Fractures of the fifth metatarsal are common injuries that must be recognized and treated appropriately to avoid poor clinical outcomes for the patient. Since orthopedic surgeon Sir Robert Jones first described these fractures in 1902, there has been an abundance of literature focused on the proximal aspect of the fifth metacarpal due to its tendency towards poor bone healing. Nevertheless, it is critical that the physician recognizes all injury patterns of the fifth metatarsal and initiate the appropriate treatment plan or referral process to avoid potential complications.
Classified by Lawrence and Bottle, the base, or proximal aspect, of the fifth metatarsal is broken up into three anatomical zones: zone 1, the tuberosity; zone 2, the metaphyseal-diaphyseal junction; and zone 3, the diaphyseal area within 1.5 cm of the tuberosity. Fractures through zone 1 have the name to as pseudo-Jones fractures, and fractures through zone 2 are referred to as Jones fractures. Additionally, a patient may sustain a shaft fracture greater than 1.5 cm distal to the tuberosity, a long spiral fracture extending into the distal metaphyseal area, the so-called dancer's fracture, or a stress fracture of the metatarsal.
Classification of these fractures is crucial to making management decisions. Metaphyseal arteries and diaphyseal nutrient arteries provide the blood supply to the fifth metatarsal base. A vascular watershed area exists in zone 2, contributing to the high nonunion rates seen with these fractures.
Zone 1 fractures are tuberosity avulsion fractures, also called pseudo-Jones fractures, and occur when the hindfoot gets forced into inversion during plantarflexion. This acute injury pattern may occur after an athlete lands awkwardly after a jump. These fractures rarely involved the fifth tarsometatarsal joint and lay proximal to the fourth and/or fifth intermetatarsal joint
Zone 2 injuries have the name Jones fractures. These acute injuries may occur with a significant adduction force to the foot with a lifted heel. This type of injury pattern can occur with a sudden change of direction by an athlete. These fractures usually involve the fourth and/or fifth metatarsal articulation and have nonunion rates as high as 15 to 30%.
Zone 3 injuries are chronic injuries of repetitive microtrauma, causing increasing pain with activity over months. There is an increased risk of nonunion with these fractures.
The dancer's fracture, or long spiral fracture of the distal metatarsal, is typically caused by the dancer rolling over their foot while in the demi-pointe position or sustained while landing a jump.
Fractures of the fifth metatarsal are the most prevalent metatarsal fractures. These fractures peak during the third decade of life for men and the seventh decade of life for women. There is a strong correlation between female gender and zone 1 fractures and dancer's fractures. Zone 1 injuries are typical of a twisting injury and are the most common fracture of the base of the fifth metatarsal.
History and Physical
These patients typically present with pain about the lateral aspect of the forefoot that is worse with weight-bearing activity. This pain may occur in the setting of acute trauma or repetitive microtrauma over weeks to months. One should be suspicious of stress fracture with antecedent pain or pain of worsening quality or duration over time. The examiner must obtain a thorough past medical history and social history to make treatment decisions and optimize patients with surgical indications. It is important to evaluate the skin for open injuries that may require more urgent debridement. Physical examination may reveal tenderness to palpation, swelling, and ecchymosis at the site of injury. Patients will also have pain with resisted foot eversion. It is critical to evaluate the patient for other injuries, including injury to the lateral ankle ligamentous structures and Lisfranc injury.
Radiographs are the initial imaging of choice used to evaluate for these injuries. AP, lateral, and oblique images of the foot are essential to making the diagnosis. In zone 1 injuries, the medial fracture line lies proximal to the fourth to the fifth intermetatarsal joint. In zone 2 injuries, the medial fracture line extends towards or even into the fourth and/or fifth intermetatarsal joint. In zone 3 injuries, the medial fracture line will typically exit distal to the fourth and/or fifth intermetatarsal joint, but some may be more proximal. The usual fracture pattern seen in dancer fractures is an oblique spiral fracture beginning distal and lateral and extending proximal and medial. Other distal diaphyseal fractures are generally seen on radiographs running in the transverse plane.
The radiographic appearance of fifth metatarsal base stress fractures classify into three types based on the Torg classification system:
Type I fractures:
No intramedullary sclerosis
Sharp fracture line with no widening
Minimal cortical hypertrophy
Minimal periosteal reaction
Evidence of intramedullary sclerosis
Widened fracture line with the involvement of both cortices
Periosteal reaction present
Complete obliteration of the medullary canal by sclerotic bone
Wide fracture line with new periosteal bone
Other imaging modalities such as CT and MRI may be considerations in the setting of delayed healing, nonunion, or high index of suspicion for a stress fracture with a normal radiograph, but these are not routine studies.
Treatment / Management
Treatment decisions have their basis on the anatomic zone of injury, the social and medical history of the injured patient, and evidence of radiographic signs of healing.
Nondisplaced zone 1 injuries can be treated conservatively with protected weight-bearing in a hard-soled shoe, walking boot, or walking cast. Progression to weight-bearing as tolerated can initiate as pain and discomfort subside over 3 to 6 weeks. Fractures involving 30% of the articular surface or with an articular step off over 2 mm have treatment with open reduction and internal fixation, closed reduction, and percutaneous pinning, or excision of the fragment.
Nondisplaced zone 2 injuries, or Jones fractures, may also be treated conservatively with 6 to 8 weeks of non-weight bearing in a short leg cast. The physician may advance weight-bearing status as radiographic evidence of bone healing appears. Indications for surgical interventions include the high-performance athlete, the informed patient who elects to proceed with surgical treatment, or displaced fractures. There are many forms of surgical interventions, including intramedullary screw fixation, tension band constructs, and low profile plates and screws. Surgical management of high-performance athletes minimizes the risk of nonunion and prevents prolonged restriction from physical activity.
Diaphyseal zone 3 stress fractures paint a more complicated picture for the patient and physician. A trial of conservative management with non-weight bearing in a short leg cast may be the initial therapy, however, immobilization for up to 20 weeks may be necessary before there is observable radiographic union, and even then, nonunion development is not uncommon. High-performance athletes or individuals with Torg Type II or III fractures may require surgical interventions. Surgical options include intramedullary screw fixation, bone grafting procedures, or a combination of the two.
The bone grafting inlay technique requires removing a 0.7 by 2.0 cm rectangular section of bone at the fracture site and replacing it with an autogenous corticocancellous bone graft of the same dimensions taken from the anteromedial distal tibia. The medullary cavity must be curetted or drilled until all of the sclerotic bone has been removed and the medullary canal reestablished prior to inserting the donor graft.
Nondisplaced dancer’s fractures and other fractures of the fifth metatarsal shaft and neck receive the same treatment as nondisplaced zone 1 injuries. Weight-bearing status can advance as tolerated by pain. If evidence of delayed union or nonunion exists, surgical interventions may be required. If there is more than 3 mm of displacement or angulation exceeds 10 degrees, the fracture should be reduced and splinted. If the fracture remains malreduced or there is evidence of loss of reduction on follow-up radiographs, surgical interventions with percutaneous pinning or plate and screw fixation should be a consideration.
Patients treated with intramedullary screw fixation or bone graft inlay technique should remain non-weight bearing in a plaster splint or short leg cast for six weeks with a gradual return to sport or activity.
Differential diagnosis of pain in this region includes:
Foreing body granuloma
Plantar plate disruption
Subchondral insufficiency fracture
Tenosynovial giant cell tumor
The majority of acute, nondisplaced fractures of the fifth metatarsal heal with conservative treatment by 6 to 8 weeks. Zones 2 and 3 injuries have a higher rate of nonunion due to the vascular watershed area mentioned earlier, with zone 2 injuries having a nonunion rate as high as 15 to 30%. Diaphyseal stress fractures may have a prolonged course of healing of up to 20 weeks.
There is an increased risk of nonunion with zones 1 and 2 injuries, as discussed earlier. There is also a risk of nonunion associated with using an intramedullary screw with a diameter under 4.5 mm or the use of a screw that is too long, causing fracture distraction or malreduction. Fixation failure rates are higher in individuals who do not abide by non-weight bearing restrictions or who return to sport or activity before evidence of radiographic union.
Postoperative and Rehabilitation Care
Patients, especially high-level athletes, should be educated regarding the risk of nonunion in specific fracture patterns, and the clinician should conduct a thorough discussion of both operative and nonoperative management.
Enhancing Healthcare Team Outcomes
An interprofessional team, including the orthopedic nurse, is most effective in the appropriate management of fifth metatarsal fractures. Generally, the patient will present to their primary care physician or the emergency department complaining of typical signs and symptoms. Proper diagnosis directs the treatment and triage of these patients. Prompt referral to an orthopedic surgeon is paramount as appropriate treatment can lead to union rates as high as 97%. [Level 4] Mismanagement of these fractures may lead to poor clinical outcomes and lifestyle alterations. Emergent referral to orthopedic surgery is necessary for an open fracture. Traditionally, intramedullary screw fixation has been an option when surgery is warranted, but newer techniques with planar plating have resulted in successful outcomes in elite athletes.
With proper identification of fracture and interprofessional communication with an orthopedic referral, outcomes of this difficult to treat fracture can stand a better chance of full recovery, but this requires an interprofessional team approach, including physicians, specialists, specialty-trained nurses, physical and occupational therapists, and pharmacists, all collaborating across disciplines to achieve optimal patient results. [Level 5]
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Image courtesy Dr Chaigasame
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Classic appears of a Jones fracture of the 5th metatarsal meta-diaphyseal junction.
Contributed by Mark A. Dreyer, DPM, FACFAS
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Jones fracture status post intramedullary screw fixation
Contributed by Mark A. Dreyer, DPM, FACFAS
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Rosenberg GA,Sferra JJ, Treatment strategies for acute fractures and nonunions of the proximal fifth metatarsal. The Journal of the American Academy of Orthopaedic Surgeons. 2000 Sep-Oct; [PubMed PMID: 11029561]
Roche AJ,Calder JD, Treatment and return to sport following a Jones fracture of the fifth metatarsal: a systematic review. Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA. 2013 Jun [PubMed PMID: 22956165]