The Physician and Sportsmedicine
Menubar Home Journal Personal Health Resource Center CME Advertiser Services About Us

Fractures of the Fifth Metatarsal

Warren D. Yu, MD; Matthew S. Shapiro, MD

THE PHYSICIAN AND SPORTSMEDICINE - VOL 26 - NO. 2 - FEBRUARY 98


In Brief: Fractures of the fifth metatarsal are common in active people. Proximal metaphyseal and distal fractures are usually amenable to conservative treatment, but some proximal fractures, such as Jones, stress, and acute-on-chronic fractures, are often associated with nonunion or delayed union. Such fractures are often best treated by early operative intervention. Correct identification of fifth metatarsal fractures is important because prompt surgical treatment when indicated can shorten recovery and allow a quick return to sports activity. Other causes of lateral foot pain, including accessory ossicles, neuromas, osteoporosis, herniated disks, and osteoid osteoma, should be considered when suspected fractures fail to show up on radiographs.

Fractures of the fifth metatarsal are commonly encountered by physicians treating active people. Choosing correctly between conservative and surgical treatment of these patients is particularly important because conservative treatment sometimes leads to an extremely slow recovery or to long-term problems. Competitive and recreational athletes are geared for a rapid return to activity, and prolonged recoveries are not well tolerated. In addition, long-term immobilization and rest can lead to muscle atrophy and stiffness, further hampering the patient's return to full athletic participation.

Fifth metatarsal fractures are of several varieties. Proximal fractures include acute fractures of the tuberosity (metaphysis), or "dancer's fractures"; the classic Jones fracture; stress fractures of the proximal diaphysis; and acute-on-chronic diaphyseal fractures. These proximal fractures may look alike, and differentiating them is critical in making the correct treatment decision. Tuberosity fractures and fractures in the midshaft, neck, and head of the metatarsal are generally more likely to respond well to conservative treatment than the others mentioned.

Proximal Metaphyseal Fractures

A fracture of the base of the fifth metatarsal—the so-called dancer's fracture—typically occurs with inversion injuries to the ankle and may accompany an ankle sprain. Because pain at the base of the fifth metatarsal is not a common finding in an ankle sprain, tenderness in this area should prompt the clinician to order whole foot—not just ankle—x-rays.

[FIGURE 1]

These fractures are almost always nondisplaced and involve the cancellous bone and thin cortices of the metaphysis. Some may present as avulsion fractures (figure 1). In the past, these avulsions were thought to be associated with tearing at the peroneus brevis tendon insertion, but it is more likely that the fracture occurs as the plantar aponeurosis is pulled from the bone (figure 2) (1,2). The prognosis for fractures in this area is excellent; they almost always heal within 4 to 6 weeks with conservative treatment.

[FIGURE 2]

Certain conditions may mimic an avulsion fracture radiographically. In the skeletally immature athlete the apophysis of the tuberosity may be confused with a nondisplaced tuberosity fracture. Unlike a fracture, a normal apophysis has a smooth radiolucent line that lies parallel to the shaft of the metatarsal. It may be seen in girls aged 9 to 11 and in boys aged 11 to 14 years (3). The radiolucent line typically disappears 2 to 3 years after it first appears. In skeletally immature patients, radiographs of both feet should be obtained so comparisons can be made.

Accessory ossicles may be confused with a displaced tuberosity fracture fragment. The os peroneum is located next to the lateral border of the cuboid and found within the peroneus longus tendon, whereas the rare os vesalianum is adjacent to the peroneus brevis insertion (3). Fractures typically have a ragged border in contrast to the smooth corticated border of an ossicle. Meticulous clinical exam ensures accurate diagnosis.

Symptomatic treatment for dancer's fractures—consisting of limited weight bearing, modified activity, ice, and analgesics—is all that is necessary. Common treatments range from immobilization in a walking cast or walking with crutches to simply wearing a wooden-soled shoe. Any of these is acceptable, but our preference is to use a removable foot-ankle fracture brace with a rocker bottom. This allows immediate discontinuation of crutches, good mobility, and a quick return to daily (but not sports) activity, with relatively little pain. Moreover, since the patient may remove the device to bathe, apply ice, do range-of-motion exercises, and even sleep, it is very well tolerated.

After 3 to 4 weeks, when pain diminishes, the brace may be removed in favor of some type of modified footwear (eg, a high-top sneaker or hiking boot, sometimes with a lightweight ankle orthosis), and the patient may gradually return to more vigorous activities. In most cases the patient will be back to sports within 6 to 8 weeks.

Operative treatment for metaphyseal fractures is rarely indicated. Some may involve the articular alignment between the base of the fifth metatarsal and the cuboid. If there is significant intra-articular or subchondral step-off at this joint (more than 2 to 3 mm), or if there is a large intra-articular fragment involving more than 30% of the articular surface, operative intervention may be indicated in order to minimize degenerative arthritis to the cuboid-fifth metatarsal articulation (4). Nonunion is exceedingly rare, but if it occurs, it may cause persistent pain requiring surgical treatment.

Jones Fractures

The term "Jones fracture" has been used indiscriminately to describe several different types of fractures of the proximal fifth metatarsal. The true Jones fracture, originally described in 1902 by Sir Robert Jones (5), consists of a transverse fracture at the junction of the diaphysis and metaphysis (figure 3). This trauma site corresponds to the area between the insertion of the peroneus brevis and tertius tendons. An oblique radiograph is essential to accurately assess this fracture. To prevent confusion, only acute fractures in this precise location should be labeled Jones fractures.

[FIGURE 3]

The Jones fracture is an acute midfoot injury with no prodrome. The injury occurs when the ankle is plantar flexed and a strong adduction force is applied to the forefoot (5,6); this can happen in soccer, football, basketball, tennis, and other sports. Because of low vascularization and high stresses at this site, Jones fractures are associated with a poor outcome (see "Anatomy and Healing in the Fifth Metatarsal," below) (4,6-13). Nonunions and delayed unions are common, particularly in patients who have received less-than-optimal treatment(1,7,13-16). Radiographic recognition of this fracture pattern should alert the physician that this injury requires special medical attention.

The optimal treatment is non-weight-bearing immobilization for a minimum of 4 weeks, followed by the use of a walking cast or orthosis for an additional 4 weeks. Athletic activity should be avoided until clinical and radiographic evidence of union appears, typically by 8 to 12 weeks. Noncompliance with treatment and an early return to athletic activities may result in nonunion of the fracture, which will significantly delay the ultimate recovery.

With Jones fractures, failure to heal by 12 weeks is not uncommon, and at this point the difficult decision must be made either to treat operatively or continue conservative treatment. Continued non-weight-bearing immobilization may ultimately lead to union, but is often not well tolerated by the athlete.

Stress and Acute-on-Chronic Fractures

Stress fractures. A stress-induced variant of a Jones fracture is commonly encountered in athletes who do a lot of running. It is often seen in soccer players, and may have something to do with their enormous amount of running, as well as their tendency to wear very narrow, tight-fitting shoes that allow the fifth metatarsal to hang over the sole laterally.

Patients typically present with pain over the lateral aspect of the foot in the area of the fifth metatarsal base, and report no significant episode of trauma (8,12,16). Radiographs typically show evidence of a stress phenomenon at the metaphyseal-diaphyseal junction (the same site as a Jones fracture) with severe intramedullary sclerosis, profound thickening of both the medial and lateral cortices, and a lucency in the lateral cortex (figure 4).

[FIGURE 4]

In our experience, conservative treatment of these stress injuries has yielded uniformly poor results. Healing is slow, and recurrence of the stress fracture is almost certain even if radiographic improvement is seen in the interim.

Our current preference is to treat these patients operatively with the percutaneous insertion of a cannulated screw, placed longitudinally down the intramedullary canal (figure 5). Active patients typically recover from this surgery quickly, bear weight within days, begin aerobic activities such as bicycling within the first week or two, and return to full activities within 6 to 8 weeks (8-11,16-18). The screw is well tolerated and may stay in place for the duration of the patient's athletic career.

[FIGURE 5]

Acute-on-chronic fractures.Occasionally a patient will present with an acute injury that results in pain at the base of the fifth metatarsal, and radiographs will appear atypical. A fracture line at the same site as a Jones fracture is easily identified on the radiograph, but there may also be features typical of a stress injury, such as cortical thickening and a lucency in the lateral cortex (figure 6).

[FIGURE 6]

A careful history will often reveal that the patient has had a prodrome consisting of intermittent pain in the region. This is an important distinguishing feature, for acute-on-chronic stress fractures will behave more like stress fractures than they do acute Jones fractures, and casting and immobilization will frequently fail. Attempted conservative treatment may result in delayed union, the loss of months of competition, and significant dysfunction from long periods of disuse, and surgery will frequently be required in the end.

It is our belief that if this fracture pattern is strongly suspected, the patient is best served by early operative intervention similar to the procedure used for typical stress fractures.

Indications for Surgery

Once nonunion at the metaphyseal-diaphyseal junction is established, further conservative treatment is not likely to result in union (1,4,7,9,10,13). Prolonged immobilization (3 to 6 months) has been recommended in the past, but with currently available surgical techniques is probably not indicated. Patients who have difficulty healing after a Jones fracture, those who present months after an injury with evidence of bony nonunion, those who have had poor or inadequate treatment, and those who have stress injuries and acute-on-chronic injuries are all candidates for surgical treatment.

Our preferred operative procedure, as described above, is intramedullary placement of a cannulated screw, but other surgical procedures are commonly used (8). Open repair with fixation and/or bone grafting yields good results. The minimal morbidity and excellent outcome of percutaneous cannulated screw placement, however, makes it very appealing for athletes.

Distal Fractures

Midshaft and neck fractures. With athletic activity, direct trauma to the fifth metatarsal midshaft and neck may result in fractures. Most will be nondisplaced, but even significant deformity may be well tolerated. The vast majority of these fractures can be treated nonsurgically. The blood supply to this area is excellent, and healing is very predictable (figure 7).

[FIGURE 7]

Lateral radiographs should be carefully evaluated for displacement in the sagittal plane. If a fracture, particularly a more distal one, heals with a significant dorsal or plantar angulation, a painful plantar keratosis may occur, accompanied by painful dorsal corns, irritation by shoes, or pain in adjacent metatarsals. If significant deformity is suspected, referral to an orthopedic foot specialist may be indicated. Displacement in other planes is well tolerated (17,19).

Nondisplaced or minimally displaced midshaft fractures can be managed with early weight bearing in a rigid-soled device such as a cast, fracture brace, or wooden-soled cast shoe (17,19). Fifth metatarsal shaft and neck fractures requiring reduction can be managed with a hematoma block and gentle traction and manipulation. Follow with weight bearing as tolerated in a cast for 4 to 6 weeks. Prolonged non-weight-bearing immobilization should be avoided; it may lead to disuse atrophy, osteopenia, and, rarely, reflex sympathetic dystrophy.

There are no universally accepted guidelines for open reduction and internal fixation of diaphyseal fractures. Generally, surgical intervention is considered if the fracture is irreducible, has residual displacement of more than 3 to 4 mm, or has angulation of more than 10° in the sagittal plane (17). Screws, K-wires, or mini-fragment plates may be used to maintain reduction.

Delayed unions and nonunions may occur, particularly in the distal metaphyseal-diaphyseal area where vascularity may be compromised by the original injury. Symptomatic nonunions may be treated with inlay bone grafting with or without internal fixation with good success (17,19).

Intra-articular metatarsophalangeal fractures. In active people, metatarsal head fractures may occasionally result from direct trauma, and these injuries require careful evaluation. The intra-articular fragment is usually displaced in the plantar and lateral direction. A subtle osteochondral fracture pattern can be noted secondary to shear injury from dorsal dislocation of the metatarsophalangeal joint.

Gentle traction and manipulation typically effect stable reduction. Early weight bearing in a rigid-soled device such as a sandal or a cast for 4 to 6 weeks is adequate for the majority of these injuries. Unstable fractures may occur when the distal fragment lacks soft-tissue attachments. These injuries may require open reduction and pinning. Stiffness and traumatic arthritis of the metatarsophalangeal joint may complicate the final result, and patients should be so advised to ensure appropriate expectations (17,19).

Other Causes of Lateral Foot Pain

When a suspected fracture is not evident on initial or follow-up radiographs, other causes of lateral foot pain must be considered. These include accessory ossicles (os peroneum or os vesalianum), neuromas, osteoporosis, herniated disks, and, rarely, an osteoid osteoma.

If other conditions have been ruled out, accessory ossicles may be the cause of a patient's lateral foot pain and disability. These ossicles can be difficult to visualize on routine radiographs, and oblique views may be needed (3). Initial treatment consists of conservative measures including anti-inflammatory medications, ice, footwear modification, and/or orthoses. A cortisone injection may be attempted in refractory cases, but if pain persists, surgical excision remains as a last resort.

Neuromas of the superficial peroneal or sural nerve should be suspected if previous trauma has occurred. Testing for Tinel's sign along the course of the nerve may reproduce the symptoms, and sometimes a palpable mass is present on exam. A cortisone injection may be attempted, but surgical excision is often required.

Osteoporosis is a common cause of foot pain in the older population but may present as lateral foot pain in young active patients—particularly in female runners who have little body fat and are not menstruating regularly. Leg injuries requiring periods of non-weight bearing, such as fractures and surgery, can cause osteoporosis in the foot and ankle, often leading to pain. The patient's bone quality should be evaluated on radiographs and a bone density scan obtained. Symptomatic treatment along with nutritional and hormonal consultation should be sought.

A herniated disk should be considered in all cases of unexplained lateral foot pain. Careful lumbosacral and neurologic examination should ensure correct diagnosis. If this condition is suspected, magnetic resonance imaging should be performed to corroborate the clinical findings. Typically, either the L-5 or S-1 nerve roots will be involved in the pathology.

Rarely, lateral foot pain can be caused by benign and malignant tumors. One of these is the osteoid osteoma (figure 8), a benign bony tumor occurring in people between the ages of 5 and 30. Patients present with gradually increasing pain, particularly at night. The pain is dramatically improved by nonsteroidal anti-inflammatory drugs. Radiographs typically reveal intensely reactive bony sclerosis that mimics a healing stress fracture, with which it may be confused. A radiolucent nidus, best seen on computed tomography scans, will confirm the diagnosis.

[FIGURE 8]

Treatment for osteoid osteoma consists of round-the-clock anti-inflammatory medications until the patient can undergo surgical excision. Several case reports of spontaneous involution of the nidus exist, but in most cases the patient will require surgery.

Promoting a Quick Return

In fifth metatarsal fractures, correctly identifying the fracture type is essential for permitting the earliest possible return to sports. Proximal metaphyseal fractures usually heal well with conservative treatment, but other proximal fractures—Jones fractures, stress fractures, and acute-on-chronic fractures—often lead to delayed union or nonunion, and are best treated by early operative intervention. More distal fractures can almost always be treated nonoperatively, except for unstable intra-articular fractures.

References

  1. Heckman JD: Fractures and dislocations of the foot, in Rockwood CA Jr, Green DP, Bucholz RW (eds): Fractures in Adults. Philadelphia, JB Lippincott Co, 1991, vol 2, pp 2041-2182
  2. Richli WR, Rosenthal DI: Avulsion fracture of the fifth metatarsal: experimental study of pathomechanics. AJR Am J Roentgenol 1984;143(4):889-891
  3. Wilson DW: Fractures of foot, in Klenerman L (ed): The Foot and its Disorders. Boston, Blackwell Scientific Publications, 1991, pp 237-238
  4. Hansen ST: Foot injuries, in Browner BD (ed): Skeletal Trauma. Philadelphia, WB Saunders, 1992, pp l984-1986
  5. Jones R: Fractures of the base of the fifth metatarsal bone by indirect violence. Ann Surg 1902;35:697-700
  6. Kavanaugh JH, Brower TD, Mann RV: The Jones fracture revisited. J Bone Joint Surg (Am) 1978;60(6):776-782
  7. Acker JH, Drez D Jr: Nonoperative treatment of stress fractures of the proximal shaft of the fifth metatarsal (Jones' fracture). Foot Ankle 1986;7(3):152-155
  8. DeLee JC, Evans JP, Julian J: Stress fracture of the fifth metatarsal. Am J Sports Med 1983;11(5):349-353
  9. Lawrence SJ, Botte MJ: Jones' fractures and related fractures of the proximal fifth metatarsal. Foot Ankle 1993;14(6):358-365
  10. Lehman RC, Torg JS, Pavlov H, et al: Fractures of the base of the fifth metatarsal distal to the tuberosity: a review. Foot Ankle 1987;7(4):245-252
  11. Sammarco GJ: The Jones fracture. Instr Course Lect 1993;42:201-205
  12. Torg JS, Balduini FC, Zelko RR, et al: Fractures of the base of the fifth metatarsal distal to the tuberosity: classification and guidelines for non-surgical and surgical management. J Bone Joint Surg (Am) 1984;66(2):209-214
  13. Zogby RG, Baker BE: A review of nonoperative treatment of Jones' fracture. Am J Sports Med 1987;15(4):304-307
  14. Glasgow MT, Naranja RJ Jr, Glasgow SG, et al: Analysis of failed surgical management of fractures of the base of the fifth metatarsal distal to the tuberosity: the Jones fracture. Foot and Ankle Int 1996;17(8):449-457
  15. Josefsson PO, Karlsson M, Redlund-Johnell I, et al: Jones fracture: surgical versus nonsurgical treatment. Clin Orthop 1994;(299):252-255
  16. Zelko RR, Torg JS, Rachun A: Proximal diaphyseal fractures of the fifth metatarsal—treatment of the fractures and their complications in athletes. Am J Sports Med 1979;7(2):95-101
  17. Anderson RB: Injuries to the midfoot and forefoot, in Lutter LD, Mizel MS, Pfeffer GB (eds): Orthopaedic Knowledge Update: Foot and Ankle. Rosemont, IL, American Academy of Orthopaedic Surgeons, American Orthopaedic Foot and Ankle Society, 1994, pp 264-267
  18. Mindrebo N, Shelbourne KD, Van Meter CD, et al: Outpatient percutaneous screw fixation of the acute Jones fracture. Am J Sports Med 1993;21(5):720-723
  19. Shereff MJ: Complex fractures of the metatarsals. Orthopedics 1990;13(8):875-882


Anatomy and Healing in the Fifth Metatarsal

With an understanding of the anatomy of the fifth metatarsal (figure A), the clinician can better understand the natural history of fractures to this area.

[FIGURE A]

The base, or proximal metaphysis, of the fifth metatarsal consists mostly of cancellous bone with extremely thin cortices. Being well-vascularized, this region heals promptly and predictably.

Anatomic limitations, however, result in poor healing of Jones fractures and proximal diaphyseal stress fractures (1,2). The cortex of the fifth metatarsal thickens considerably and the medullary canal narrows at the junction of the proximal metaphysis and diaphysis (figure B), marking a transition from mostly cancellous to relatively avascular cortical bone. This has important implications for fracture healing, especially for active people, because the cortices of the metaphyseal-diaphyseal junction can thicken even more when running focuses stress on this weight-bearing area. This thickening causes the already poor blood supply to be further diminished. The poor vascularity retards bone healing because the proteins and cells required for bone healing and remodeling require adequate circulation.

[FIGURE B]

Midshaft, neck, and head fractures generally heal well. The blood supply to this part of the metatarsal, surrounded as it is by the soft tissues of the intermetatarsal and plantar areas, is quite good, and healing is very predictable.

References

  1. Shereff MJ, Yang WM, Kummer FJ, et al: Vascular anatomy of the fith metatarsal. Foot Ankle 1991;11(6):350-353
  2. Smith JW, Arnoczky SP, Hersh A:The intraosseous blood supply of the fith metatarsal: Implications for proximal fracture healing. Foot Ankle 1992;13(3)143-152


Dr Yu is a senior resident and Dr Shapiro is an associate professor, both in the department of orthopedic surgery at the University of California School of Medicine in Los Angeles. Address correspondence to Matthew S. Shapiro, MD, UCLA Center for Health Sciences, Dept of Orthopedic Surgery, 10833 Le Conte Ave, Los Angeles, CA 90024-6902; e-mail to [email protected].


RETURN TO FEBRUARY 1998 TABLE OF CONTENTS

HOME  |   JOURNAL  |   PERSONAL HEALTH  |   RESOURCE CENTER  |   CME  |   ADVERTISER SERVICES  |   ABOUT US  |   SEARCH

The McGraw-Hill Companies Gradient

Copyright (C) 1998. The McGraw-Hill Companies. All Rights Reserved
Privacy Policy.   Privacy Notice.