Fractures of the Proximal Fifth Metatarsal

Bulletin of the NYU Hospital for Joint Diseases 2012;70(1):49-55
49
Fractures of the Proximal Fifth Metatarsal
Keeping Up with the Joneses
Bryan C. Ding, M.D., Justin M. Weatherall, M.D., Kenneth J. Mroczek, M.D.,
Steven C. Sheskier, M.D.
Abstract
Fractures of the proximal fifth metatarsal are among the
most common fractures of the foot. History, physical examination, and subsequent radiographic work-up can help
with the diagnosis of such a fracture. Many fractures of the
proximal fifth metatarsal can have an associated prodrome,
thereby establishing a level of chronicity to the problem.
Identification of the location of the fracture plane within the
proximal fifth metatarsal can have prognostic implications
in regards to fracture union rate and guide treatment options, due to the particular vascular anatomy of the region.
Additional findings on physical exam, such as heel varus,
can also impact prognosis and treatment options. Treatments
can range from nonoperative to operative modalities, and
time to weightbearing can vary. Within the realm of operative treatment, identification of certain parameters can aid
in successful reduction and fixation of the fracture and
thus impact healing. Careful consideration of the patient’s
particular constellation of social and professional needs,
clinical and radiographic parameters, and acceptance of
different options can help guide treatment recommendations
in the individual patient.
F
ractures of the proximal fifth metatarsal are the most
common fracture seen in the foot.1 Anecdotally once
felt to be a rare occurrence, these injuries were initially described in 1902 by Sir Robert Jones in a series of six
cases including one in his own foot. Prior to his description
Bryan C. Ding, M.D., Justin M. Weatherall, M.D., Kenneth J.
Mroczek, M.D., and Steven C. Sheskier, M.D., are in the department of Orthopaedic Surgery, NYU Hospital for Joint Diseases
Orthopaedic Institute, New York, New York.
Correspondence: Bryan C. Ding, M.D., Winthrop Orthopaedic
Associates, Winthrop University Hospital, Department of Orthopaedics, 1300 Franklin Avenue, UL-3A, Garden City, New York
11530; [email protected].
of sustaining the injury through “indirect violence,” it was
widely accepted that the predominant mechanism by which
a proximal fifth metatarsal fracture could be sustained was
by direct load on the region of fracture.2 Epidemiological
studies in populations greater than 5 years of age have demonstrated that the twisting of the foot or fall from standing
height to be by far most common mechanism of injury.1,3,4
Age distribution peaks were noted in the third and sixth
decades of life, with a shift from younger males becoming
injured in sports like soccer to elderly females.1,5,6
It has been estimated that 1 in 10,000 people sustain an
injury to the foot or ankle daily, with an estimated 5 million radiographic series ordered annually in Canada and the
United States.7,8 The differential diagnosis of a proximal fifth
metatarsal injury may include midfoot and ankle sprains,
plantar fascial ruptures, ruptures of the peroneal tendons, and
fractures of other midfoot and hindfoot bones. To delineate
those injuries which require further radiological investigation, the Ottawa Foot Rules were devised as an extension
of the Ottawa Ankle Rules for the purpose of reducing unnecessary radiographs in the diagnosis of midfoot injuries.
The criteria for the Ottawa Foot Rules are displayed in
Table 1. A radiographic workup is indicated if the patient
has pain in the midfoot zone and any one of the following:
bone tenderness at the base of the fifth metatarsal, bone
tenderness at the navicular, and an inability to bear weight
both immediately and in the ER for four steps. They have
been found to be up to 100% sensitive and 79% specific for
the identification of proximal fifth metatarsal fractures.8-11
Additionally, by history this complaint may be acute,
chronic, or acute-on-chronic involving a prodrome of pain
with sudden worsening after a particular injury. Careful
history taking may provide clues to a possible underlying
etiology for the fracture sustained, which in combination
with radiographic findings may influence the treatment
rendered.12,13
Ding BC, Weatherall JM, Mroczek KJ, Sheskier SC. Fractures of the proximal fifth metatarsal: keeping up with the Joneses. Bull NYU Hosp Jt Dis.
2012;70(1):49-55.
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Bulletin of the NYU Hospital for Joint Diseases 2012;70(1):49-55
Table 1 Ottawa Foot Rules–Determine the Need for
Radiographic Evaluation of the Foot
Pain in the region of the midfoot and one of the following:
Bone tenderness at the base of the fifth metatarsal
Bone tenderness at the navicular
Inability to bear weight both immediately and in the ER
for 4 step
Classification Schemes through History
A subset of proximal fifth metatarsal fractures have been
identified for their potential to develop into a delayed or
nonunion, while others proceed on to heal uneventfully with
little to no intervention. A number of classification schemes
describing proximal fifth metatarsal fractures have been devised over the years to help physicians determine prognosis
and treatment, in what has been determined to be distinctly
different fracture injuries.
In 1960, Stewart described a classification scheme based
on the fracture location and morphology (Table 2). Stewart’s
classification differentiated between type I, extra-articular
fracture between the metatarsal base and diaphysis; type
II, intra-articular fracture of the metatarsal base; type III,
avulsion fracture of the base; type IV, comminuted fracture
with intra-articular extension; and type V, partial avulsion
of the metatarsal base with or without a fracture.
Subsequent series described and classified proximal fifth
metatarsal fractures based on differences in outcome in relation to anatomic location.14
Dameron in 1976 noted that patients with fractures
through the fifth metatarsal tuberosity tended to have an uneventful healing course, whereas those with fractures distal
to the insertion of the peroneus brevis were more prone to
prolonged symptoms and delayed union.15 Later contributions to the literature have described anatomic classifications
of proximal fifth metatarsal fracture into 3 zones: zone 1,
tuberosity avulsion; zone 2, metaphyseal-diaphyseal junction; and zone 3, proximal diaphyseal stress fracture (Table
2).15-17 Currently, it is commonly accepted that fractures in
zone 2 are true “Jones fractures” (Fig. 1) and fractures in
zone 1 are “pseudo-Jones fractures” (Fig. 2). In a review of
Table 2 Classification Systems
Stewart
Dameron
Torg
Type I - Extra-articular fracture between
the metatarsal base and diaphysis
Type II - Intra-articular fracture of the
metatarsal base
Type III - Avulsion fracture of the base
Type IV - Comminuted fracture with
intra-articular extension
Type V - Partial avulsion of the
metatarsal base with or without a fracture
Zone 1 – Tuberosity avulsion
Zone 2 – Metaphyseal – Diaphyseal
junction
Zone 3 – Proximal diaphyseal stress
fracture
Type I – Acute – Narrow fracture line
with no intramedullary sclerosis
Type II – Delayed Union – Widened
fracture gap and intramedullary sclerosis
Type III – Nonunion – Obliteration of
the medullary canal
Figure 1 Jones fracture.
Bulletin of the NYU Hospital for Joint Diseases 2012;70(1):49-55
51
Figure 2 Pseudo-Jones fracture.
32 Jones fractures as compared to 29 proximal diaphyseal
fifth metatarsal fractures, Chuckpaiwong noted no difference in outcomes due to the location of the fracture with a
similar treatment protocol. They found a higher union rate
with operative treatment of meta-diaphyseal and diaphyseal
fractures.18
As the eponym “Jones fracture” elicits a connotation
of the possibility of delayed or nonunion, Torg reviewed
qualitative radiographic parameters and union rates in his
series of patients. He used this information to describe a
new classification system, which delineated the degree of
radiographic sclerosis on presentation to help determine the
age of the fracture on presentation. He then correlated the
age of the fracture with the outcome. The Torg classification
(Table 2) is divided into three types: Type I (acute), which
had a narrow fracture line with no IM sclerosis; Type II
(delayed union), with a widened fracture gap and intramedullary sclerosis; and Type III (nonunion), which demonstrated
obliteration of the medullary canal. He noted that all but
1 of 15 of his Type I patients healed in 6 to12 weeks in a
non-weightbearing cast. In contrast, Type II patients treated
nonoperatively required an average of 14.8 months (range
8 to 26) to achieve union. All of the patients in the series
treated operatively (all Type III and some Type II) were seen
to heal in 12 to14 weeks time.19
arteries where the peroneus brevis inserts and distally from
a nutrient artery which enters a foramen on the tibial side
of the bone which tracks proximally.21,23 With a relatively
limited blood supply in the region, the meta-diaphyseal region of the fifth metatarsal becomes prone to poor healing
and self-repair.
The most common mechanism of injury in fifth metatarsal
fractures involves a fall from standing height or an ankle
twist with the forefoot fixed. In this position, a pulling force
from the lateral cord of the plantar aponeurosis along with
tension from the peroneus brevis tendon causes a longitudinal and torsional strain. The act of repetitive cyclic loading,
especially in the setting of a young athlete or military recruit,
can lead to a chronic overloading predisposing one to a stress
reaction and ultimately fracture.
Gu investigated the stress loads on the metatarsals during
landing in a 3-dimensional finite element model of the foot.
One of the peaks in stress points was found to be the proximal fifth metatarsal. As the angle of landing was changed
to increasing inversion, lateral metatarsal stress was seen to
increase.24 Clinically and radiographically, Raikin noted that
18 of 21 Jones fractures treated in his series had evidence of
hindfoot varus, and he concluded that fractures of the fifth
metatarsal may have a predisposing chronic etiology.25
Anatomy of Injury and Healing
Since the early 1900s, treatment of fractures of the proximal
fifth metatarsal has varied from soft dressings or rigid shoes
to casting or ultimately surgical intervention. Different treatments have been met with a wide range of results, largely dependent on fracture type and location. It, therefore, becomes
of utmost importance to properly determine the fracture
pattern in order to select the most appropriate treatment.
There is a consensus that non-displaced fractures of the
tuberosity of the fifth metatarsal, also known as an avulsion
or “pseudo-Jones” fracture, tend to heal uneventfully within
3 to12 weeks without operative intervention in nearly all
As early as 1902, in Jones’ original description of his namesake fracture pattern and Carp’s 1927 series of 21 cases, the
surrounding anatomy about the proximal fifth metatarsal
has been implicated in its predisposition to injury and problematic healing.2,20 The blood supply of the proximal fifth
metatarsal in the meta-diaphyseal junction has been implicated as the leading factor in the development of a delayed
or nonunion in Jones fractures. The meta-diaphyseal junction represents a watershed region between blood supplies
coming from proximally at the tuberosity via metaphyseal
Treatment Options
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Bulletin of the NYU Hospital for Joint Diseases 2012;70(1):49-55
patients, despite level of treatment rendered. However, dome
patients may have some residual symptoms up to 6 months
or 1 year’s time.26 Multiple studies, including a 12-week
randomized control trial of 89 consecutive patients with
fifth metatarsal tuberosity avulsion fractures, have compared
treatment using a nonrigid, soft Jones’ dressing consisting
of alternating layers of cast padding and elastic bandages
with a rigid short leg casting. Treatment was seen to be no
different in outcomes of time in treatment modality, time
to radiographic healing, and functional foot score, and the
Jones’ dressing had a significant 28% reduction in time to
return to pre-injury levels of activity.27-29 Additionally, Vorlat
found that the duration of the non-weightbearing period is
the most important variable linked to final clinical outcome
after an avulsion fracture of the proximal fifth metatarsal
and noted poor functional outcome with non-weightbearing
treatment. Other series have found good results when patient
were allowed to bear weight as tolerated.30
Surgical treatment of avulsion fractures has been advocated when there is greater than 2 mm of displacement at
the fracture site or when the fracture extends into the cubometatarsal joint, though some may argue that these injuries
represent more than a simple avulsion fracture based on the
populations surveyed.31,32 Of note, as a consequence of operative treatment, additional protection by casting and partial
weightbearing for the duration of bone healing should be
provided.
Treatment of the true Jones fracture should include a
period of non-weightbearing. In Torg’s series, even those
fractures judged to be acute with no evidence of delayed or
nonunion (“Type I”) at presentation, there was a 100% incidence of delayed or nonunion when patients were allowed to
bear weight as tolerated. Sixty percent of these patients were
symptomatic and went on to union after surgical intervention
and a postoperative period of non-weightbearing.19
Radiographic healing occurs in a medial-to-lateral
direction and callus formation at the fracture site without
intramedullary sclerosis can be seen by 6 to 8 weeks. For
fractures that demonstrate little or no callus formation at 6
to 8 weeks, pulsed electromagnetic field therapy has been
reported to be an effective alternative to surgery for the
management of delayed union and nonunion of the proximal
fifth metatarsal, with a mean time to healing of 3 months
(range 2 to 4 months).33
Aside from radiographic and clinic evidence of a delayed
or nonunion event, considerations for the treatment of a Jones
fracture with surgical intervention may include regard for
the patient population, whether they are a high-performance
athlete, military recruit, or simply an informed patient who
prefers surgery to the risk of nonunion with nonsurgical
treatment. For these patients, reliability of treatment and time
to healing may be of utmost importance. In a randomized
controlled trial of 37 military recruits, Mologne found 95%
union rate with early fixation versus 66% union with casting, with earlier radiographic healing (6.9 vs. 14.5 weeks)
and return to sport (7.9 vs. 15.6 wks). The only failure
of operative fixation was attributed to the possibility that
weightbearing was re-started prior to the fracture being fully
healed. That patient went on to union after repeat fixation
with bone-grafting.12 Other series also note high rates of
union with operative fixation within a similar timeframe.
Operative contraindications may include patient factors,
such as vascular compromise, local infection, or medical
instability. However, a patient with well controlled diabetes
is not necessarily a contraindication to surgery. Yue and
Marcus reported success with open reduction and internal
fixation of Jones fracture with bone grafting in patients with
diabetes. They also noted that delayed open reduction and
internal fixation with bone grafting after a trial of casting
does not limit healing potential in these patients.34
Surgical Fixation through the Ages
Historically, operative treatment of the Jones fracture has
included crossed K-wire fixation, tension band constructs,
and intramedullary devices. K-wire and tension band
constructs are more poorly tolerated and tend to require
hardware removal. Additionally, intramedullary screws have
been shown to have statistically significant fixation strength
improvement over tension banding for avulsion fractures in
both polystyrene foam models and fresh, nonpreserved frozen cadaveric samples.31 Intramedullary devices have, thus,
become the mainstay of surgical treatment of Jones fractures.
Intramedullary fixation devices may include locked intramedullary nails or intramedullary screws. In a retrospective
study comparing an intramedullary nailing system locked
with wires versus tension band constructs, IMNs were noted
to be faster, with a smaller approach, theoretically biomechanically stronger, and had improved radiographic results.
However, there was a slightly higher rate of irritation from
the interlocking wires (56% vs. 51%), and hardware was
removed in 68% of patients. There have been no comparisons
to intramedullary screws.35
Operative Technique of Intramedullary
Screws
Intramedullary screws (Fig. 3) are currently the mainstay
of treatment for operatively treated Jones fractures. The
incisional approach for proximal fifth metatarsal fractures
should be made proximal to the fifth metatarsal base between
the peroneus brevis and longus tendons. A guidewire should
be started in a high and inside position at the base of the fifth
metatarsal. Intraoperative fluoroscopy is used to guide the
placement of a guidewire and down the metatarsal shaft, and
subsequently a screw is placed in the desired position.17,36
Care should be taken to avoid selection of an improper screw
angle, which can lead to unicortical gapping at the fracture
site and a prolonged time to union.
Selection of the appropriate parameters can lead to successful fixation of the fracture. In selecting a particular size
screw to use, the selected screw size must allow adequate
Bulletin of the NYU Hospital for Joint Diseases 2012;70(1):49-55
53
Figure 3 Jones fracture treated with a
partially threaded intramedullary screw.
endosteal bite of the screw threads with the screw threads
passing the fracture for compression to occur. It has been
noted that a better pull-out strength was achieved with a 6.5
mm screw as opposed to a 5.0 mm screw.37 On the other
hand, maximizing screw diameter did not enhance bending
stiffness, but it did increase risk of periprosthetic fracture.38
In terms of length, longer 5.0 mm screws are torsionally
equivalent to 6.5 mm screws if they are long enough.39 However, the screw should not be excessively long, to prevent
straightening of the naturally curved fifth metatarsal. Additionally, the use of a supplemental lateral hindfoot wedge
orthotic has been advocated in the setting of hindfoot varus.
In one report, 18 of 21 operative Jones fractures were noted
to have some degree of hindfoot varus, versus a previous
estimate of approximately 25% of the general population
having hindfoot varus. In six of these patients, an event of
re-fracture of screw breakage was noted without the use of
a supplemental orthotic. Their study noted a 100% union
rate with return to prior activity level and no recurrence of
fractures, when operative Jones fractures with hindfoot varus
were supplemented with an orthotic to offload the varus.25
Complications
Complications of operative treatment of a proximal fifth
metatarsal can include sural nerve injury, infection, refracture, nonunion, and potentially the need for subsequent
surgical removal of hardware due to symptomatic hardware.
Though clinical rates of nerve injury are not published in
the literature, investigation of potential nerve injury was
performed using a cadaveric study of 10 feet after undergoing placement of a cannulated screw. Exploration of the
specimens revealed that the dorsolateral branch of the sural
nerve was most at risk. Their results showed that the nerve
was injured in one specimen; the nerve was contacted without frank injury in another; and the nerve was within 2 mm
of the screw in 5 of 10 specimens and within 3 mm of the
screw in 8 of 10 specimens.40
Studies that have included rates of re-fracture and nonunion generally hypothesize that occurrences were due to
the commencement of weightbearing activities too soon
post-operatively. These events are relatively rare, and may
also be due to an underlying varus hindfoot deformity.12,25,41
Lastly, no specific studies regarding removal of hardware
due to symptomatology of cannulated screws have been
reported.
Costs of Treatment
In an age of cost-consciousness in healthcare, one study
from a private orthopaedic suburban practice noted very high
satisfaction rates with treatment of proximal fifth metatarsal
fractures with nonoperative measures. Their average cost
for the total fracture care was $1,414.09 (range $692.50 to
$2,820.50), which included physician fees, radiographs, and
orthopaedic supplies. In this patient population, satisfaction
with treatment was noted to be 100%, even in a patient with
a delayed union of longer than 6 months. The investigators
recommended nonoperative treatment of fifth metatarsal
fractures for patients in whom the time to return to full activities is not critical.42 In comparison, no studies have estimated
the cost of prolonged treatment with immobilization and
weightbearing restrictions in regards to lost productivity.
Summary
The literature is full of many studies documenting the outcomes of fractures in the meta-diaphyseal and tuberosity
regions of the proximal fifth metatarsal, treated in various
nonoperative and operative modalities. Most series have a
limited number of patients and represent Level IV evidence,
though there are a handful of Level I and II studies in the
literature. General consensus indicates that treatment of
tuberosity avulsion fractures will be largely successful
with nonoperative means with weightbearing as tolerated
without immobilization. However, the true “Jones” fracture
is one that is prone to nonunion without, at the minimum,
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a restriction of non-weightbearing in conjunction to immobilization or an operative treatment. This injury itself may
represent a chronic or acute-on-chronic injury, based on
clinical prodromes, radiographic findings of a stress reaction
or delayed or nonunion, or the presence of a hindfoot varus
in the setting of chronically loaded and stressed region of
the foot. Nonoperative treatment has been shown to involve
longer times to union and return to sport, though patients
may still report a satisfactory result. Most surgeons would
agree that operative indications include athletes needing to
return to sport to sustain livelihood, nonunions, and widely
displaced fractures. Given a thorough understanding of the
risks, benefits, and alternatives of treatment options for their
injury, an educated patient willing to undergo operative
management of the fracture may also be an indication for
surgery. In short, treatment of a fracture of the proximal fifth
metatarsal should be based on the patient’s social situation,
clinical and radiographic parameters, and willingness to
undergo the treatment prescribed.
Disclosure Statement
None of the authors have a financial or proprietary interest
in the subject matter or materials discussed, including, but
not limited to, employment, consultancies, stock ownership,
honoraria, and paid expert testimony.
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