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Basics ⬇

Author(s): RyanReese, DO and Mark E.Lavallee, MD, CSCS, FACSM

Description

  • Fractures of the proximal 5th metatarsal of the foot occur at different locations, often with different etiologies. Prognosis and treatment differ vastly, and there is potential to have chronic pain and instability of the foot if not treated properly. Proximal 5th metatarsal fractures are classified into three types by region, especially in relation to the joint at the base of the 4th/5th metatarsals (1,2,3,4):
    • Avulsion fracture of the tuberosity:
      • Near splayed insertion of the peroneus brevis tendon (within 0.5 cm from proximal tip of 5th metatarsal)
      • Located extra-articular and do not extend into the joint between the 4th and 5th metatarsal. These fractures intersect cubometatarsal joint
    • Jones fracture (metaphyseal–diaphyseal junction):
      • Fracture line extends into or toward the articulation between the bases of the 4th and 5th metatarsals (measuring usually between 0.5 cm and 1.5 cm from the proximal tip of the 5th metatarsal).
      • They heal more slowly and are prone to delayed union and nonunion because they have a relatively poor blood supply and have increased stresses across intertarsal ligament and fracture site.
    • Diaphyseal stress fractures:
      • Most commonly occur just distal to the 4th and 5th intermetatarsal articulation to midshaft
      • Result of chronic, repetitive microtrauma, especially in younger athletes
      • Heal most slowly and have greatest risk of delayed union, nonunion, and recurrence.
    • Torg classification according to healing potential (2):
      • Type I (acute): acute without prior fracture. X-rays show clean fracture without sclerosis.
      • Type II (delayed union): involves prior symptoms or a known stress fracture. X-rays show medullary sclerosis and a widened fracture line.
      • Type III (nonunion): involves prior symptoms or a known stress fracture. X-rays show evidence of repeated trauma, widened fracture line, and exuberant sclerosis (suggesting fracture nonunion).
  • Synonym(s): dancer’s, tennis, or pseudo-Jones fracture: avulsion fracture of base of the 5th metatarsal

Epidemiology

  • 5th metatarsal fractures account for 68% of metatarsal fractures (2).
  • Avulsion fractures are the most common type of fracture (93% of fractures).
  • Diaphyseal stress fractures are the least common type of fracture (3% of fractures).

Etiology and Pathophysiology

  • Avulsion fracture of the tuberosity: inversion ankle injuries
  • Jones fracture: twisting injuries of the forefoot, vertical forces over the lateral aspect of forefoot while foot is plantarflexed, trauma to the area
  • Stress fracture: repetitive impact to the lateral foot (3)

Risk-Factors

  • Previous fracture to the proximal 5th metatarsal
  • Lateral ankle instability
  • Static forefoot adduction

Commonly Associated Conditions

Associated injuries and complications:

  • Lateral ankle sprain: Tuberosity avulsion fractures are commonly associated with ankle sprains with the foot inverted and plantarflexed. The anterior talofibular and calcaneofibular ligaments often are injured, and there may be swelling and ecchymosis just anterior and distal to the lateral malleolus.
  • Proximal 5th metatarsal stress fracture: Patient may have had a previously undiagnosed and slightly symptomatic stress fracture of the proximal 5th metatarsal.
  • There is a high incidence of delayed union, nonunion, and refracture with Jones and diaphyseal stress fractures.

Diagnosis ⬆ ⬇

History

  • Q: How and when did it occur?
  • A: Mechanism of injury is important to determine.
  • Q: Did athlete injure this foot previously?
  • A: Determine presence of previous fracture of the 5th metatarsal.
  • Q: Was there a recent history of ankle sprain prior to this injury?
  • A: Loss of proprioception and reflex inhibition may have predisposed athlete to this injury.
  • Q: History of other medical conditions?
  • A: Osteoporosis, multiple stress fractures, diabetes or other causes of peripheral neuropathy

Physical Exam

  • Signs and symptoms:
    • Patient may complain of pain over the lateral aspect of foot, especially when weight-bearing on plantarflexed foot.
    • Jones fractures often occur due to a pivot in the direction opposite the planted foot.
    • Often, there may be swelling or ecchymosis of the proximal 5th metatarsal and lateral foot.
  • Physical examination:
    • Patient is tender to palpation over the proximal 5th metatarsal.
    • Palpate the peroneus brevis tendon to assess its integrity.
    • Check neurovascular status: posterior tibial and dorsalis pedis pulses and normal capillary refill.
    • Resisted eversion/external rotation of foot activates the peroneus brevis muscle and checks its strength; will typically reproduce pain at fracture site with activation
    • Full examination of the distal fibular, lateral ligaments, and foot helps identify associated ankle or foot injury.
    • Check sensation: If decreased around lateral aspect of foot, the lateral dorsal cutaneous nerve, a branch off the sural nerve, may be injured.

Differential Diagnosis

  • Peroneus brevis or peroneus longus tendon injury
  • Anterior process calcaneus fracture
  • Apophysis (Secondary ossification center closes between ages 9 and 11 yr in girls, 11 and 14 yr in boys.)
  • Apophysitis (Iselin disease) or apophyseal avulsion fracture
  • Accessory ossicles
  • Hematoma of lateral proximal foot
  • Midshaft diaphyseal fracture of the 5th metatarsal
  • Sprain of the cubometatarsal joint

Diagnostic Tests & Interpretation

  • Standard x-ray films: anteroposterior (AP), lateral, and oblique views of the foot. If findings are suggestive of ankle trauma meeting the Ottawa criteria (patient between ages of 15 and 55 yr old with inability to walk five steps after injury or tender over posterior third of distal fibula), ankle films (AP, lateral, and oblique views) should also be taken.
  • Acute stress fractures may not be detected on initial radiographs. Repeat radiographs recommended in 10 to 14 days if clinically suspected (2).

Treatment ⬆ ⬇

Acute treatment:

  • ANALGESIA:
    • Apply ice, rest, and elevate foot.
    • Oral pain relief (acetaminophen or tramadol) or topical lidocaine are often sufficient if reduction not necessary.
    • If reduction is needed, performing a hematoma block (2 to 5 mL of 1% lidocaine)
    • Significantly displaced fracture warrants an orthopedic referral for possible surgery.
  • REDUCTION TECHNIQUES:
    • Generally, not recommended if surgical fixation is an option
    • Grab the 5th toe and distract in a longitudinal plane. Apply plantar or dorsal pressure to the proximal portion of the 5th metatarsal.
  • POSTREDUCTION EVALUATION:
    • Check alignment via postreduction radiographs.
  • IMMOBILIZATION:
    • Avulsion fractures:
      • Place in a hard-soled shoe or postoperative shoe for 3 to 4 wk (1)[A].
      • Can place in a walking boot or walking cast if can’t ambulate without pain in shoe, or if worried about patient compliance. Will reduce plantar flexion thus forefoot load; may weight-bear as tolerated (1,3)[A].
    • Jones (metaphyseal–diaphyseal) fractures and diaphyseal stress fractures:
      • Type I (acute): For nondisplaced or minimally displaced fractures (<2 mm), can place patient in short leg cast and make strict non–weight-bearing for 6 to 8 wk (or longer). Otherwise, consider surgical fixation (1,3)[A]. Nonsurgical fracture healing rates approach 75%.
      • Type II (delayed union/stress): Consider surgical fixation because of better prognosis and quicker return to activity. Occasionally can consider prolonged immobilization (up to 16 wk) with non–weight-bearing for selective patients (1,2)[A].
      • Type III (nonunion): Consider surgical fixation (1,3)[A].

Additional Therapies

  • Special considerations: When deciding on treatment for type II fractures, consider the athlete’s timetable and previous medical history.
  • Operative treatment is preferred for elite athletes who wish to avoid the prolonged immobilization of conservative treatment.
  • Occasionally after conservative treatment, a nonunion develops secondary to “distal to proximal” vascular supply to the bone.
  • Bone stimulation (electrical or ultrasound) has shown in some cases to improve healing for delayed union and nonunion fractures (1)[B]. Progression to surgery may be indicated instead of using bone stimulation or if there is inadequate healing with bone stimulation.
  • REHABILITATION:
    • Avulsion fractures: Start with range of motion and progress to strengthening of the peroneus brevis (external rotation and pronation of the foot). Patient may return to play after 3 to 4 wk and when no longer symptomatic.
    • Jones fractures: Once no longer immobilized, start with range of motion and progress to strengthening. Electrical stimulation may help patient initially learn to reactivate musculature. Resume weight-bearing activities slowly after radiographic and clinical healing progressive rehab for strength and proprioception.

Surgery/Other Procedures

  • Avulsion fractures rarely require surgery (3)[A].
  • Jones (metaphyseal–diaphyseal) and diaphyseal stress fractures:
    • Type I: Consider surgical fixation (open reduction, internal fixation with a cannulated screw) for athletes and active patients who wish quicker return to play (1,2,3,5)[A].
    • Type II (delayed union) and type III (nonunion): Refer for surgical evaluation (1,3)[A].

Ongoing Care ⬆ ⬇

Follow-up Recommendations

Referral/disposition:

  • Orthopedic referral for surgery as indicated above and for avulsion fractures that are displaced (rare), comminuted (rare), or involve >30% of the cubometatarsal articulation
  • Patients not responding to home exercise programs after immobilization is complete may benefit from referral to physical therapy.
  • Type I Jones or diaphyseal stress fractures should be referred to an orthopedist if patient prefers surgery in order to return to play quicker or the fracture is displaced or comminuted.

Additional Reading ⬆ ⬇

Porter DA. Fifth metatarsal jones fractures in the athlete. Foot Ankle Int. 2007;39(2):250–258.

References ⬆ ⬇

  1. Bowes J, Buckley R. Fifth metatarsal fractures and current treatment. World J Orthop. 2016;7(12):793–800.
  2. Cheung CN, Lui TH. Proximal fifth metatarsal fractures: anatomy, classification, treatment and complications. Arch Trauma Res. 2016;5(4):e33298.
  3. Fetzer GB, Wright RW. Metatarsal shaft fractures and fractures of the proximal fifth metatarsal. Clin Sports Med. 2006;25(1):139–150.
  4. Hatch RL, Alsobrook JA, Clugston JR. Diagnosis and management of metatarsal fractures. Am Fam Physician. 2007;76(6):817–826.
  5. Yates J, Feeley I, Sasikumar S, et al. Jones fracture of the fifth metatarsal: is operative intervention justified?A systematic review of the literature and meta-analysis of results. Foot (Edinb). 2015;25(4):251–257.

Clinical Pearls ⬆

Physician responses to common patient questions:

  • Q: How long until I can play again?
  • A: Avulsion fractures and diaphyseal stress fractures: up to 20 wk with conservative therapy. Type 1: ≥8 wk. Types 2 and 3: if casted, 3 to 5 mo and 8 wk for surgery