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Treatment Strategies for Acute Fractures and Nonunions of the Proximal Fifth Metatarsal

Dr. Rosenberg is Staff Physician, Kaiser-Permanente, Los Angeles, and Co-Director, Orthopaedic Foot and Ankle Service, Wadsworth Veterans Administration Hospital, Wadsworth, Calif. Dr. Sferra is Head, Section of Foot and Ankle Surgery, Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland.

Reprint requests: Dr. Rosenberg, Department of Orthopaedic Surgery, Southern California Permanente Medical Group, 4747 Sunset Boulevard, Los Angeles, CA 90027.

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.