics of these fractures.
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NewsBot · Feb 10, 2015

Re: Proximal fifth metetarsal fractures

The Epidemiology of Fifth Metatarsal Fracture
Justin M. Kane et al
Foot Ankle Spec February 9, 2015

Background. A paucity of data exists studying the epidemiology of fifth metatarsal fractures. While a number of studies exist focusing on specific fracture patterns and patient populations, a large comprehensive epidemiologic study on the general public does not.
Objective. We reviewed 1275 fifth metatarsal fractures treated at a multicenter orthopaedic practice attempting to classify mechanism of injury and patient demographics as they pertain to specific fracture patterns.
Methods. Patient demographics were recorded and fractures categorized by location and mechanism of injury. Demographics and mechanism of injury were assessed to determine their predictive value for the type of fracture.
Statistical analysis was used to predict whether demographics and mechanism of injury were statistically significant for types of fractures and whether gender and age were positive predictive values for fifth metatarsal fractures.
Results. Twisting injuries were a statistically significant predictor of zone 1 injuries. A significant correlation between gender and fracture location was seen with women sustaining 75% of zone 1 injuries and 84% of dancer’s fractures. A positive predictive value existed for age and gender with respect to the incidence of fractures. Males accounted for more fractures among younger patients and females accounting for the majority of fractures among older patients.
Conclusion. Mechanism of injury is a predictor for fracture location. Gender and age have a role in fracture incidence. In younger patient populations, males account for the majority of fifth metatarsal fractures. In older patient populations, females account for the majority of fifth metatarsal fractures.
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NewsBot · Mar 12, 2015

Re: Proximal fifth metetarsal fractures

Likelihood of Surgery in Isolated Pediatric Fifth Metatarsal Fractures
Mahan, Susan T. MD, MPH; Hoellwarth, Jason S. MD; Spencer, Samantha A. MD; Kramer, Dennis E. MD; Hedequist, Daniel J. MD; Kasser, James R. MD
Journal of Pediatric Orthopaedics: April/May 2015 - Volume 35 - Issue 3 - p 296–302

Background: Fractures of the fifth metatarsal bone are common and surgery is uncommon. The “Jones” fracture is known to be in a watershed region that often leads to compromised healing, however, a “true Jones” fracture can be difficult to determine, and its impact on healing in pediatric patients is not well described. The purpose of this study was to retrospectively assess patterns of fifth metatarsal fracture that led to surgical fixation in an attempt to predict the likelihood for surgery in these injuries.

Methods: A retrospective review was performed on patients aged 18 and under who were treated for an isolated fifth metatarsal fracture from 2003 through 2010 at our pediatric hospital. Patient demographics, treatment, and complications were noted. Radiographs were reviewed for location of fracture and fracture displacement. Patients and fracture characteristics were then compared.

Results: A total of 238 fractures were included and 15 were treated surgically. Most surgical indications were failure to heal in a timely manner or refracture and all patients underwent a trial of nonoperative treatment. Jones criteria for fracture location were predictive of needing surgery (P<0.01) but confusing in the clinic setting. Fractures that occurred between 20 and 40 mm (or 25% to 50% of overall metatarsal length) from the proximal tip went on to surgery in 18.8% (6/32) of the time, whereas those that occurred between <20 mm had surgery in 4.9% (9/184). This was a statistically significant correlation (P=0.0157).

Conclusions: Although fractures of the fifth metatarsal are common, need for surgery in these fractures is not. However, a region of this bone is known to have trouble healing, and it can be difficult to identify these “at-risk” fractures in the clinical setting. We found simple ruler measurement from the proximal tip of the fifth metatarsal to the fracture to help determine this “at-risk” group and found a significant difference in those patients with a fracture of <20 mm compared with those 20 to 40 mm from the tip; this can help guide treatment and counsel patients.
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NewsBot · Mar 15, 2015

Re: Proximal fifth metetarsal fractures

Designing a Prognostic Scoring System for Predicting the Outcomes of Proximal
Fifth Metatarsal Fractures at 20 Weeks.
Tahririan MA, Momeni A, Moayednia A, Yousefi E.
Iran J Med Sci. 2015;40(2):104-109.

Background: Fractures of the proximal fifth metatarsal bone
are among the most common fractures observed in the foot and
their classification and management has been subject to much
discussion and disagreement. In this study, we aim to identify
and quantify the effect of possible predictors of the outcome of
the treatment of proximal fifth metatarsal fractures.
Methods: Patients with established proximal fifth metatarsal
fractures were enrolled in this prospective cohort and the
outcome of their treatment was assessed using the AOFAS mid
foot scale at 6 and 20 weeks.
Results: 143 patients were included in the study. Our study
showed that displacement, weight and type III fractures were
significant independent predictors of poor outcome at 6 weeks
while at 20 weeks in addition to these factors, gender and diabetes
mellitus were also shown to be significant independent predictors
of poor outcome. A scoring system was designed by assigning
weight to these factors and it was shown to be a strong predictor
of outcome at 20 weeks.
Conclusion: We recommend that our scoring system would
help surgeons to decide whether patients’ prognostic factors are
significant enough for him/her to opt for a surgical approach to
treatment rather than a conservative approach.
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NewsBot · May 14, 2015

Re: Proximal fifth metetarsal fractures

Base fractures of the fifth proximal phalanx can be treated conservatively with buddy taping and immediate mobilisation.
Vadstrup LS, Jørring S, Bernt P, Boeckstyns ME.
Dan Med J. 2014 Aug;61(8):A4882.

INTRODUCTION:
Treatment of base fractures in the proximal phalanx depends on the fracture type, the degree of displacement and whether fracture reduction is stable or not. Internal fixation often leads to decreased mobility of the injured finger despite exact reduction of the fracture. Our treatment is focused upon function and to a lesser extent on exact reposition of the fractured fifth digit. Buddy taping was used after initial, closed reduction of the fracture allowing for immediate mobilisation.
MATERIAL AND METHODS:
This was a prospective follow-up study of 53 consecutive conservatively managed base fractures in 53 patients with a mean age of 39 years. All fractures were treated with buddy taping to the fourth digit and immediate mobilisation.
RESULTS:
The subjective outcome showed high overall satisfaction, and only four patients reported mild pain at rest or work. Malrotation was noted in three cases, none of which needed corrective surgery. All but one patient regained full flexion of the affected finger. Satisfactory extension was seen as only two patients had a lack of extension in both the metacarpo-phalangeal and the proximal interphalangeal joint. No nonunion or delayed unions occurred.
CONCLUSION:
In the literature there is no consensus on the treatment of fractures in the base of the proximal phalanx in the fifth digit. We propose conservative management with buddy taping which enables immediate mobilisation of this particular fracture.
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NewsBot · May 23, 2015

Re: Proximal fifth metetarsal fractures

A Retrospective Review of the Effect of Metatarsus Adductus on Healing Time in the Fifth Metatarsal Jones Fracture
Robert M. Yoho, Vassilios Vardaxis, Jeffrey Dikis
The Foot; Article in Press

Highlights
•There exist biomechanical risks factors should be taken into considerate for the Jones fracture.
•Healing time in the Jones fracture is highly related to metatarsus adductus.
•A predictive bone healing time algorithm based on the metatarsus adductus angle is presented.
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Purpose
The fifth metatarsal Jones fracture is a unique injury. Previous studies have identified possible biomechanical risk factors related to this fracture, as well as potential subsequent effects on bone healing complications. The purpose of this retrospective study was to determine the effect of metatarsus adductus (MAA) on bone healing in patients following intramedullary screw fixation of the Jones fracture.

Methods
This study reviewed 14 Jones fractures that underwent intramedullary screw fixation. Serial radiographs taken approximately every two weeks were evaluated to determine bone healing time (BHT). Weight-bearing antero-posterior radiographs were used to determine the MAA using standard osseous landmarks.

Results
There was a strong positive correlation between MAA and BHT. Moderate correlations were also found between age and BHT and between age and MAA. A prediction algorithm derived from the regression model shows that 63.2% of the variability in the Jones fracture healing time (BHT) can be predicted by a minimum of 22.7 days increased by an average of 1.23 days for each degree of MAA.

Conclusion
This study suggests healing time in Jones fractures to be highly related to the MAA following intramedullary screw fixation. The ability to predict osseous union of Jones fracture offers advantages such as patient expectations as well as individualized rehabilitation programs.
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NewsBot · May 24, 2015

Re: Proximal fifth metetarsal fractures

A Retrospective Review of the Effect of Metatarsus Adductus on Healing Time in the Fifth Metatarsal Jones Fracture
Robert M. Yohc, Vassilios Vardaxis, Jeffrey Dikis
The Foot; Article in Press

Highlights
•There exist biomechanical risks factors should be taken into considerate for the Jones fracture.
•Healing time in the Jones fracture is highly related to metatarsus adductus.
•A predictive bone healing time algorithm based on the metatarsus adductus angle is presented.
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Purpose
The fifth metatarsal Jones fracture is a unique injury. Previous studies have identified possible biomechanical risk factors related to this fracture, as well as potential subsequent effects on bone healing complications. The purpose of this retrospective study was to determine the effect of metatarsus adductus (MAA) on bone healing in patients following intramedullary screw fixation of the Jones fracture.

Methods
This study reviewed 14 Jones fractures that underwent intramedullary screw fixation. Serial radiographs taken approximately every two weeks were evaluated to determine bone healing time (BHT). Weight-bearing antero-posterior radiographs were used to determine the MAA using standard osseous landmarks.

Results
There was a strong positive correlation between MAA and BHT. Moderate correlations were also found between age and BHT and between age and MAA. A prediction algorithm derived from the regression model shows that 63.2% of the variability in the Jones fracture healing time (BHT) can be predicted by a minimum of 22.7 days increased by an average of 1.23 days for each degree of MAA.

Conclusion
This study suggests healing time in Jones fractures to be highly related to the MAA following intramedullary screw fixation. The ability to predict osseous union of Jones fracture offers advantages such as patient expectations as well as individualized rehabilitation programs.
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NewsBot · Jun 15, 2015

Re: Proximal fifth metetarsal fractures

The peroneus brevis tendon at its insertion site on fifth metatarsal bone
Nurcan İmre, Necdet Kocabiyik, Murat Uysal, Hatice Tuba Sanal, Fatih Yazar, Hasan Ozan
Foot and Ankle Surgery; Published Online: June 13, 2015

The differences at the attachment site of peroneus brevis (PB) to the fifth metatarsal bone is important in terms of the forces exerted on the bone and hence the mechanism of fractures involving this structure. In this study, we investigated the anatomical properties of PB at the intertion site to the base of fifth metatarsal bone, its possible intertendinous connections with peroneus tertius (PT) and their possible effects on the fracture occurance at the bony attachment site. The length and the width of PB tendons at their mid-and end- points were measured and classified according to the intertion types. Besides, the length and the width of the base of fifth metatarsal bone were assessed. The slips extending from the PB tendons and their relationship with PT were also evaluated. The data was compared statistically with each other and between the right and left sides. The length of PB tendon was measured 79.57 ± 15.40 mm on the right side; 81.48 ± 14.31 mm on the left. The width of PB tendon at the mid-point was 4.46 ± 0.80 mm on the right side; 4.42 ± 0.94 mm on the left. The width of the tendon at its insertion point was measured 14.85 ± 3.40 mm and 15.16 ± 3.42 mm on the right and left sides respectively. PB was divided into three types according to its attachment to base of fifth metatarsal bone (5thMB). Type I, Type II and Type III were observed at the rates of 59.5%, 28.6% and 11.5% respectively. It was observed that the slips to the bone were extending more commonly from PB than from PT and that the large majority of them was single having their insertions on the base of the proximal phalanx of the fifth toe. Knowing the width and intertional types of PB aids in understanding the mechanism of fractures at the site of bony attachment. The existance of slips may help the surgeon in the procedures involving PB or the lateral side of the forefoot.
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NewsBot · Jul 2, 2015

Re: Proximal fifth metetarsal fractures

Failed Surgical Management of Acute Proximal Fifth Metatarsal (Jones) Fractures
A Retrospective Case Series and Literature Review
Jaymes D. Granata et al
Foot Ankle Spec June 30, 2015

Nonunion, delayed union, and refracture after operative treatment of acute proximal fifth metatarsal fractures in athletes is uncommon. This study was a failure analysis of operatively managed acute proximal fifth metatarsal fractures in healthy athletes. We identified 149 patients who underwent operative treatment for fifth metatarsal fractures. Inclusion criteria isolated skeletally mature, athletic patients under the age of 40 with a minimum of 1-year follow-up. Patients were excluded with tuberosity fractures, fractures distal to the proximal metaphyseal-diaphyseal region of the fifth metatarsal, multiple fractures or operative procedures, fractures initially treated conservatively, and medical comorbidities/risk factors for nonunion. Fifty-five patients met the inclusion/exclusion criteria. Four (7.3%) patients required a secondary operative procedure due to refracture. The average time to refracture was 8 months. All refractures were associated with bent screws and occurred in male patients who participated in professional basketball, professional volleyball, and college football. The average time for release to progressive weight-bearing was 6 weeks. Three patients were revised to a bigger size screw and went on to union. One patient was revised to the same-sized screw and required a second revision surgery for nonunion. All failures were refractures in competitive athletes who were initially treated with small diameter solid or cannulated stainless steel screws. The failures were not associated with early postoperative weight-bearing protocol. Maximizing initial fixation stiffness may decrease the late failure rate in competitive athletes. More clinical studies are needed to better understand risk factors for failure after screw fixation in the competitive, athletic population.
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NewsBot · Aug 12, 2015

Re: Proximal fifth metetarsal fractures

Jones fracture of the fifth metatarsal: Is operative intervention justified? A systematic review of the literature and meta-analysis of results
Jeffrey Yates, Iain Feeley, Sanskriti Sasikumar, Gurender Rattan, Ailish Hannigan, Eoin Sheehan
The Foot; Article in Press

Highlights
•Fractures of the metatarsal bones are a common injury presenting to orthopaedic clinics with a reported incidence of 6.7 fractures per 10,000 people.
•There is lack of clarity in the literature surrounding classification and treatment of Jones’ fractures, and the natural history of healing of Jones fractures has been shown to be suboptimal.
•Our meta-analysis showed a statistically significant difference in the odds of nonunion in those treated conservatively against those who underwent surgical intervention (29/122 vs. 3/115, OR 5.74, 95% CI 2.65–12.40, P < 0.001, I2 = 0%).
•We found there to be a lower non-union rate, faster time to union and return to sports and activity in patients who underwent operative therapy.
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Background
This study assesses the outcomes of surgical versus conservative management in the treatment of the Jones fracture.

Materials and Methods
A systematic review using four databases from their inception until September 2014 was undertaken. Six studies were found evaluating operative therapy compared to conservative treatment.

Results
Six relevant studies were included, with a total of 237 patients. Of these, 51% were treated non-operatively, and 49% had surgical intervention. Those in the non-operative group were found to have a significantly higher odds ratio (OR) of fracture non-union (OR 5.74, 95% Confidence interval (CI) 2.65–12.40, P < 0.001). Studies also reported a prolonged healing time and a longer time to return to sports. Of the trials with time to union as an outcome measure, 3 of 4 trials found favourable results in the operative cohort.

Conclusions
Surgical intervention is recommended for patients presenting with a Jones fracture as it is found to result in a lesser non-union rate and an improved time to union.
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NewsBot · Sep 10, 2015

Re: Proximal fifth metetarsal fractures

Return to Play in National Football League Players After Operative Jones Fracture Treatment
Craig R. Lareau, MD; Andrew R. Hsu, MD; Robert B. Anderson, MD
Foot & Ankle International September 9, 2015

Background: Jones fractures commonly occur in professional athletes and operative treatment remains the standard of care in this patient population. In our clinical experience, an aggressive postoperative rehabilitation protocol for National Football League (NFL) players with an average return to play (RTP) between 8 and 10 weeks can have successful outcomes with few complications. The purpose of this study was to quantify RTP and rate of complications, including nonunion, refracture, and reoperation among a cohort of NFL players with operatively treated Jones fractures.
Methods: Between 2004 and 2014, 25 consecutive NFL players who underwent acute Jones fracture fixation by a single surgeon were reviewed. Operative treatment for the majority of patients involved fixation with a Jones-specific intramedullary screw and iliac crest bone marrow aspirate with demineralized bone matrix injected at the fracture site. Additionally, our protocol involved the use of noninvasive bone stimulators, application of customized orthoses, and an aggressive patient-specific rehabilitation protocol. Patient demographics were recorded along with position played, seasons played after surgery, RTP, and complications. RTP was defined as the ability to play in a single regular-season NFL game after surgery. At the time of surgery, average age for all patients was 24.0 years and BMI 31.0.
Results: Player positions included 8 wide receivers, 4 linebackers, 4 tight ends, 2 defensive tackles, 2 cornerbacks, 1 offensive tackle, 1 center, 1 tackle, 1 defensive end, and 1 quarterback. Seventy-six percent of players underwent operative fixation during their first 3 seasons. Forty-eight percent were diagnosed before or during their rookie (first) season.
RTP was 100% for all players and 80% were still playing at time of publication. Three patients (12.0%) refractured and required revision surgery. Time until RTP was influenced by other variables and difficult to measure because many surgeries were performed early in the offseason. All 9 players who underwent surgery between July and October, and were therefore eligible to return to play in the same season, had an average RTP of 8.7 weeks (range 5.9-13.6).
Conclusion: With an appropriately placed intramedullary screw and an aggressive rehabilitation protocol, early RTP was achievable with a low refracture rate in professional athletes. All NFL players in this series were able to return to play after surgery. We observed that these injuries were more likely to occur in the first 3 seasons of play and in wide receivers, linebackers, and tight ends. This at-risk subset of players may benefit from improved preventative measures.
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NewsBot · Sep 19, 2015

Re: Proximal fifth metetarsal fractures

Pathogenesis of Fifth Metatarsal Fractures in College Soccer Players
Kohei Fujitaka et al
Orthopaedic Journal of Sports Medicine September 2015 vol. 3 no. 9

Background: The pathogenesis of fifth metatarsal stress fractures remains uncertain.
Hypothesis: Physical characteristics and environmental factors, which have received limited attention in the literature thus far, might be involved in the development of fifth metatarsal stress fractures.
Study Design: Case-control study; Level of evidence, 3.
Methods: To test the study hypothesis, a medical examination and survey of the living environment of collegiate soccer players was conducted and correlated with the existence of fifth metatarsal stress fractures. The survey and measurements were conducted in 273 male athletes from the same college soccer team between 2005 and 2013. A medical examination comprising assessment of stature, body weight, body mass index, foot?arch height ratio, toe-grip strength, quadriceps angle, leg-heel angle, functional reach test, single-leg standing time with eyes closed, straight-leg raise angle, finger-floor distance, heel-buttock distance, ankle joint range of motion, and a general joint laxity test were performed once a year, along with a questionnaire survey. The survey was also repeated when a fifth metatarsal stress fracture was diagnosed. The study participants were separated into a fifth metatarsal stress fracture injury group and a noninjury group. The measurement items and survey items were compared, and the association between the factors and the presence or absence of injuries was analyzed.
Results: Toe-grip strength was significantly weaker in the injury group compared with the noninjury group, suggesting that weak toe-grip is associated with fifth metatarsal stress fracture (P < .05). In addition, fifth metatarsal stress fractures were more common in the nondominant leg (P < .05). Between-group comparisons of the other items showed no statistically significant differences.
Conclusion: The association between weak toe-grip strength and fifth metatarsal fracture suggests that weak toe-grip may lead to an increase in the load applied onto the lateral side of the foot, resulting in stress fracture. The finding of stress fracture being more common in the nondominant leg needs further study.
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NewsBot · Oct 2, 2015

Re: Proximal fifth metetarsal fractures

Plate Fixation of Proximal Fifth Metatarsal Fracture.
Assaf Kadar, Ran Ankory, Ronen Karpf, Elhanan Luger, and Shlomo Elias
Journal of the American Podiatric Medical Association: September 2015, Vol. 105, No. 5, pp. 389-394.

Background: Intramedullary screw fixation of fractures of the proximal fifth metatarsal bone may not be satisfactory in comminuted fractures or when the lateral metatarsal bowing has to be restored. We report our experience with plate fixation in these circumstances.

Methods: Between June 1, 2009, and January 31, 2013, 13 patients who had comminuted fracture or nonunion of fracture of the proximal fifth metatarsal bone underwent plate fixation. Study patients were followed up for a mean of 500 days (range, 51?1238 days). Their medical records and radiographs were retrospectively reviewed for demographic and operative data and radiologic evidence of fracture healing. At their most recent follow-up, patients were evaluated for pain levels with a visual analog scale, for foot function with the Foot and Ankle Disability Index, and for quality of life with the 12-Item Short-Form Health Survey.

Results: Fracture union was evident in 12 patients after a mean of 56.8 days (range, 30?92 days). There was only one major complication of sural nerve neuroma and reflex sympathetic dystrophy. Four patients required reoperation for plate removal. Plate fixation of proximal fifth metatarsal comminuted fractures is associated with high union rates, relief of pain, and patient satisfaction. However, plate removal for various reasons was required in approximately one-third of the study patients. This high revision rate might be avoided by better selection of patients and meticulous intraoperative identification and preservation of the sural nerve.

Conclusions: We recommend reserving plate fixation for proximal fifth metatarsal fractures for cases of laterally bowed fifth metatarsal or comminuted fractures.
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NewsBot · Nov 5, 2015

Re: Proximal fifth metetarsal fractures

Pathogenesis of Fifth Metatarsal Fractures in College Soccer Players.
Fujitaka K et al
Orthop J Sports Med. 2015 Sep 18;3(9):2325967115603654

BACKGROUND:
The pathogenesis of fifth metatarsal stress fractures remains uncertain.
HYPOTHESIS:
Physical characteristics and environmental factors, which have received limited attention in the literature thus far, might be involved in the development of fifth metatarsal stress fractures.
STUDY DESIGN:
Case-control study; Level of evidence, 3.
METHODS:
To test the study hypothesis, a medical examination and survey of the living environment of collegiate soccer players was conducted and correlated with the existence of fifth metatarsal stress fractures. The survey and measurements were conducted in 273 male athletes from the same college soccer team between 2005 and 2013. A medical examination comprising assessment of stature, body weight, body mass index, foot-arch height ratio, toe-grip strength, quadriceps angle, leg-heel angle, functional reach test, single-leg standing time with eyes closed, straight-leg raise angle, finger-floor distance, heel-buttock distance, ankle joint range of motion, and a general joint laxity test were performed once a year, along with a questionnaire survey. The survey was also repeated when a fifth metatarsal stress fracture was diagnosed. The study participants were separated into a fifth metatarsal stress fracture injury group and a noninjury group. The measurement items and survey items were compared, and the association between the factors and the presence or absence of injuries was analyzed.
RESULTS:
Toe-grip strength was significantly weaker in the injury group compared with the noninjury group, suggesting that weak toe-grip is associated with fifth metatarsal stress fracture (P < .05). In addition, fifth metatarsal stress fractures were more common in the nondominant leg (P < .05). Between-group comparisons of the other items showed no statistically significant differences.
CONCLUSION:
The association between weak toe-grip strength and fifth metatarsal fracture suggests that weak toe-grip may lead to an increase in the load applied onto the lateral side of the foot, resulting in stress fracture. The finding of stress fracture being more common in the nondominant leg needs further study.
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NewsBot · Nov 14, 2015

Re: Proximal fifth metetarsal fractures

Treatment of proximal fifth metatarsal bone fractures in athletes.
Japjec M et al
Injury. 2015 Nov 9

Proximal fifth metatarsal (V MT) bone fractures are common injuries that are a major diagnostic and therapeutic challenge. Lawrence and Botte considered different treatment options and the possibility of recovery and divided these fractures into three different regions: tuberosity avulsion fractures (zone I), acute fractures of the metaphysis at the level of the intermetatarsal junction (zone II) and proximal diaphysis stress fracture (zone III). A total of 42 athletes with fracture of the V MT bone in zone II and III were treated in our institution during a 6-year period. All patients were offered surgical treatment, but nine patients refused surgery. Thus, the patients were divided into two groups: group 1 comprised 33 patients who underwent an intramedullary screw fixation operation under regional anaesthesia immediately after the fracture was diagnosed; group 2 contained the remaining nine patients who had refused surgery and received conservative therapy with non-weight-bearing short-leg casts or orthosis. Follow-up ranged from 6 to 24 months. All fractures healed in group 1: healing occurred within 8 weeks in 26 patients and was prolonged to 16 to 18 weeks in four patients. In group 2, fractures healed in four patients but did not heal in five patients even after 6 months. Four of the five patients in whom the fracture did not heal required subsequent osteosynthesis because they had constant problems that caused absence from sport. After the operation, their fractures healed in an average of 10 weeks. One patient decided not to undergo the operation due to the absence of subjective symptoms. Three patients in group 1 who started intensive training sustained a refracture and underwent re-operation in which osteosynthesis was performed with a stronger screw. The fractures then healed again. Treatment results were evaluated radiologically and clinically using the Modified Foot Score. Results in group 1 were significantly better than those in group 2 and there was an earlier return to full athletic activity. The authors concluded that intramedullary fixation of V MT zone II and III fractures with cannulated compression screws was associated with excellent functional results and early and complete recovery.
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NewsBot · Dec 2, 2015

Re: Proximal fifth metetarsal fractures

Return to Play and Performance After Jones Fracture in National Basketball Association Athletes
John P. Begly et al
Sports Health: A Multidisciplinary Approach December 1, 2015

Background: Basketball players are at risk for foot injuries, including Jones fractures. It is unknown how this injury affects the future play and performance of athletes.
Hypothesis: National Basketball Association (NBA) players who sustain Jones fractures of the base of the fifth metatarsal have high rates of return to play and do not experience a decrease in performance on return to competition when compared with preinjury and with control-matched peers.
Study Design: Retrospective cohort study.
Level of Evidence: Level 5.
Methods: Data on 26 elite basketball players with Jones fractures over 19 NBA seasons (1994-1995 to 2012-2013) were obtained from injury reports, press releases, player profiles, and online public databases. Variables included age, body mass index (BMI), player position, experience, and surgical treatment. Individual season statistics pre- and postinjury were collected. Twenty-six controls were identified by matched player position, age, and performance statistics.
Results: The mean age at the time of injury was 24.8 years, mean BMI was 24.7 kg/m2, and the mean experience prior to injury was 4.1 NBA seasons. Return to previous level of competition was achieved by 85% of athletes. There was no change in player efficiency rating (PER) when pre- and postinjury performance was compared. When compared with controls, no decline in PER measured performance was identified.
Conclusion: The majority of NBA players sustaining a Jones fracture return to their preinjury level of competition. These elite athletes demonstrate no decrease in performance on their return to play.
Clinical Relevance: Jones fractures are well-studied injuries in terms of etiology, diagnosis, and management. However, the effect of these injuries on future performance of athletes is unknown. Using the findings of our study, orthopaedic surgeons may be better prepared to counsel and educate elite athletes who sustain a Jones fracture.
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NewsBot · Dec 5, 2015

Re: Proximal fifth metetarsal fractures

Biomechanical Comparison of Intramedullary Screw Versus Low-Profile Plate Fixation of a Jones Fracture
Jeannie Huh et al
Foot & Ankle International December 4, 2015

Background: Intramedullary screw fixation of fifth metatarsal Jones fractures often produces satisfactory results, however, nonunion and refracture rates are not negligible. The low-profile “hook” plate is an alternative fixation method that has been promoted to offer improved rotational control at the fracture site, but this remains to be proven. The purpose of this study was to document biomechanical performance differences between this type of plate and a contemporary solid, dual-pitch intramedullary screw in a cadaveric Jones fracture model.
Methods: Simulated Jones fractures were created in 8 matched pairs of fresh-frozen cadaveric fifth metatarsals. One bone from each pair was stabilized using an intramedullary TriMed Jones Screw and the other using a TriMed Jones Fracture Plate (TriMed, Inc, Santa Clarita, CA). Controlled bending and torsional loads were applied. Bending stiffness and fracture site angulation, as well as torsional stiffness, peak torque, and fracture site rotation were quantified and compared.
Results: Intramedullary screw fixation demonstrated greater bending stiffness and less fracture site angulation than plate fixation during plantar-to-dorsal and lateral-to-medial bending. Torsional stiffness of screw-fixed metatarsals exceeded that of plate-fixed bones at initial loading; however, as rotation progressed, the plate resisted torque better than the screw. No difference in peak torque was demonstrable between fixation methods, but it was reached earlier in specimens fixed with screws and later in those fixed with plates as rotation progressed.
Conclusion: In this cadaveric Jones fracture model, intramedullary screw fixation demonstrated bending stiffness and resistance to early torsional loading that was superior to that offered by plate fixation.
Clinical Relevance: Although low-profile “hook” plates offer an alternative for fixation of fifth metatarsal Jones fractures, intramedullary screw fixation may provide better resistance to bending and initiation of fracture site rotation. The influence of these mechanical characteristics on fracture healing is unknown, and further clinical investigation is warranted.
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NewsBot · Dec 18, 2015

Re: Proximal fifth metetarsal fractures

Multiplanar CT Analysis of Fifth Metatarsal Morphology
Implications for Operative Management of Zone II Fractures
Bridget DeSandis et al
Foot & Ankle International December 17, 2015

Background: Percutaneous internal fixation is currently the method of choice treating proximal zone II fifth metatarsal fractures. Complications have been reported due to poor screw placement and inadequate screw sizing. The purpose of this study was to define the morphology of the fifth metatarsal to help guide surgeons in selecting the appropriate screw size preoperatively.
Methods: Multiplanar analysis of fifth metatarsal morphology was completed using computed tomographic (CT) scans from 241 patients. Specific parameters were analyzed and defined in anteroposterior (AP), lateral, and oblique views including metatarsal length, distance from the base to apex of curvature, apex medullary canal width, apex height, and fifth metatarsal angle.
Results: The average metatarsal length in the AP view was 71.4 ? 6.1 mm and in the lateral view 70.4 ? 6.0 mm, with 95% of patients having lengths between 59.3 and 83.5 mm and 58.4 and 82.4 mm, respectively. The average canal width at the apex of curvature was 4.1 ? 0.9 mm in the AP view and 5.3 ? 1.1 mm in the lateral view, with 95% of patients having widths between 2.2 and 5.9 mm and 3.2 and 7.5 mm, respectively. Average distance from apex to base was 42.6 ? 5.8 mm in the AP and 40.4 ? 6.4 mm in the lateral views. Every measurement taken in all 3 views had a significant correlation with height.
Conclusions: When determining screw length, we believe lateral radiographs should be used since the distance from the base of the metatarsal to the apex was smaller in the lateral view. On average, the screw should be 40 mm or less to reduce risk of distraction. For screw diameter, the AP view should be used because canal shape is elliptical, and width was found to be significantly smaller in the AP view. Most canals can accommodate a 4.0- or 4.5-mm-diameter screw, and one should use the largest diameter screw possible. Larger individuals were likely to have more bowing in their metatarsal shaft, which may lead to a higher tendency to distract.
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NewsBot · Jan 19, 2016

Re: Proximal fifth metetarsal fractures

Operative Treatment of Fifth Metatarsal Jones Fractures (Zones II and III) in the NBA
Martin O?Malley et al
Foot & Ankle International January 18, 2016

Background: Proximal fractures of the fifth metatarsal (zone II and III) are common in the elite athlete and can be difficult to treat because of a tendency toward delayed union, nonunion, or refracture. The purpose of this case series was to report our experience in treating 10 NBA players, determine the healing rate, return to play, refracture rate, and role of foot type in these athletes.
Methods: The records of 10 professional basketball players were retrospectively reviewed. Seven athletes underwent standard percutaneous internal fixation with bone marrow aspirate concentrate (BMAC) whereas the other 3 had open bone grafting primarily in addition to fixation and BMAC. Radiographic features evaluated included fourth-fifth intermetatarsal, fifth metatarsal lateral deviation, calcaneal pitch, and metatarsus adductus angles.
Results: Radiographic healing was observed at an overall average of 7.5 weeks and return to play was 9.8 weeks. Three athletes experienced refractures. There were no significant differences in clinical features or radiographic measurements except that the refracture group had the highest metatatarsus adductus angles. Most athletes were pes planus and 9 of 10 had a bony prominence under the fifth metatarsal styloid.
Conclusion: This is the largest published series of operatively treated professional basketball players who exemplify a specific patient population at high risk for fifth metatarsal fracture. These players were large and possessed a unique foot type that seemed to be associated with increased risk of fifth metatarsal fracture and refracture. This foot type had forefoot metatarsus adductus and a fifth metatarsal that was curved with a prominent base. We continue to use standard internal fixation with bone marrow aspirate but advocate additional prophylactic open bone grafting in patients with high fourth-to-fifth intermetatarsal, fifth metatarsal lateral deviation, and metatarsus adductus angles as well as prominent fifth metatarsal styloids in order to improve fracture healing and potentially decrease the risk of refracture.
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NewsBot · Feb 2, 2016

Re: Proximal fifth metetarsal fractures

From latest Podiatry Today:
Keys To Treating Proximal Fifth Metatarsal Fractures

NewsBot · Mar 19, 2016

Re: Proximal fifth metetarsal fractures

Operative Versus Nonoperative Treatment of Jones Fractures: A Decision Analysis Model.
Bishop JA, Braun HJ, Hunt KJ.
Am J Orthop (Belle Mead NJ). 2016 Mar-Apr;45(3):E69-E76.

Optimal management of metadiaphyseal fifth metatarsal fractures (Jones fractures) remains controversial. Decision analysis can optimize clinical decision-making based on available evidence and patient preferences. We conducted a study to establish the determinants of decision-making and to determine the optimal treatment strategy for Jones fractures using a decision analysis model. Probabilities for potential outcomes of operative and nonoperative treatment of Jones fractures were determined from a review of the literature. Patient preferences for outcomes were obtained by questionnaire completed by 32 healthy adults with no history of foot fracture. Derived values were used in the model as a measure of utility. A decision tree was constructed, and fold-back and sensitivity analyses were performed to determine optimal treatment. Nonoperative treatment was associated with a value of 7.74, and operative treatment with an intramedullary screw was associated with a value of 7.88 given the outcome probabilities and utilities studied, making operative treatment the optimal strategy. When parameters were varied, nonoperative treatment was favored when the likelihood of healing with nonoperative treatment rose above 82% and when the probability of healing after surgery fell below 92%. In this decision analysis model, operative fixation is the preferred management strategy for Jones fractures.
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NewsBot · May 29, 2016

Re: Proximal fifth metetarsal fractures

Symptomatic treatment or cast immobilisation for avulsion fractures of the base of the fifth metatarsal: a prospective, randomised, single-blinded non-inferiority controlled trial.
Akimau PI et al
Bone Joint J. 2016 Jun;98-B(6):806-811

AIMS:
The purpose of this study was to compare symptomatic treatment of a fracture of the base of the fifth metatarsal with immobilisation in a cast. Our null hypothesis was that immobilisation gave better patient reported outcome measures (PROMs). The alternative hypothesis was that symptomatic treatment was not inferior.
PATIENTS AND METHODS:
A total of 60 patients were randomised to receive four weeks of treatment, 36 in a double elasticated bandage (symptomatic treatment group) and 24 in a below-knee walking cast (immobilisation group). The primary outcome measure used was the validated Visual Analogue Scale Foot and Ankle (VAS-FA) Score. Data were analysed by a clinician, blinded to the form of treatment, at presentation and at four weeks, three months and six months after injury. Loss to follow-up was 43% at six months. Multiple imputations missing data analysis was performed.
RESULTS:
At four weeks and six months, symptomatic treatment proved non-inferior in terms of primary outcome.
TAKE HOME MESSAGE:
Immobilisation is no better than symptomatic treatment in the management of a fracture of the base of the fifth metatarsal when judged by PROMs. Significant loss to follow-up with this injury could be expected in longer term.
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NewsBot · Jun 11, 2016

Treatment of Acute Jones Fractures Without Weightbearing Restriction
Geoffrey S. Marecek et al
JFAS; Article in Press

Jones fractures are reportedly prone to nonunion and generally treated with a period of non-weightbearing or operative treatment. Extended non-weightbearing can have adverse effects, and operative treatment poses various risks. We report the clinical results of patients treated without weightbearing restriction. All patients treated for metatarsal fractures by a single surgeon from January 1, 2000 to December 31, 2009 were identified through the clinical billing records by International Classification of Diseases, ninth revision, code. Through a radiographic and medical record review, 27 consecutive patients with acute Jones fractures treated without weightbearing restriction were identified. The demographic information and clinical and radiographic results were recorded. Of the 27 patients, 24 (89%) had achieved clinical union at a mean of 8.0 ? 2.6 weeks. Complete radiographic union was noted in 13 (48%) patients, and 13 (48%) others had made significant progress toward radiographic union but had not yet reached it. Two (8.3%) patients were lost to follow-up. One patient (4%) developed nonunion. Patients with acute Jones fractures can be treated without weightbearing restriction. This protocol results in rapid clinical union and a low rate of nonunion.
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NewsBot · Jun 11, 2016

Comparison of clinical and radiologic outcomes between non-operative and operative treatment in 5th metatarsal base fractures (Zone 1).
Lee TH et al
Injury. 2016 May 20

The treatment of Zone 1 fractures of the 5th metatarsal base with >2mm of displacement remains controversial. We prospectively analyzed 29 patients with 5th metatarsal base fractures (Zone 1) during 2009-2014. Radiography was performed to assess the degree of fracture gap and metatarsal length. Patients with gaps of 2mm or less were treated conservatively using a short leg cast or splint (Group A), while patients with fracture gap >2mm were randomly assigned to one of two groups. Group B patients were managed with open reduction and internal fixation (ORIF), and Group C patients were placed in a short leg cast only. Visual analog scale (VAS) score and American orthopedic foot and ankle society (AOFAS) score were obtained at the initial consult and at the last follow-up after treatment; change of the 5th metatarsal length was also measured at the initial consult and after complete bony union. Our study demonstrated that radiographic union of all cases was observed with a significant decrease in VAS and AOFAS scores, regardless of the initial fracture gap and type of management. Additionally, there was no difference seen in final VAS scores for patients with longer metatarsals when compared to those in whom the metatarsals were unchanged or shortened.
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NewsBot · Jun 23, 2016

Return to Play and Performance After Jones Fracture in National Basketball Association Athletes
John P. Begly et al
Sports Health: A Multidisciplinary Approach July/August 2016 vol. 8 no. 4 342-346

Background: Basketball players are at risk for foot injuries, including Jones fractures. It is unknown how this injury affects the future play and performance of athletes.
Hypothesis: National Basketball Association (NBA) players who sustain Jones fractures of the base of the fifth metatarsal have high rates of return to play and do not experience a decrease in performance on return to competition when compared with preinjury and with control-matched peers.
Study Design: Retrospective cohort study.
Level of Evidence: Level 5.
Methods: Data on 26 elite basketball players with Jones fractures over 19 NBA seasons (1994-1995 to 2012-2013) were obtained from injury reports, press releases, player profiles, and online public databases. Variables included age, body mass index (BMI), player position, experience, and surgical treatment. Individual season statistics pre- and postinjury were collected. Twenty-six controls were identified by matched player position, age, and performance statistics.
Results: The mean age at the time of injury was 24.8 years, mean BMI was 24.7 kg/m2, and the mean experience prior to injury was 4.1 NBA seasons. Return to previous level of competition was achieved by 85% of athletes. There was no change in player efficiency rating (PER) when pre- and postinjury performance was compared. When compared with controls, no decline in PER measured performance was identified.
Conclusion: The majority of NBA players sustaining a Jones fracture return to their preinjury level of competition. These elite athletes demonstrate no decrease in performance on their return to play.
Clinical Relevance: Jones fractures are well-studied injuries in terms of etiology, diagnosis, and management. However, the effect of these injuries on future performance of athletes is unknown. Using the findings of our study, orthopaedic surgeons may be better prepared to counsel and educate elite athletes who sustain a Jones fracture.
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NewsBot · Jul 29, 2016

Dynamic Loading Assessment at the Fifth Metatarsal in Elite Athletes with a history of Jones Fracture
Kenneth Hunt, Yannick Goeb
Orthopaedic Journal of Sports Medicine July 2016 vol. 4 no. 7 suppl4

Objectives: Fractures of the proximal metaphysis of the fifth metatarsal (i.e., Jones fractures) are common in the athletic population and frequently require surgical fixation to optimize healing rates and return to sport. Subtle hindfoot varus alignment, which likely results in greater forces at the fifth metatarsal, has been associated with increased risk of Jones fractures due to presumed increase in forces on the lateral foot. The goal of the present study was to dynamically assess plantar pressure loads at the fifth metatarsal in elite athletes with a history of Jones fracture. We hypothesize that athletes who have suffered Jones fractures will apply significantly higher loads at the fifth metatarsal base during athletic activities compared to matched uninjured athletes.
Methods: Sixteen elite, competitive athletes were recruited to participate. Eight athletes had a history of Jones fracture and eight age, gender and position-matched athletes without a history of foot injury were recruited as controls. While wearing calibrated, wireless pressure mapping insoles, all athletes performed a standardized series of athletic movements including walking, running and cutting. Tests were repeated with the patient?s standard corrective insole. Peak pressure, mean pressure, maximum force, and force-time integral (i.e., impulse) were recorded for each activity. Comparison between groups was performed using a paired Wilcoxon Sign Rank test.
Results: Athletes with a history of Jones fracture showed a significantly increased peak pressure (183 ?23 kPA vs. 138?7 kPA), mean pressure (124?14 kPA vs. 95?4 kPA), and maximum force (15?1.2%BW vs. 12?1.2%BW) at the fifth metatarsal base during walking and running compared to uninjured matched controls (all P<0.05). Use of the corrective orthotic insole did not significantly reduce peak or mean pressure, maximum force, or impulse at the fifth metatarsal base during running or cutting.
Conclusion: Athletes with a history of Jones fracture exert significantly increased peak and mean forces at the base of the fifth metatarsal during common athletic activities. Standard corrective orthoses do not appear to offload this region in all cases. These increased loads may contribute to the development of stress injury to the fifth metatarsal during repetitive loading, and ultimately fracture of the bone. Identifying patients at risk for Jones fracture using dynamic loading assessment may facilitate an injury prevention program. Further study of orthotic devices, training programs, shoe wear, and devices designed to offload the fifth metatarsal is necessary.
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NewsBot · Oct 13, 2016

Can Fifth Metatarsal Morphology Predict Proximal Fifth Metatarsal Fracture Risk? A Radiographic Analysis of National Football League Players
Andrew J. Rosenbaum, MD et al
Foot & Ankle Orthopaedics September 2016 – December 2016 vol. 1 no. 1

Introduction/Purpose: Fractures of the proximal fifth metatarsal are one of the most common foot injuries in athletes. Unfortunately, optimal treatment is often challenging, as the repetitive stresses endured by the fifth metatarsal can lead to delayed union and refracture following treatment. We therefore performed a radiographic analysis of fifth metatarsal morphology and foot type in NFL players, in search of morphologic risk factors for these injuries.
Methods: NFL players treated by the senior authors between 1992 and 2012, as well as participants in the 2014 NFL Combine were evaluated. A total of 96 feet (51 athletes) were included. Fractures were present in 15 of the feet. Two reviewers assessed fifth metatarsal morphology and foot type on anteroposterior (AP), lateral and oblique radiographs, after receiving measurement training by the senior authors. Table 1 lists the specific parameters studied. Reviewers’ measurements were averaged, as were those from the radiographic series for each athlete. Differences in foot type and metatarsal morphology between athletes with and without fractures were determined via Student’s t-test analysis.
Results: Athletes had an average height of 6’2” (range 5’8” to 6’8”) ft’in”, weight of 251 (range 184 to 336) lbs, and age of 22.4 (range 21.0 to 26.0) years. Reviewers’ inter-observer reliability was generally good to very good. On AP radiographs, statistically significant differences in apex medullary canal width, 4-5 intermetatarsal angle, 5th metatarsal angle, and talar head uncovering were observed between fractured and non-fractured feet (p=0.001, 0.003, 0.004, 0.008, respectively; Table 1). On lateral radiographs, statistically significant differences in the 5th metatarsal length, distance to apex, apex height, 5th metatarsal angle, and talocalcaneal angle were observed between fractured and non-fractured feet (p=0.04, 0.01, 0.02, 0.01, 0.01, respectively; Table 1). On oblique radiographs, a statistically significant difference was observed in apex height between fractured and non-fractured feet (p=0.002; Table 1).
Conclusion: This investigation elucidates the relationship between fifth metatarsal morphology, foot type and proximal fifth metatarsal fractures. Specifically, individuals with long, straight and narrow fifth metatarsals, with an adducted forefoot are most at risk. Given athletes’ predisposition to refracture and nonunion following treatment of proximal fifth metatarsal fractures, which is at times career threatening, we believe that these findings are clinically relevant. With such insight, attempts at fracture prevention can be implemented via footwear modifications, orthoses, and off-loading braces that account for those aforementioned morphologic attributes that place athletes at-risk. Admittedly, future research must evaluate the utility of such interventions.
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NewsBot · Dec 25, 2016

Acupuncture Treatment of a Metatarsus Proximal End Fracture: A Case Report.
Sezgin Y et al
J Acupunct Meridian Stud. 2016 Dec;9(6):319-321. doi: 10.1016/j.jams.2015.11.039

A tuberosity fracture is an avulsion fracture in an area 1.5 cm proximal to the fifth metatarsus. Six to eight weeks of immobilization may be required. A patient with a short leg plaster splint came to our clinic because of pain. The patient had a diagnosis of a fifth metatarsus fracture. Significant edema, fluctuation on the dorsolateral section of the left foot, and red color changes (0.2- to 0.3-cm diameter) on the skin of the anterolateral tibial area of the affected leg were noted. The locations of these skin changes corresponded to the GB34 (Yanglingguan) and the ST37 (Shanqiuxu) acupoints. The patient was successfully treated with acupuncture at these and several other acupoints. After 3 weeks (i.e., eight sessions), the patient returned to her routine life without any pain. This interesting case of metatarsus proximal end fracture shows that some acupoints may be visible during the progress of the disease. We used these acupoints in acupuncture treatment. Pain and edema were rapidly relieved, which may be attributable to the recovery of the lymphatic system in the affected area via acupuncture treatment.
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