Abstract
Whether the office of the foot and ankle specialist or the general orthopedist, the fifth metatarsal fracture is an injury routinely diagnosed. Found in both young and old, athlete and nonathlete, these injuries have their own set of challenges that make healing difficult. In this month’s roundtable discussion, we were able to assemble a team of the country’s leading experts to provide insight on how they treat the classic Jones fracture, as well as equally as challenging Zone A and C fractures.
Let us start with the Zone A fifth metatarsal fracture. Describe your typical treatment for a nonathlete that presents in the office?
I have been very conservative about treating these patients. I place them in a boot, non–weight bearing for 4 weeks. Thereafter I let them weight bear them in a controlled ankle motion (CAM) boot for 2 more weeks. I have seen a run of patients who are allowed to walk on their fracture immediately with a boot who then went on to a nonunion. These patients ultimately required surgery. I have not seen this happen with the more conservative approach that I have been using.
As long as these fractures are displaced less than 1 cm, I allow them to be weight bearing as tolerated in a postoperative shoe or boot for 8 weeks. I then allow them to be in a carbon fiber insole and regular shoe at 8 weeks, starting physical therapy at that time.
These fractures are rarely taken to the operating room and are often treated with a boot and in many cases weight bearing. If there is gapping that is 2 mm or so, a cast may be applied with 2 to 3 weeks of no weight. If there is rotation of the articular surface or angulation that extends into the articular surface, fixation with 1 or 2 small screws is performed followed by 2 to 3 weeks of casting an heel weight and 3 weeks in a weight bearing boot. These fractures rarely have issues and are mainly nonarticular.
My protocol is very similar to Dr Pedowitz. These are typically treated conservatively with a boot. Rigid support and physical therapy are important parts of our treatment protocol.
Does this treatment change with an athlete? And if so, does the type of athlete and level of athletics factor into your treatment?
The short answer is yes—but only if displaced. Highly competitive athletes occasionally get symptomatic fibrous unions at the base and require additional surgery. In these cases, I still often lean toward conservative care but carefully discuss the options with the athlete and make sure they are comfortable.
With an athlete, I do protect them and make them non–weight bearing for 2 weeks in a CAM boot. During this time, I do allow them to come out of the boot for range of motion activities. At week 2, they begin nonimpact activities. At week 4, I let them progress to more sports-related activities.
I tend to always fix in an athlete. I am very aggressive with these injuries whether nondisplaced or displaced.
I rarely operate on these even in athletes. Articular cartilage angulation may require surgical correction, but I think the risk of surgery does not outweigh the length to recovery. In cases of gapping that is larger, I will put a screw across the fracture, and if there is any issue with a nonhealing fracture that is small, I will remove the piece if needed. That being said, I think cast or boot allows these to heal most if not all of the time.
If surgical treatment is necessary, briefly describe your approach
Surgery has 3 options. Gapping but aligned fragments are done percutaneously with smaller screws. I prefer two 2.0 screws to have even compression and less stress risers. The second is angulated intraarticular fracture. This is treated with an open incision and anatomic alignment of the fracture. A single 4.0 screw or two 2.0 screws are used depending on the size of the fracture. If the fragment is very small and has not healed after 6 weeks, removal of the fragment and peroneal tendon anchoring is performed.
It really depends on the size of the fragment. If large enough, I will reduce the fracture and fix with a small screw. If it is a small fragment, then I will remove the piece. Depending on the location of the insertion of the peroneal brevis, I will reflect the tendon as required.
If the fragments can handle screw fixation, I prefer to utilize a 2.0 or 3.0 cannulated screw placed percutaneously. If the fragment is soft or comminuted, I will utilize plate fixation to contour the fragments for stability.
For small pieces, a small cannulated or solid screw can be placed usually 3.0 to 3.5 mm. If the piece is comminuted or otherwise will not tolerate a single screw, I occasionally use a precontoured hook-plate.
Now on to Zone B fractures, or more commonly called the Jones fracture. Describe your typical treatment for a nonathlete that presents into the office?
I have been very proactive with treating these patients. My threshold to place a screw is very low. If they are even moderately active, I think that surgery with an intramedullary solid screw allows them to return to activities quicker.
For Zone B Jones fractures, I again will be conservative as much as possible. These are often placed non–weight bearing for at least 3 weeks and then radiographic check with some level of healing allows weight bearing to begin in a cast for an additional 3 to 6 weeks. I will only consider surgery in the acute setting if there is significant gapping or rotation of the fracture.
For patients over 60, I typically allow WBAT (weight bearing as tolerated) in a CAM boot for 8 weeks. In patients under 40 who are active, we typically favor surgery for a more reliable outcome following ORIF (open reduction internal fixation) versus the possibility of a symptomatic nonunion. For patients between 40 and 60, I give them both options for them to choose, which is typically based on their activity level.
I am fairly aggressive with these injuries. I offer surgical treatment to all patients.
In the nonathlete, how much time will you give conservative treatment before you employ surgical treatment?
Depending on the activity level my tolerances will slightly fluctuate. In general, I tend to give 8 weeks of conservative treatment before we move to a surgical procedure. Again, this is only if a patient chooses not to have surgery out of the gate. As I answered in the previous question, I offer surgery to these patients as an initial treatment option.
If these patients are moderately active, I will provided support for surgical treatment. I will not wait for conservative care. In the patients who are less active, I will follow them clinically. These patients will be placed in a short leg non–weight bearing cast for approximately 6 weeks. If they remain tender at that time, they are placed into another cast for another 4 weeks. If they are not tender, I will allow them to weight bear as tolerated in a CAM boot. At week 10, they are back in their shoes.
The decision is typically made at the onset of treatment. If they fail this after 3 months, then they can consider ORIF with bone grafting versus a trial of a bone stimulator.
I usually give it 3 months on most patients. I have done as early as 6 weeks if there is no sign of healing and I feel compression will help.
If an athlete presents with a Jones fracture, does your treatment regimen change? Are you more aggressive?
Competitive athletes are typically not willing to undergo 6 to 8 weeks of conservative care and a trial of 4 to 6 weeks of therapy only to find out that they need surgery, which requires another 6 weeks of non–weight bearing. Most athletes choose surgery at the onset of treatment.
For athletes, my preference is surgery, surgery, surgery. I use a solid, intramedullary screw.
I am conservative again with athletes but use a bone stimulator right away if possible. I will perform surgery if the person needs to be back to activity very quickly as I think healing is earlier with a screw fixation on an acute basis but it can also result in early a return to activity and refracture. I have not seen great difference in the acute setting with surgery or nonsurgical care if the fracture is well aligned with minimal gapping. If there is gapping, fixation is best.
Surgery with intramedullary screw fixation.
Describe your surgical preference for treatment of Jones fractures. If you like to use screws, do you prefer solid or cannulated? Does metal type matter? Do you like plates? And also, how does bone graft factor into the procedure?
My preference for treating Jones fractures is with an intramedullary solid screw. The metal that I select is stainless steel; however, I do not think titanium is inferior. I do not routinely use plates, as I am concerned with hardware irritation, especially in the athlete. In general, I do not routinely bone graft these procedures with a separate incision. By tapping the bone, I feel there is adequate graft that is deposited into the fracture site.
I use a noncannulated large diameter screw in most cases. Better fixation and stronger stability are the main reasons. I do not care about type of metal so much. I do use a plate if I want to place bone graft which I do with a trocar through the lateral heel. I make a bone marrow concentrate mixed with calcaneal bone graft and place a linear plate and locking screws. I am aggressive with resection of the nonunion in these cases. Bone grafting is important in these cases.
On average I tend to use a 5.0 titanium cannulated screw. I will harvest calcanea bone graft from the ipsilateral calcaneus.
I only use solid screws and I prefer titanium. Since these screws act as an intramedullary implant, I prefer titanium for its modulus of elasticity, which is very similar to bone.
What is your postoperative course for a Jones fracture repair?
I will not weight bear a Jones repair for 6 to 8 weeks. These have a high rate of issues in the surgical cases, especially in nonunion revision cases. I will also get a compute tomography (CT) scan when I think the area is fairly well healed prior to return to shoes. I have found that early return to activity will cause refracture if you are not careful, and I tend to be conservative and careful with these for about 3 months prior to getting more active with high-impact exercise. I do allow exercise bike and swimming at about 3 weeks if a person needs to stay in cardiovascular shape.
My typical course is 2 weeks in a posterior slab with a sugar tong splint. Then I transition to, on average, 4 weeks in a non–weight bearing cast. At that point I will transition into a CAM boot and therapy. No running or jumping for my patients for 16 weeks.
Non–weight bearing for 6 weeks in a CAM boot then progressive weight bearing and starting physical therapy. No running for 12 weeks.
Patients are placed non–weight bearing in a short leg splint for 2 weeks. Thereafter, they are placed in a CAM walking boot. By week 2, range of motion activities are started. At week 4, the boot is removed. More aggressive, sports-related therapy is initiated. By week 5/6, I allow the athlete to return to play.
How does your surgical and postoperative approach change if the situation is a revision Jones fracture?
In a revision case, I will inject bone marrow aspirate to the fracture site. I will continue to use an intramedullary screw; however, it is typically larger than the primary screw that was used. On rare occasions, I will use a plate. Postsurgically, I will protect these patients longer. They will be in a cast, non–weight bearing, for 4 weeks. They will then be protected in a CAM boot for 4 additional weeks, allowing them to weight bear.
Revision Jones are treated with bone graft every time, and in most cases, I use a locking plate on these. I know intramedullary screw fixation can be done but I tend to resect the nonunion and place bone graft in the shaft and fracture site and have found a plate helps. Again I get a CT scan prior to taking the person out of a boot and allowing increased activity. I also place the patient non–weight bearing for the entire time until I see consolidation and pain relief at which point they are in a weight bearing boot until CT shows almost complete healing and bone bridging.
I employ bone grafting from the calcaneus. Fixation depends on the quality of the bone.
I will often add calcaneal autograft and make them non weight bearing for 8 weeks.
Finally, the Zone C fracture. If a patient comes to the office with a shaft fracture, describe your algorithm for treatment?
If it is a stress fracture, I will typically put them in a boot and see if it heals. Weight bearing in the boot is only appropriate, in my opinion, if patients are asymptomatic once wearing it. If pain persists, they need to be non–weight bearing. Those who fail this treatment get intramedullary screw fixation.
My biggest concern with these fractures is that I believe there is a component of length issue as well as rotational issues. Therefore, on x-rays, if I see significant loss of height, if there is any rotational deformity of the fifth toe, or I see any dorsal or plantar displacement of the head, I will operate on these.
If there is gapping, significant shortening, or angulation, I will treat it surgically. If there is fairly good alignment, I leave it alone in a boot. It is rare to cast these. I usually place the patient in a boot and allow heel weight. These usually fracture in a way that moves the capital fragment medially, which is similar to a tailor’s bunion position so it is rare to need surgery.
That being said, in an athlete, I will repair these more often than not. I think the weight distribution is essential to be balanced in an athlete and therefore I am more aggressive.
If it is a nondisplaced fracture, I will have these patients in a CAM boot and perform serial radiographs. If it is displaced, I will typically treat surgically with screw or plate fixation.
When Zone C injuries are treated surgically, describe your technique
Typically, I will treat these patients with a miniature plate. It will be an open technique, mobilizing the fragments, and restoring length and rotation. I will allow them to weight bear at week 4 in a CAM boot. At week 8, they are back into their shoes. At 3 months, all restrictions on activities are lifted.
My technique is similar to that of a Jones’s fracture: intramedullary screw fixation, non–weight bearing for 6 weeks.
Typically open technique with plate fixation. These patients are then non–weight bearing for 6 weeks on average. Physical therapy starts at the 6 week mark.
Usually I use two to three 2.0 screws are these are spiral fractures. I may use a small plate if there is fragmentation and I need added stability but I find the screws easier and actually better as I can get multiplane compression. Rarely, I will use compression screws and a plate if I need to get a person weight bearing and moving rapidly. I allow weight bearing at 3 weeks postsurgery and usually patients are moved to shoes at 6 weeks or so.