Introduction
- Timothy S. Mologne, MD
Epidemiology
- •
Fractures of the fifth metatarsal are relatively common in athletic individuals.
- •
There is no association with age or sex, but they are more common in athletes who participate in cutting type sports, particularly basketball and football players. They are also seen in female dancers.
Pathophysiology
Intrinsic Factors
- •
Fractures at the base of the fifth metatarsal can result from an inversion injury, with resultant avulsion of the peroneal brevis tendon or plantar aponeurosis. The injury mechanism is similar to that seen with an acute lateral ankle sprain.
- •
Fractures of the middle and distal diaphysis commonly involve a fall on a plantarflexed and inverted foot. This mechanism is often seen in dancers.
- •
Fractures of the proximal fifth metatarsal distal to the tuberosity (Jones fracture) usually occur from a vertical oriented force, a medial-lateral force, or a combination of the two as the patient raises the heel and puts pressure on the metatarsal head.
- •
There are strong stabilizing ligaments between the base of the fifth metatarsal and the cuboid and fourth metatarsal. These ligaments and the capsular attachments help to stabilize the fifth metatarsal and result in force concentration to the fifth metatarsal just distal to the articulation with the fourth metatarsal.
- •
A varus hindfoot has been associated with fifth metatarsal Jones fractures.
Traumatic Factors
- •
Dancer’s fracture
- •
Inversion injury and styloid avulsion
- •
Vertical/medial-lateral force as the heel is raised
Classic Pathological Findings
- •
Fractures of the fifth metatarsal can be divided into shaft and neck fractures, styloid fractures, and fractures at the metadiaphyseal junction—the so-called Jones fracture.
- •
Stress fractures at the metadiaphyseal junction can results in cortical hypertrophy, periosteal new bone formation, and widening at the fracture site.
- •
Nonunions can also be seen, with intramedullary sclerosis.
Clinical Presentation
History
- •
A thorough evaluation of the patient’s history may help distinguish a stress fracture from an acute fracture.
- •
Prodromal pain at the site of the fracture prior to an acute injury might signify a stress type fracture.
- •
Patients often report a twisting injury to the ankle or an inversion injury to the foot.
- •
Patients with acute fractures usually have difficulty ambulating or applying pressure on the affected foot.
Physical Examination
- •
Tenderness to palpation at the fracture site
- •
Accentuation of pain with foot inversion
- •
Occasional swelling and ecchymosis at the fracture site
- •
Difficulty bearing weight on the affected foot
Imaging
- •
An anteroposterior, oblique, and lateral radiograph of the affected foot are helpful in establishing a diagnosis.
- •
A styloid fracture should be assessed for displacement and comminution ( Figure 44-1 )
FIGURE 44-1
A nondisplaced styloid avulsion fracture.
- •
Fractures of the proximal fifth metatarsal distal to the tuberosity (Jones fracture) should be assessed for chronicity. Torg classified Jones fractures as (1) acute fractures, (2) delayed unions, and (3) nonunions. The acute fracture was defined as a fracture with a sharp fracture line with no widening, no intramedullary sclerosis, and little to no cortical hypertrophy ( Figure 44-2 ). The delayed union was defined as a fracture with a widened fracture line, a fracture involving both cortices and with a periosteal reaction, and some intramedullary sclerosis ( Figure 44-3 ). The nonunion was defined as a fracture with a wide fracture line, periosteal new bone, and complete obliteration of the intramedullary canal with sclerotic bone ( Figure 44-4 ).
FIGURE 44-2
An acute Jones fracture with a sharp fracture line, no widening, no periosteal reaction, and no cortical hypertrophy.
FIGURE 44-3
A delayed union Jones fracture with widening of the fracture line, and some intramedullary sclerosis.
FIGURE 44-4
A nonunion of a Jones fracture with a widened fracture line and obliteration of the intramedullary canal with sclerotic bone.
- •
In skeletally immature patients, the base of the fifth metatarsal has an apophysis, which should not be confused for a fracture. The apophysis is parallel to the shaft of the metatarsal.
Differential Diagnosis
- •
Fractures at the base of the fifth metatarsal can be mimicked by:
- •
Fifth metatarsal apophysis in skeletally immature patients. The apophysis is parallel to the shaft and does not extend proximally into the fifth metatarsal-cuboid articulation.
- •
Os peroneum. An ossicle in the peroneus longus tendon adjacent to the base of the fifth metatarsal. The ossicle is rounded as compared to an acute fracture.
- •
Treatment
Nonoperative Management
- •
Styloid avulsion fractures have an excellent chance of successful treatment with conservative treatment. Treatments can vary with the size of the fracture fragment, displacement, and amount of comminution, and can include protective ambulation in a hard sole shoe, a firm last boot, a CAM walker, or a short leg walking cast.
- •
Metatarsal shaft and neck fractures also have an excellent chance of successful treatment without surgery. Immobilization in a CAM walker or short leg walking cast for 4 to 6 weeks is common.
- •
Jones fractures can be challenging to get to heal conservatively. Nonunions and refractures are common. If conservative treatment is elected, a short leg non–weight-bearing cast for 6 to 8 weeks, followed by protected weight bearing until fracture union.
Guidelines for Choosing Among Nonoperative Treatments
- •
In general, styloid avulsion fractures and shaft and neck fractures are treated conservatively.
- •
Acute Jones fractures can be successfully treated with nonsurgical treatment but can result in a lengthy recovery. Athletes may be less tolerant of prolonged immobilization, especially if there is a real probability of a refracture once they return to competitive sports.
- •
Conservative management of Jones fractures may be very dysfunctional for nonathletes, especially those who have difficulty ambulating with crutches and those who do not have the balance or upper body strength to ambulate non–weight-bearing on the affected limb.
Surgical Indications
- •
There are no absolute surgical indications.
- •
Widely displaced or angulated shaft fractures can be managed with open reduction and internal fixation.
- •
Large, displaced styloid fractures can also be managed with reduction and internal fixation.
- •
Although rare, symptomatic styloid fracture nonunions are also an indication for surgical intervention.
- •
Relative indications for surgical intervention include Jones fractures that are classified as delayed unions or nonunions at initial presentation; refractures; Jones fractures in athletes; and Jones fractures in individuals who are unwilling or unable to adhere to the 6 to 8 week non–weight-bearing guideline for conservative treatment.
Aspects of Clinical Decision Making When Surgery Is Indicated
- •
Size of the metatarsal and intramedullary canal will influence the size of screw used for fixation. Intramedullary screws smaller than 4.5 mm have been associated with a failure of surgery for Jones fractures ( Figure 44-5 ).
FIGURE 44-5
Successful union of a Jones fracture using an intramedullary 4.5-mm malleolar screw.
- •
For displaced and angulated shaft fractures, one must decide whether the fracture can be managed with interfragmentary screws, plate fixation, or a combination.
Evidence
Multiple-Choice Questions
- QUESTION 1.
Fractures of the middle and distal diaphysis commonly involve a fall on the
- A.
inverted foot.
- B.
plantarflexed foot.
- C.
plantarflexed and inverted foot.
- D.
plantarflexed and everted foot.
- A.
- QUESTION 2.
Which foot postural alignment is associated with a Jones fracture?
- A.
Hindfoot varus
- B.
Hindfoot valgus
- C.
Forefoot valgus
- D.
Forefoot varus
- A.
- QUESTION 3.
Stress fractures at the metadiaphyseal junction can result in
- A.
cortical hypertrophy.
- B.
periosteal new bone formation.
- C.
widening at the fracture site.
- D.
All of the above.
- A.
- QUESTION 4.
Immobilization in a CAM walker or short leg walking cast for metatarsal shaft and neck fractures should be done for
- A.
10 weeks.
- B.
4 to 6 weeks.
- C.
2 to 3 weeks.
- D.
10 to 12 weeks.
- A.
- QUESTION 5.
Jones fractures, if treated conservatively, should be in a short leg non–weight-bearing cast for
- A.
6 to 8 weeks.
- B.
2 weeks.
- C.
10 to 12 weeks.
- D.
4 to 6 weeks.
- A.
Answer Key
- QUESTION 1.
Correct answer: C (see Pathophysiology, Intrinsic Factors )
- QUESTION 2.
Correct answer: A (see Pathophysiology, Intrinsic Factors )
- QUESTION 3.
Correct answer: C (see Pathophysiology, Classic Pathological Findings )
- QUESTION 4.
Correct answer: B (see Treatment, Nonoperative Management )
- QUESTION 5.
Correct answer: A (see Treatment, Nonoperative Management )
Nonoperative Rehabilitation of Fifth Metatarsal Fractures (Including Jones Fracture)
- Brad McMahon, MPT
- Laura Lundgren, PA-C
- Timothy S. Mologne, MD
- Laura Lundgren, PA-C
- •
Restore ankle and subtalar range of motion.
- •
Restore ankle and foot strength.
- •
Improve proprioception and balance.
- •
Protect the healing of the bone during the rehabilitation process.
- •
Maintain cardiovascular fitness throughout the rehabilitation process.
- •
Possibly improve mechanics and shoe wear to help prevent future injury.
Phase I (weeks 4 to 8 depending on the fracture site)
- •
In general, physical therapy is not initiated in the early phases of treatment of fifth metatarsal fractures.
- •
Cardiovascular fitness can be maintained by the use of an upper extremity bike and upper extremity workouts can be continued to maintain the fitness of the athlete.
| PHASE I (weeks 4 to 8 depending on fracture site) | PHASE II (weeks 4 to 16) | PHASE III (weeks 8 to 16) |
|---|---|---|
|
|
|
Protection
- •
Fifth metatarsal shaft/neck fractures are managed in a walking cast or walking boot for 4 to 6 weeks. Immobilization is critical for fracture union, and as such, therapy, other than instruction and education in the proper use of crutches, is not indicated.
- •
Jones fractures are managed in a non–weight-bearing short leg cast for 6 to 8 weeks. Therapy other than crutch training is also not indicated in this phase.
- •
Styloid avulsion fractures can be managed in a protective boot or shoe, usually for 4 weeks because the ankle does not need to be immobilized.
- •
Bone stimulators (pulsed electromagnetic fields) have been shown to be effective in the management and healing of nonunions and delayed unions.
Management of Pain and Swelling
- •
Pain can be managed with appropriate use of analgesics.
- •
Because nonsteroidal anti-inflammatory agents have been shown to delay bone healing, these are generally avoided for the first 6 weeks.
- •
Ice and electrical stimulation can also be used to manage pain and swelling.
Phase II (Shaft and neck fractures: weeks 4 to 6; styloid avulsion fractures, weeks 4; Jones fractures: weeks 8 to 16)
Protection
- •
Shaft and neck fractures should be nearly asymptomatic at 6 weeks.
- •
A firm last shoe can help to limit stress across the metatarsal.
- •
Patients with styloid avulsion fractures can usually resume regular shoe wear by 4 weeks.
- •
Patients with Jones fractures are managed in a removable CAM walker boot after the initial 6 to 8 weeks of non–weight-bearing immobilization.
Management of Pain and Swelling
- •
Swelling is usually not present in this phase, but again can be managed with ice and electrical stimulation if needed.
Techniques for Progressive Increase in Range of Motion
- •
Prolonged immobilization can result in ankle stiffness, muscle weakness, ligamentous and fascial tightness, and disuse atrophy of the foot and leg muscles.
- •
Full range of motion needs to be achieved.
- •
Ankle range of motion exercises in all planes (dorsiflexion, plantar flexion, inversion and eversion)
- •
Wall stretch, towel stretch, self-stretches with wobble boards or hand ( Figure 44-6 )
FIGURE 44-6
Towel stretch for dorsiflexion ROM.
- •
- •
Plantar fascia stretching
- •
Rolling with a can or bottle ( Figure 44-7 )
FIGURE 44-7
Plantar fascia stretching with bottle.
- •
Other Therapeutic Exercises
- •
Again, maintaining whole-body cardiovascular fitness is a main goal. Pool workouts, stationary bike, and stair climbers can all be used as an alternative to running.
- •
Core stability exercises and upper extremity strengthening can be continued.
Activation of Primary Muscles Involved
- •
Peroneals, gastrocnemius, soleus, tibialis anterior/posterior, toe extensors/flexors
- •
Thera-Band ankle strengthening in all directions
- •
Balance exercises (see the following)
- •
Calf raises (knee extended/knee bent)
- •
Towel pick-ups
- •
Heel/toe walks
- •
Sensorimotor Exercises
- •
Start with weight-shifting and progress to single leg balance.
- •
Single leg balance on wobble boards, Dyna Discs, trampoline, incline surfaces, biomechanical ankle platform system (BAPS) ( Figure 44-8 )
FIGURE 44-8
Balance and proprioception rehabilitation using the biomechanical ankle platform system (BAPS).
Open and Closed Kinetic Chain Exercises
- •
Thera-Band ankle strengthening in all directions, toe flexor/extensor exercises (towel pick-ups), heel raises, squats/lunges, hip strengthening with Thera-Band ( Figure 44-9 )
FIGURE 44-9
Hip strengthening with Thera-Band.
Neuromuscular Dynamic Stability Exercises
- •
Dynamic reaction drills on the trampoline and progression into ball toss and perturbations on balance boards ( Figure 44-10 ).
FIGURE 44-10
Single balance on wobble boards.
- •
Standing single balance movement drills
- •
Slide board or Pro-fitter
Functional Exercises
- •
Will start with early weight shifting, gait training, and eventual walking with no gait deviations
Milestones for Progression to the Next Phase
- •
The patient’s pain level over the fracture area dictates the level of activity or progression of stages.
- •
Absence of pain, full ankle range of motion, restoration of strength in the foot and ankle
- •
Evidence of union of the fracture on follow up radiographs
Phase III (weeks 10 to 12, shaft and neck fractures; weeks 8 to 10, styloid avulsion fractures; weeks 14 to 16 Jones fractures)
Management of Pain and Swelling
- •
Ice and electrical stimulation if needed.
Techniques for Progressive Increase in Range of Motion
- •
In this phase, we attempt to get the athlete and patient back to his or her preinjury level of function. This includes running and jumping sports.
- •
The patient should have full ankle and subtalar range of motion.
- •
Stretching techniques from Phase II can be continued for warm-up or cool-down before heavy work-out or sport practice.
Other Therapeutic Exercises
- •
Continued from Phase II
Activation of Primary Muscles Involved
- •
Peroneals, gastrocnemius, soleus, tibialis anterior/posterior, toe extensors/flexors
- •
Thera-Band ankle strengthening in all directions
- •
Balance exercises (see the following)
- •
Calf raises (knee extended/knee bent)
- •
Towel pick-ups
- •
Heel/toe walks
- •
Sensorimotor Exercises
- •
Continue with Phase II exercises.
- •
Progressing to Thera-Band resistance, ball toss, and perturbations
Open and Closed Kinetic Chain Exercises
- •
Continue with Phase II exercises.
Neuromuscular Dynamic Stability Exercises
- •
Continue with Phase II exercises.
Plyometrics
- •
Starting with double leg and progressing to single leg ( Figure 44-11 )
Related posts:
Epiphyseolysis and Osteochondritis
Cervical Spine Disc Injuries
Lateral Collateral Ligament and Posterolateral Ligament Injuries
Triangular Fibrocartilage Complex Injuries
Leg Pain in the Athlete: Stress Fractures, Medial Tibial Stress Syndrome, and External Compartment Syndromes
Ulnar Collateral Ligament Injuries
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