DEFINITION

The fifth metatarsal is the most frequently fractured metatarsal bone. Of these, proximal fractures are the most common.8

Proximal fifth metatarsal fractures are traditionally classified into three types, based on the zone or location of the fracture (FIG 1):

Zone I: tuberosity avulsion fracture that may extend to the fifth metatarsal-cuboid articulation

Zone II: classic “Jones fracture” at the metaphyseal-diaphyseal junction that extends into, but not beyond, the fourth and fifth intermetatarsal articulation

Zone III: proximal diaphyseal stress fracture

Identifying the correct zone is important because the healing characteristics and management differ for fractures occurring in each.

 

 

ANATOMY

 

 

The fifth metatarsal consists of a head, diaphysis, metaphysis, and tuberosity. The tuberosity is the most proximal and plantar structure of the fifth metatarsal.

 

 

Proximally, the fifth metatarsal has articulations with the cuboid and fourth metatarsal. There are four main soft tissue attachments to the proximal aspect of the fifth metatarsal:

 

The peroneus brevis tendon inserts on the dorsolateral tuberosity.

 

The peroneus tertius tendon attaches on the dorsal aspect of the metaphysis.

 

The lateral band of the plantar fascia attaches to the plantar aspect of the fifth metatarsal base.

 

 

 

FIG 1 • Three anatomic zones of the proximal fifth metatarsal with corresponding fracture types.

 

 

Dorsal, plantar, and interosseus ligaments attach between the bases of the fourth and fifth metatarsals.

 

Blood supply to the proximal fifth metatarsal is derived from two sources (FIG 2):

 

 

Metaphyseal vessels supply the tuberosity.

 

An intramedullary nutrient artery enters from the medial cortex at the proximal diaphysis and flows retrograde, terminating at the metaphyseal-diaphyseal junction.

 

The region at which these blood vessels converge corresponds to a relatively avascular watershed area, making it a tenuous area for healing.13

 

The dorsolateral branch of the sural nerve usually lies approximately 2 to 3 mm proximal to the tuberosity and often courses at the incision site used for surgical fixation.4

 

The peroneus longus courses lateral to and then plantar to the cuboid, immediately proximal to the fifth metatarsal base (FIG 3).

 

PATHOGENESIS

 

Different mechanisms of injury have been associated with the different fracture zones:

 

 

Zone I (tuberosity) fractures result from forces exerted on the peroneus brevis tendon or the lateral band of the plantar fascia with foot inversion.

 

Zone II (Jones) fractures result from an indirect, large adduction force applied to the forefoot with the ankle in plantarflexion.

 

 

The ligaments at the base of the fourth and fifth metatarsals are resistant to displacement, resulting in fracture just distal to them, at the level of the fourth and fifth intermetatarsal joints.

 

 

P.985

 

 

 

FIG 2 • Vascular supply to the proximal fifth metatarsal. Note the watershed segment between the metaphyseal arteries and the intramedullary nutrient artery located at the metaphyseal-diaphyseal junction (zone II), where fractures are notoriously at high risk for delayed union and nonunion.

 

 

Zone III (diaphyseal stress) fractures result from overuse or overload injuries.

 

 

These injuries may be acute or chronic.

 

 

Underlying hindfoot varus alignment has been implicated in overloading the lateral foot and is considered a predisposing factor for proximal fifth metatarsal fractures as well as nonunion and refracture if not addressed at the time of surgical stabilization.11

NATURAL HISTORY

 

Zone I (tuberosity) fractures nearly always heal with conservative management alone. Although patients can expect to return to their preinjury level of function, recovery may take 6 months or longer.5

 

Zones II (Jones) fractures are notorious for a high incidence of delayed union and nonunion (up to 28%)1 when treated conservatively and is thought to be due to their tenuous location:

 

 

Relatively avascular watershed zone

 

The peroneus brevis and the lateral band of the plantar fascia cause continued motion at the fracture site despite immobilization.

 

Zone III (diaphyseal stress) fractures are also notorious for their protracted healing time and risk of nonunion (shown to develop in up to 25% of nonoperatively treated cases).2

PATIENT HISTORY AND PHYSICAL FINDINGS

 

History

 

 

 

Usually entails injury to the foot during sports activity, especially basketball or football In the nonathlete, tripping off a curb with the foot inverted is a common mechanism.

 

 

 

FIG 3 • Structures at risk during surgical fixation of proximal fifth metatarsal fractures. Typically, the sural nerve and peroneus brevis tendon are retracted dorsally, whereas the peroneus longus tendon is retracted plantarward.

 

 

In the setting of an overuse injury, the patient may describe prodromal symptoms.

 

The patient will complain of painful weight bearing and tenderness over the lateral border of the foot that is reproducible with direct palpation.

 

Physical examination

 

 

 

Swelling and ecchymosis over the lateral border of the foot is often present. Pain and/or weakness with eversion may be noted.

 

Evaluate for potential sources of lateral foot overload (ie, hindfoot varus), which can have implications on healing after fixation of a proximal fifth metatarsal fracture, if not simultaneously addressed.

 

Assess for signs of Lisfranc injury with direct palpation over the tarsometatarsal joint complex and presence of plantar ecchymosis.

 

IMAGING AND OTHER DIAGNOSTIC STUDIES

 

Anteroposterior (AP), lateral, and oblique radiographs of the affected foot are sufficient to diagnose a proximal fifth metatarsal fracture (FIG 4A-C).

 

If there is suspicion for Lisfranc injury, weight-bearing radiographs of the affected foot should be obtained.

 

Computed tomography (CT) scan is rarely indicated but may assist in differentiating between acute and chronic fractures and degree of union after treatment (FIG 4D,E).

DIFFERENTIAL DIAGNOSIS

 

Cuboid fracture

 

 

Fifth metatarsal shaft fracture Lisfranc injury

 

P.986

 

 

 

FIG 4 • Non-weight-bearing AP (A), oblique (B), and lateral (C) radiographs of the foot of a 16-year-old high school soccer player with a nonunited zone III stress fracture of the fifth metatarsal base. Patient presented with a 3-month prodrome of symptoms not responsive to conservative management. CT scan of the foot (D,E) demonstrates persistent nonunion at the fracture site.

 

NONOPERATIVE MANAGEMENT

 

Conservative treatment is typically reserved for the following:

 

 

Zone I fractures

 

 

Patients of low activity demand with a zone II or III fracture Patients with medical comorbidities that preclude surgery

 

Zone I fracture: weight bearing as tolerated in a hard-soled shoe or boot (6 to 8 weeks)

 

Zone II/III fractures: six weeks of cast immobilization and non-weight bearing, followed by an additional 6 weeks of boot immobilization with gradual advancement of weight bearing

 

SURGICAL MANAGEMENT

 

 

The indications for surgical fixation of proximal fifth metatarsal fractures remain. Surgical treatment is indicated in the following:

 

 

 

Zone II or III fracture in athletes or individuals desiring a quicker return to activity1,2,7 Informed patients who prefer surgery to the risk of nonunion with nonsurgical treatment.1,2,7 Zone III fractures with symptomatic delayed union/nonunion2,3

 

Zone I fractures with symptomatic delayed union/nonunion

 

Preoperative Planning

 

Determine the appropriate type and method of fixation.

 

 

Percutaneous intramedullary screw fixation is the most widely used technique.

 

 

A variety of screw options exist and each have their advantages and disadvantages (ie, solid vs. cannulated, stainless steel vs. titanium, fully threaded vs. partially threaded vs. variable pitch).

 

Although the biomechanical properties of various screws have been shown to vary, no single type of screw has clinically been shown to be superior.

 

Recently, low-profile, precontoured proximal fifth metatarsal fracture plates have become popularized as an alternative fixation option. These plates have tines or “hooks” at one end, which serve to engage the proximal fracture fragment and provide rotational control. Indications for plate fixation may include the following:

 

 

 

Comminuted zone II fractures (FIG 5) Osteoporotic bone

 

Revision cases after failed intramedullary screw fixation

 

Cases in which intramedullary screw fixation is less than optimal (ie, loss of cortical integrity, canal diameter too small to accommodate a minimum 4.5-mm screw)

 

Symptomatic delayed union or nonunion of zone I fractures

 

 

Determine if bone graft is desired.

 

 

We typically use bone graft harvested from the ipsilateral calcaneus in cases of comminution, osteoporotic bone, delayed and nonunions.

 

Determine if an underlying source of lateral foot overload (ie, hindfoot varus, chronic lateral ankle instability, etc.) is present and ensure that it is addressed, either surgically or conservatively (ie, orthotics, bracing), in conjunction with stabilization of the proximal fifth metatarsal fracture.

 

Positioning

 

The patient is placed supine with a bolster under the ipsilateral hip to internally rotate the leg, providing better access to the lateral foot.

 

 

P.987

 

 

 

FIG 5 • Non-weight-bearing AP (A), oblique (B), and lateral (C) radiographs of the foot of a 34-year-old female with a displaced and comminuted zone II fracture of the fifth metatarsal base.

 

 

Place the surgical foot at the lateral edge of the operating table. This facilitates use of a mini-fluoroscopy unit that will serve as a lateral extension of the table for portions of the case.

 

A calf tourniquet is used to avoid bleeding that may obscure structures at risk in the surgical field. Ensure it is placed distal to the fibular head to avoid pressure on the common peroneal nerve.

 

TECHNIQUES

• Percutaneous Intramedullary Screw Fixation

Incision and Dissection

The surgical approach is similar to intramedullary fixation of a long bone.

Make a 2-cm longitudinal incision, approximately 1 cm proximal to the base of the fifth metatarsal, in line with the longitudinal axis of the shaft. Avoid referencing solely off the tip of the tubercle, as this will put you more plantar than the actual axis of the shaft.

Identify and protect the following three structures:

Dorsolateral branch of the sural nerve, which courses directly at the incision site Peroneus brevis tendon, which inserts on the dorsolateral tuberosity

 

 

 

 

TECH FIG 1 • The high and inside starting position and resultant screw position during intramedullary fixation of proximal fifth metatarsal fractures. The dorsal and medial starting position aligns the screw with the intramedullary canal. A. Coronal view of screw position relative to the fifth metatarsal. B. End-on view of the proximal fifth metatarsal with screw in place. (continued)

 

 

Peroneus longus tendon, which courses lateral to and then plantar to the cuboid, immediately proximal to the fifth metatarsal base

 

Keep the sural nerve and peroneus brevis tendon protected by retracting them dorsally, whereas the peroneus longus is retracted plantarward.

 

Throughout the duration of the case, a soft tissue guide should be used during pinning, drilling, and tapping to further protect the structures at risk.

Guide Pin Positioning and Drilling

 

Place the guide pin at the “high and inside” starting position. This corresponds to the dorsal and medial aspects of the proximal end of the fifth metatarsal, which will optimally keep the pin within the longitudinal axis of the metatarsal (TECH FIG 1A,B).

 

P.988

 

 

TECH FIG 1 • (continued) C. Fluoroscopic image shows guide pin positioning for intramedullary screw fixation of fifth metatarsal base fracture. AP (D), oblique (E), and lateral (F) views show the guide pin advanced to the fracture site. G. Protective drill sleeve used to protect structures at risk, in addition to retraction of the peroneal tendons and sural nerve, when drilling for intramedullary screw fixation of a proximal fifth metatarsal fracture. H. Fluoroscopic image. Drilling is necessary only to the level that will allow the threads of the partially threaded screw to cross the fracture site. I. Fluoroscopic image shows drilling of sclerotic bone to promote fracture healing at the nonunion site.

 

 

Confirm the starting position under fluoroscopy. It is important to use all three planes (AP, lateral, and oblique).

 

Start with the oblique plane, as this places the metatarsal in profile and is the easiest position in which to interpret the pin's position on fluoroscopy (TECH FIG 1C).

 

Refrain from advancing the pin until its proper position has then been confirmed in the other two planes. It is difficult to make subtle adjustments with a guide pin once a hole has been created near the ideal starting position, as the pin will tend to fall back into the improperly placed hole.

 

Once the optimal starting point is confirmed, aim the pin so that it is directed into the center of the fifth

metatarsal intramedullary canal and partially advance (TECH FIG 1D-F).

 

Confirm that the trajectory of the guide pin is appropriate and then advance it across the fracture or nonunion site.

 

Because the fifth metatarsal is a curved bone and intramedullary fixation is performed with a straight screw, the guide pin, drill, tap, and screw only need to be advanced so that all of the screw's threads are distal to the fracture/nonunion site. This typically only involves the proximal 50% of the metatarsal. If the final screw is too long, it may impinge on the distal medial cortex of the curved fifth metatarsal, thereby creating a lateral cortical gap at the fracture site and potentially promoting nonunion.

 

If there is a concern that the guide pin will dislodge during drilling or tapping, then the guide pin may be advanced farther down the metatarsal, but there is no need to drill or tap that far.

 

Use the cannulated drill (with drill sleeve) to overdrill the guide pin, just beyond the fracture site (TECH FIG 1G,H).

 

In the setting of nonunion, a small-diameter drill bit may be used to disrupt the sclerotic bone at the nonunion site to promote fracture healing (TECH FIG 1I).

 

P.989

 

 

 

TECH FIG 2 • Use of the tap in intramedullary screw fixation of a proximal fifth metatarsal fracture. Fluoroscopic image shows the tap engaged with the inner cortex of the metatarsal shaft. Note that the tap is advanced only far enough to allow the threads of the partially threaded screw to cross the fracture.

Use of the Tap

 

The tap is introduced over the guide pin with its soft tissue sleeve (TECH FIG 2).

 

 

The tap serves two purposes: Prepares the canal for the screw

 

Gauges the size of screw that will afford the best purchase in the distal fragment. This is performed

using a set of graduated taps of increasing diameter.

 

While advancing the tap with one hand, the surgeon holds the distal aspect of the metatarsal with the other hand to gauge and resist torque that is created.

 

The tap only needs to be advanced far enough for all threads of the eventual screw to cross the fracture/nonunion site.

 

The optimal screw diameter is determined by the tap size that creates a firm torque on the distal fragment with each turn of the tap.

Determining Screw Size

 

Screw diameter

 

 

Optimal screw diameter is determined by the diameter of the tap that best engages the distal fragment. A screw that is too large in diameter risks cortical compromise and stress shielding.

 

Although biomechanical data exist that suggest improved fracture fixation with a larger screw diameter, the clinical evidence to support this is weak.

 

In general, most advocate use a screw diameter of at least

 

4.5 mm in skeletally mature patients.9,12 Screw length

 

Optimal screw length is that which will allow all screw threads to cross the fracture site, without contacting the distal medial cortex, as this may lead to gapping of the lateral cortex and potentially nonunion.

 

Screw length can be determined by any of the following three methods:

 

Use a cannulated depth gauge with the intramedullary guide pin tip at the desired position for the tip of the screw. Ensure the gauge is flush against bone.

 

Use two guide pins and measure the difference, with the intramedullary guide pin in the optimal position and the second placed to the level of the base of the fifth metatarsal.

 

 

 

TECH FIG 3 • Determining screw length for open reduction and internal fixation of a proximal fifth metatarsal fracture. Intraoperative photograph shows the surgeon holding the screw adjacent to the metatarsal for a fluoroscopic image. Although the surgeon must account for magnification error, this technique provides some guidance as to the length of screw needed for the threads to cross the fracture.

 

 

Hold the screw immediately adjacent to the fifth metatarsal base to determine if the threads will cross the fracture site (must account for a slight magnification effect) (TECH FIG 3).

Screw Insertion

 

With the ideal diameter and length determined, the screw is advanced into the prepared canal.

 

As the screw engages the distal fragment, the surgeon must use the opposite hand to (TECH FIG 4A):

 

Resist the torque that is created by the screw in the distal fragment so that the screw fully advances in the metatarsal without excessive rotation at the fracture site.

 

Apply an axial force on the distal fragment to provide compression and ensure that the screw fully advances without distraction at the fracture site.

 

Final fluoroscopic images in all three planes are checked to confirm that the screw is fully seated with all threads beyond the fracture site and that the fracture is reduced and compressed (TECH FIG 4B-D).

 

 

 

TECH FIG 4 • Screw insertion in intramedullary screw fixation of a proximal fifth metatarsal fracture. A. Intraoperative photograph shows the surgeon holding the distal fragment with one hand while placing the screw with the other. This technique allows for axial compression and assessment of how well the screw is engaging the inner cortex of the distal fragment. (continued)

 

 

P.990

 

 

 

TECH FIG 4 • (continued) Intraoperative AP (B), oblique (C), and lateral (D) fluoroscopic images confirm that the screw is in proper position, with all threads across the fracture site; the fracture is reduced; and there are no associated stress fractures.

• Open Reduction and Internal Fixation Using a Low-Profile, Precontoured Proximal Fifth Metatarsal Fracture Plate

Incision and Dissection

 

Make a 5-cm longitudinal incision directly along the lateral border of the fifth metatarsal, starting 1 cm

proximal to the tuberosity, extending distally (TECH FIG 5A).

 

Identify and protect the dorsolateral branch of the sural nerve.

 

 

Identify and protect the peroneus brevis dorsally and peroneus longus plantarly. Gently retract the sural nerve in the direction with the least resistance.

 

Develop dorsal and plantar skin flaps along the length of the incision to expose the proximal metatarsal.

 

Avoid soft tissue and periosteal stripping, except for at the tip of the tuberosity, which will serve as an anchor point for the proximal tines of the plate (TECH FIG 5B).

 

 

 

TECH FIG 5 • A. Skin incision for plate fixation of proximal fifth metatarsal fracture. The longitudinal incision should center along the axis of the proximal metatarsal and extend approximately 1 cm proximal to the tubercle. B. The plate guide in proper position about the proximal metatarsal. Note a crossing branch of the sural nerve, which should be protected through the duration of the case. Also note that the fifth metatarsal soft tissue and periosteum has been preserved under the guide.

Initial Reduction

 

 

Sometimes, the fracture may be nondisplaced and obviate the need for formal reduction. If reduction is needed, remove 2 mm of periosteum and soft tissue only at the fracture site.

 

Gently débride and irrigate any interposed soft tissue and hematoma.

 

If desired, place bone graft into the fracture site at this time (TECH FIG 6A).

 

Use a pointed reduction forcep or Kirschner wire (K-wire) to obtain provisional reduction of the fracture.

 

Seat the plate guide along the lateral border of the proximal metatarsal in the position where it best contours and lies flush against the bone. Secure the plate with its accompanying K-wires.

 

Confirm satisfactory fracture reduction and guide position under fluoroscopy (TECH FIG 6B-D).

 

Use the proximal guide holes to drill two holes through the outer cortex of the tuberosity with a 1.75-mm drill bit.

 

P.991

 

 

 

TECH FIG 6 • A. If desired, bone graft may be placed into the fracture site at this time. Fluoroscopic AP (B), oblique (C), and lateral (D) images demonstrate the position of the guide, which is well contoured and flush to the native metatarsal cortex.

Applying the Plate

 

Determine the appropriate length plate for the fracture.

 

Remove the guide and engage the proximal tines or hooks of the plate into the drilled holes at the tuberosity (TECH FIG 7A).

 

Use the mini-impactor to completely seat the tines into bone (TECH FIG 7B).

 

 

 

TECH FIG 7 • Inserting and securing the plate. A. Intraoperative photograph shows the plate ready to be

inserted. This is done by engaging the hooks into the previously drilled holes in the tubercle created with the guide. B. A tamp is used to seat the plate so that it is flush to bone. Intraoperative oblique (C) and lateral (D) fluoroscopic images confirm plate position. (continued)

 

 

The plate should lie centered and flush against the proximal metatarsal. Confirm appropriate plate position under fluoroscopy (TECH FIG 7C,D).

 

Secure the distal end of the plate to the metatarsal shaft using the 1.75-mm drill bit in the oblong hole, followed by the appropriate sized 2.3-mm bicortical screw.

 

If compression at the fracture site is desired, drill eccentrically in the hole (away from the fracture) (TECH FIG 7E).

 

Leave the screw slightly untightened (TECH FIG 7F).

 

 

P.992

 

 

 

TECH FIG 7 • (continued) E. Eccentric drilling of the oblong hole, furthest away from the fracture, to provide compression through the plate. F. The screw is engaged to the plate and bone but not fully tightened.

Compressing the Fracture

 

 

 

If compression is not desired (ie, excessive comminution), this step may be skipped. Engage the screwdriver tip of the expander/compression tool into the head of the screw. Insert the opposite jaw of the tool into the adjacent distal hole in the plate.

 

 

 

TECH FIG 8 • Compression is applied (A), and the screw is completely tightened to the plate (B), maintaining the compression across the fracture site. C. The screw head is now closest to the fracture site in the oblong hole. Also note preservation of the crossing branch of the sural nerve as well as the periosteum over the metatarsal shaft.

 

 

 

Gently squeeze the handle of the tool until the desired amount of compression is obtained (TECH FIG 8A). Maintaining compression, completely tighten and seat the screw (TECH FIG 8B).

 

Evidence of compression is depicted by a more proximal position of the screw in the oblong hole (TECH FIG 8C).

Final Fixation

 

Place additional 2.3-mm screws in the distal and proximal fragments as needed.

 

Proximally, ensure the screws are directed appropriately to maintain intraosseous position.

 

Obtain final fluoroscopic images in three planes to evaluate reduction and hardware position (TECH FIG 9).

 

 

 

TECH FIG 9 • AP (A), oblique (B), and lateral (C) fluoroscopic images confirm that the hardware is appropriately seated against bone and that the fracture is reduced.

 

 

 

 

P.993

 

PEARLS AND PITFALLS
	Operating room setup ▪ Position the foot at the distal lateral border of the operating table so that it can be easily moved onto the adjacently positioned fluoroscopy unit when needed. Use a bolster under the ipsilateral hip to internally rotate the foot and provide easy access to its lateral border.     Intramedullary screw fixation

 

	Avoid iatrogenic injury to ▪ Use retractors and a drill guide or sleeve when drilling, tapping, and the sural nerve and upon screw application. peroneal tendons.     Ideal starting position ▪ Use the high and inside starting position, dorsal and medial on the proximal end of the fifth metatarsal.     Ideal screw diameter ▪ Must allow adequate endosteal bite of the screw threads Avoid too large a diameter, as this risks cortical compromise and stress shielding.     Ideal screw length ▪ Screw threads must cross the fracture site for compression to occur. Avoid too long a screw, as this risks gapping at the fracture site as the screw attempts to straighten the native distal curve of the bone.     Plate fixation     Avoid excessive soft tissue ▪ If direct reduction is needed, only expose directly at the fracture stripping. site.     Avoid compression when ▪ Instead, bridge the comminution and use the plate as a template for there is significant fracture fracture reduction. comminution.     Prevent hardware irritation. ▪ Manually contour the plate with plate benders as needed to ensure it sits flush against bone its entire length.

 

 

POSTOPERATIVE CARE

 

The patient is kept immobilized in a postoperative splint for the first 2 weeks after surgery to allow their incision to heal.

 

They are then transitioned to a short-leg cast or CAM walker and kept protected weight bearing until 6 weeks postoperatively.

 

Gradual progression of weight bearing in a CAM walker is instituted at 6 weeks postoperatively, followed by transition to regular shoes.

 

Return to full activities and athletics is allowed once complete radiographic healing is observed and the patient is nontender at the fracture site (10 to 12 weeks postoperatively). Consider obtaining CT scan before returning high level athletes to play14 (FIG 6).

 

 

 

FIG 6 • AP (A), oblique (B), and lateral (C) radiographs obtained at 3-month follow-up after intramedullary screw fixation of the zone III proximal fifth metatarsal stress fracture in the 16-year-old soccer player presented in this chapter. Bridging trabeculation at the fracture site was suggested on all three radiographs. D. CT scan at 4-month follow-up confirmed complete healing across the fracture site. The foot was nontender on clinical examination, and the patient was released to full return to athletics without complications.

 

 

In the patient with preoperative flexible hindfoot varus, we recommend a custom rigid orthotic insert (lateral hindfoot wedge extended to a lateral forefoot post) to offload the fifth metatarsal base and potentially reduce the

risk of refracture.11

 

 

OUTCOMES

Compared to nonoperative management, surgical management of proximal fifth metatarsal fractures has been shown to result in faster time to union and return to sports activities.7

The overall healing rate with intramedullary screw fixation has been reported to be better than 90%.3,7,10

P.994

Proximal fifth metatarsal plate

There is little published data on the outcomes after plate fixation of proximal fifth metatarsal fractures.

Lee et al6 treated 19 patients with zone I (12) and zone II (7) proximal fifth metatarsal fractures with a locking compression distal ulna hook plate. Radiographic bony union occurred in all patients at an average of 7.4 weeks (range 4 to 16). All patients returned to their regular sports activities and daily life

at a mean of 11.2 weeks (range 9 to 19).6

 

 

COMPLICATIONS

Intramedullary screw

Delayed union, nonunion, and refractures have been associated with use of screw diameters smaller than 4.5 mm, incomplete reaming of a sclerotic canal, and early return to vigorous activity.

Refracture can occur after healing and screw removal. As a result, some recommend the following14: Leaving the screw in place until the end of the patient's athletic career

Considering functional bracing, shoe modification, or an orthosis with return to play

Using advanced imaging to help document complete healing before returning to play

Distal fracture at the tip of the screw (peri-implant fracture)

 

Prominent screw head Sural neuralgia

Injury to the peroneus brevis or longus tendons Proximal fifth metatarsal plate

Rates of refracture have not been published. Hardware irritation, requiring removal

Sural neuralgia Delayed wound healing

 

 

REFERENCES

1. Clapper MF, O'Brien TJ, Lyons PM. Fractures of the fifth metatarsal. Analysis of a fracture registry. Clin Orthop Relat Res 1995;(315):238-241.

    

    

2. Dameron TB Jr. Fractures of the proximal fifth metatarsal: selecting the best treatment option. J Am Acad Orthop Surg 1995;3:110-114.

    

    

3. DeLee JC, Evans JP, Julian J. Stress fracture of the fifth metatarsal. Am J Sports Med 1983;11:349-353.

    

    

4. Donley BG, McCollum MJ, Murphy GA, et al. Risk of sural nerve injury with intramedullary screw fixation of fifth metatarsal fractures: a cadaver study. Foot Ankle Int 1999;20:182-184.

    

    

5. Egol K, Walsh M, Rosenblatt K, et al. Avulsion fractures of the fifth metatarsal base: a prospective outcome study. Foot Ankle Int 2007; 28(5):581-583.

    

    

6. Lee SK, Park JS, Choy WS. Locking compression plate distal ulna hook plate as alternative fixation for fifth metatarsal base fracture. J Foot Ankle Surg 2014;53(5):522-528.

    

    

7. Mologne TS, Lundeen JM, Clapper MF, et al. Early screw fixation versus casting in the treatment of acute Jones fractures. Am J Sports Med 2005;33(7):970-975.

    

    

8. Petrisor BA, Ekrol I, Court-Brown C. The epidemiology of metatarsal fractures. Foot Ankle Int 2006;27:172-174.

    

    

9. Porter DA, Duncan M, Meyer SJ. Fifth metatarsal Jones fracture fixation with a 4.5-mm cannulated stainless steel screw in the competitive and recreational athlete: a clinical and radiographic evaluation. Am J Sports Med 2005;33(5):726-733.

    

    

10. Portland G, Kelikian A, Kodros S. Acute surgical management of Jones' fractures. Foot Ankle Int 2003;24:829-833.

     

     

11. Raikin SM, Slenker N, Ratigan B. The association of a varus hindfoot and fracture of the fifth metatarsal metaphyseal-diaphyseal junction: the Jones fracture. Am J Sports Med 2008;36:1367-1372.

     

     

12. Shah SN, Knoblich GO, Lindsey DP, et al. Intramedullary screw fixation of proximal fifth metatarsal fractures: a biomechanical study. Foot Ankle Int 2001;22:581-584.

     

     

13. Smith JW, Arnoczky SP, Hersh A. The intraosseous blood supply of the fifth metatarsal: implications for proximal fracture healing. Foot Ankle 1992;13:143-152.

     

     

14. Wright RW, Fischer DA, Shively RA, et al. Refracture of proximal fifth metatarsal (Jones) fracture after intramedullary screw fixation in athletes. Am J Sports Med 2000;28:732-736.