Bending stiffness and pull-out strength of tapered, variable pitch screws, and 6.5-mm cancellous screws in acute Jones fractures

BACKGROUND: Stabilization of fifth metatarsal Jones fractures with intramedullary screws is popular, particularly in athletes, because nonoperative treatment involves prolonged casting and a distinct risk of nonunion or delayed union. Conventional lag screws of various diameters are routinely used for Jones fracture fixation. More recently, tapered, headless, variable pitch screws have become available as an option. These screws have the advantage of not having a protruding screw head, but information regarding their performance in Jones fracture fixation is limited. To determine whether differences exist in the mechanical integrity of fifth metatarsals fixed with each type of screw, this study was designed to compare Jones fracture fixation with 6.5-mm partially-threaded lag screws and headless, tapered, variable pitch compression screws with a 4-mm leading-thread diameter and 5-mm trailing-thread diameter. METHODS: Simulated Jones fractures were created in 20 matched pairs of fresh-frozen fifth metatarsals. One bone from each pair was stabilized with a tapered, variable pitch screw, and the contralateral with a 6.5-mm partially-threaded cancellous lag screw. The stiffness in lateral-to-medial bending of the resulting constructs and the resistance of the screws to pulling out of the distal fragment were quantified. RESULTS: There was no demonstrable difference in bending stiffness between metatarsals fixed with the two types of screws (p = 0.688). The 6.5-mm screw provided significantly higher resistance to pull-out (p = 0.001). CONCLUSIONS: Headless, tapered, variable pitch compression screws of the size tested are not entirely comparable to 6.5-mm lag screws in this application. They are effective in resisting bending but do not offer equivalent resistance to thread pull-out.     

Treatment strategies for acute fractures and nonunions of the proximal fifth metatarsal

There are at least three distinct fracture patterns that occur in the proximal fifth metatarsal: tuberosity avulsion fractures, acute Jones fractures, and diaphyseal stress fractures. Each of these fracture patterns has its own mechanism of injury, location, treatment options, and prognosis regarding delayed union and nonunion. Tuberosity avulsion fractures are the most common in this region of the foot. The majority heal with symptomatic care in a hard-soled shoe. The true Jones fracture is an acute injury involving the fourth-fifth intermetatarsal facet. These injuries are best treated with non-weight-bearing cast immobilization for 6 to 8 weeks. The rate of successful union with this treatment has been reported to be between 72% and 93%. For the high-performance athlete with an acute Jones fracture, early intramedullary-screw fixation is an accepted treatment option. Nonacute diaphyseal stress fractures of the proximal fifth metatarsal and Jones fractures that develop into delayed unions and nonunions can both be managed with operative fixation with either closed axial intramedullary-screw fixation or autogenous corticocancellous grafting. Early results with the use of electrical stimulation are promising; however, prospective studies are needed to better define the role of this modality in managing these injuries.     

Nonoperative treatment of fifth metatarsal fractures in an orthopaedic suburban private multispeciality practice

BACKGROUND: The purpose of this study was to review consecutive fifth metatarsal fractures in the author's (KFK) practice from August, 1999, to November, 2003. METHODS: During this period 64 patients (66 fractures; 35 tuberosity fractures, 10 Jones fractures, three stress fractures, two segmental shaft fractures and 16 oblique distal shaft/neck fractures) were treated nonoperatively. Initial treatment was started from the day of injury to as long as 8 weeks after injury. All patients were treated ambulatory with immediate weightbearing. RESULTS: The time to bony union averaged 3.7 months. The union rate was 98.5% with a satisfaction rate of 100%. CONCLUSIONS: By using closed treatment techniques bony union was predictable with minimal cost and a high satisfaction rate. We recommend nonoperative treatment of fifth metatarsal fractures for patients in whom the time to return to full activities is not critical.     

Fractures of the Proximal Fifth Metatarsal: Selecting the Best Treatment Option

Because of circulatory differences in the three zones of the proximal fifth metatarsal, the location of a fracture must be considered when selecting treatment. The most proximal portion of the base of the fifth metatarsal has good blood supply. Fractures in this zone usually extend into the fifth metatarsocuboid joint. The second zone is associated with Sir Robert Jones, who in 1902 first asserted that fractures of the fifth metatarsal are commonly caused by indirect violence. Fractures in this zone take longer to heal than more proximal fractures, and treatment should be individualized. Whether to use a functional metatarsal brace, a stiff-soled shoe, a short-leg cast, or even internal fixation with a screw depends on the patient's lifestyle and desired activity level. Fractures in the third zone occur between the distalmost portion of the metaphysis and the proximal 1.5 cm of the diaphyseal tubular bone. This zone begins just distal to the ligamentous complex holding the proximal fourth and fifth metatarsals together. In active athletes, fractures in this zone often are stress injuries. For anatomic and mechanical reasons, such fractures are the most difficult to heal. Without surgical treatment, they may take 2 to 21 months to unite and are therefore more likely to need aggressive treatment.     

Jones fractures in the elite football player

The Jones fracture, defined as a proximal junctional metaphyseal/diaphyseal fracture of the fifth metatarsal, presents a challenge to the orthopaedic surgeon, especially in the competitive athlete. The purpose of this study is to characterize the Jones fracture in the elite athletic community and review the variety of treatments for these fractures in the National Football League (NFL). Between 1988 and 2002, 4758 elite collegiate football players participated in the NFL Combine. All athletes were evaluated clinically and radiographically. There were 86 Jones fractures identified in 83 athletes (incidence of 1.8%). Fifty-three percent (46 of 86) of the fractures were treated surgically. Eighty-nine percent (41 of 46) healed without complications and 7% (3 of 46) developed a nonunion. Twenty percent (8 of 40) of the fractures treated nonoperatively developed a nonunion while 80% (32 of 40) healed. The NFL injury surveillance system was also studied and revealed 17 Jones fractures occurred during the seasons 1996--2001. All of these fractures were treated with intramedullary screw fixation. The union rate was 94% (16 of 17 fractures). A questionnaire was also sent to all NFL team physicians regarding their experience with these fractures. The concensus was that this is not a common injury, but when it occurs, surgical treatment is recommended (77%) over nonsurgical treatment (23%). After reviewing the data, it was found that intramedullary screw fixation of Jones fractures is the treatment of choice for most physicians who treat elite collegiate and professional football athletes.     

Fractures of the fifth metatarsal in children and adolescents

OBJECTIVE: Fractures of the fifth metatarsal are the most common metatarsal fractures in children. Their treatment is based on the adult literature. The purpose of our study was to identify the different types of fifth metatarsal fractures, to determine the mean time to healing, and to examine whether current adult recommendations can be extrapolated to children and adolescents. METHODS: A total of 103 patients met the inclusion criteria. The fractures were classified according to location. Type I represented an apophyseal injury. Type II represented tubercle fractures with intra-articular extension. Type III injuries represented Jones fracture. Metatarsal neck and shaft fractures were included separately. RESULTS: Apophyseal fractures did well with a short-leg walking cast for 3 to 6 weeks. Displaced intraarticular fractures had a significant delay in healing versus nondisplaced ones. Jones fractures had delays in healing if not treated surgically. Neck and shaft fractures did well with casting. CONCLUSIONS: Most fractures of the fifth metatarsal in the pediatric population do well clinically after a course of walking cast, unless the fracture is an intra-articular displaced fracture type or the fracture occurs in the proximal diaphyseal area. Fixation of Jones fractures in active adolescents should be considered to allow faster return to regular activities and prevent refracture. We recommend non-weight bearing casts for all angulated or displaced intra-articular injuries to avoid delays in healing and angulation. From our series, it is evident that most pediatric fifth metatarsal fractures behave as those found in adults and can be treated similarly.     

Fractures of the proximal fifth metatarsal - keeping up with the joneses

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.     

Surgical treatment of Jones fractures

Summary A transverse fracture of the proximal part of the fifth metatarsal is rarely caused by direct trauma but is usually secondary to overload [8]. These fractures, when treated conservatively, have a high recurrence rate and give rise to prolonged sporting inactivity. The clinical and radiographical difference between an acute versus a stress fracture will decide on further treatment. A reversed graft, by an asymmetrical trapezoid autograft, offers a simple and effective surgical solution for non-union and delayed union of Jones fractures in sportsmen.     

Metatarsal fractures

Generally nondisplaced metatarsal fractures can be treated nonoperatively. Fracture angulation of more than 10 degrees or fracture displacement of more than 3-4 mm are a valid indication for open or closed reduction. Fractures of the metatarsal bases are often associated with Lisfranc injury. Special attention must be paid to proximal fractures of the fifth metatarsal (avulsion, Jones, proximal diaphyseal fracture). Dislocated midshaft fractures of the first and fifth metatarsals should be treated operatively to realign foot geometry. Subcapital fracture malalignment causes post-traumatic metatarsalgias. Stress and children's fractures are treated most times nonoperatively.     

Plate Fixation With Autogenous Calcaneal Dowel Grafting Proximal Fourth and Fifth Metatarsal Fractures: Technique and Case Series

Metaphyseal and proximal diaphyseal fractures of the lateral column metatarsals can have problems with healing. In particular, those involving the fifth metatarsal have been associated with a high nonunion rate with nonoperative treatment. Although intramedullary screw fixation results in a high union rate, delayed healing and complications can occur. We describe an innovative technique to treat both acute and chronic injuries involving the metatarsal base from the metaphysis to the proximal diaphyseal bone of the fourth and fifth metatarsals. The surgical technique involves evacuation of sclerotic bone at the fracture site, packing the fracture site with compact cancellous bone, and plate fixation. In our preliminary results, 4 patients displayed 100% radiographic union at a mean of 4.75 (range 4 to 6) weeks with no incidence of refracture, at a mean follow-up point of 3.5 (range 1 to 5) years. The early results with our small series suggest that this technique is a useful treatment choice for metaphyseal and proximal diaphyseal fractures of the fourth and fifth metatarsals.     

Lisfranc injury and Jones fracture in sports

This article provides an update and overview of Lisfranc injury and Jones fracture in the athletic population. Sports-related Lisfranc sprains or fractures are subtle injuries that can be easily missed. Now, there is greater understanding of midfoot sprains that represent a spectrum of injury to the Lisfranc ligament complex. Most types of fifth metatarsal fractures have a favorable prognosis and can be treated conservatively. The treatment options for Jones fractures in athletes have been much debated. This article discusses issues related to anatomy, mechanism of injury, clinical presentation, imaging, and diagnosis, which are necessary to appropriately treat these injuries.     

Metatarsale Frakturen

Generally nondisplaced metatarsal fractures can be treated nonoperatively. Fracture angulation of more than 10° or fracture displacement of more than 3–4 mm are a valid indication for open or closed reduction. Fractures of the metatarsal bases are often associated with Lisfranc injury. Special attention must be paid to proximal fractures of the fifth metatarsal (avulsion, Jones, proximal diaphyseal fracture). Dislocated midshaft fractures of the first and fifth metatarsals should be treated operatively to realign foot geometry. Subcapital fracture malalignment causes post-traumatic metatarsalgias. Stress and children’s fractures are treated most times nonoperatively.     

The Use of Percutaneous Screw Fixation Without Fracture Site Preparation in the Treatment of Fifth Metatarsal Base Nonunion

Nonunion after a proximal fifth metatarsal fracture can cause considerable pain, with high morbidity and loss of work. Although many authors advocate early surgical management of zone 3 injuries (Jones fractures), zone 1 and 2 fractures are generally expected to heal with conservative management. Uncommonly, zone 1 and 2 fractures can develop nonunions. The aim of this study was to evaluate the efficacy of closed intramedullary screw fixation for nonunions of the fifth metatarsal base. We performed a prospective study involving all fifth metatarsal base nonunions treated in our department over 2 years. Only minimally displaced adult fractures were considered for this study. The fracture pattern was categorized using the Dameron classification (zone 1, styloid process; zone 2, metadiaphyseal area; zone 3, proximal diaphysis). All nonunions were fixed percutaneously under radiographic guidance, without fracture site preparation. Zone 1 injuries were fixed using a 3-mm headless compression screw, and those of zones 2 and 3, with an intramedullary 4-mm screw. Of 30 patients included in this study, a minimum 6-month clinical follow-up was obtained. The average time from injury to treatment was 5.9 months (range 3 to 36). There were no smokers in this patient cohort. There were 12 zone 1 injuries, 9 zone 2 injuries, and 9 zone 3 injuries. All patients achieved union by 3 months after screw fixation, with 29 of 30 achieving union by 6 weeks. All patients had resolution of symptoms. There were no complications. We conclude that percutaneous fixation of fifth metatarsal base nonunions, without fracture site preparation, achieves excellent results. We believe that the screw alters the strain of the fracture, thus promoting fibrous-to-osseous conversion and therefore union.     

Existing fixation modalities for Jones type fifth metatarsal fracture fixation pose high rates of complications and nonunion

Jones type fifth metatarsal fractures pose a challenge to the foot and ankle surgeon, given documented high nonunion rates as well as high complication rates including hardware prominence, nerve injury, and screw breakage for existing treatment modalities including screw and plantar plate fixation. We call for the design of innovative Jones-fracture specific implants which contour to the natural curve of the fifth metatarsal. Future research should aim to expand upon existing literature for Jones fracture fixation and evaluate efficacy of novel implants which are designed to address unacceptably high complication rates for existing treatment modalities.     

The Jones fracture—transverse proximal diaphyseal fractures of the fifth metatarsal: frequency by radiology

1477 consecutive foot X-rays were reviewed over an 11-month period from the Lehigh Valley Hospital Center Emergency Services. 49 fifth metatarsal fractures were identified. Two transverse proximal diaphyseal fractures 3.0 cm distal from the fifth metatarsal tuberosity, the Jones fracture, were identified. The frequency of the Jones fracture in this group of fifth metatarsal fractures (n = 49) is 4%.     

High-risk stress fractures: evaluation and treatment

Stress fractures are common overuse injuries seen in athletes and military recruits. The pathogenesis is multifactorial and usually involves repetitive submaximal stresses. Intrinsic factors, such as hormonal imbalances, may also contribute to the onset of stress fractures, especially in women. The classic presentation is a patient who experiences the insidious onset of pain after an abrupt increase in the duration or intensity of exercise. The diagnosis is primarily clinical, but imaging modalities such as plain radiography, scintigraphy, computed tomography, and magnetic resonance imaging may provide confirmation. Most stress fractures are uncomplicated and can be managed by rest and restriction from the precipitating activity. A subset of stress fractures can present a high risk for progression to complete fracture, delayed union, or nonunion. Specific sites for this type of stress fracture are the femoral neck (tension side), the patella, the anterior cortex of the tibia, the medial malleolus, the talus, the tarsal navicular, the fifth metatarsal, and the great toe sesamoids. Tensile forces and the relative avascularity at the site of a stress-induced fracture often lead to poor healing. Therefore, high-risk stress fractures require aggressive treatment.     

Acute surgical management of Jones' fractures

The purpose of this study was to evaluate the effectiveness of surgical management for acute Jones' fractures and Torg types I and II proximal diaphyseal stress fractures presenting acutely in both athletes and nonathletes. Twenty-two patients underwent intramedullary screw fixation between 1994 and 1999. Immediate intramedullary screw fixation of acute Jones' fractures and type I stress fractures resulted in a 100% union rate with an average time to union of 6.2 weeks. Fixation of type II stress fractures had a union rate of 100% with a mean time to union of 8.3 weeks. The overall complication rate was 9%. Surgical intervention allowed an earlier return to weight-bearing with a more rapid and predictable union rate. The authors recommend intramedullary fixation as a treatment of choice for the management of fifth metatarsal fractures distal to the tuberosity in nonathletes as well as athletes.     

Metatarsal fractures

Metatarsal fractures are relatively common and if malunited, a frequent source of pain and disability. Nondisplaced fractures and fractures of the second to fourth metatarsal with displacement in the horizontal plane can be treated conservatively with protected weight bearing in a cast shoe for 4-6 weeks. In most displaced fractures, closed reduction can be achieved but maintenance of the reduction needs internal fixation. Percutaneous pinning is suitable for most fractures of the lesser metatarsals. Fractures with joint involvement and multiple fragments frequently require open reduction and plate fixation. Transverse fractures at the metaphyseal-diaphyseal junction of the fifth metatarsal ("Jones fractures") require an individualized approach tailored to the level of activity and time to union. Avulsion fractures of the fifth metatarsal bone are treated by open reduction and tension-band wiring or screw fixation if displaced more than 2 mm or with more that 30% of the joint involved. The metatarsals are the most common site of stress fractures, most of which are treated nonoperatively. Symptomatic posttraumatic deformities need adequate correction, in most cases by osteotomy across the former fracture site.