The Journal of Foot & Ankle Surgery xxx (2016) 1–4

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The Journal of Foot & Ankle Surgery

journal homepage: www.jfas.org

Original Research

Treatment of Acute Jones Fractures Without Weightbearing Restriction

Geoffrey S. Marecek, MD 1, Jeffrey S. Earhart, MD 2, William P. Croom, MD 3,
Bradley R. Merk, MD 4
1
Assistant Professor, Department of Orthopaedic Surgery, University of Southern California Keck School of Medicine, Los Angeles, CA
2
Assistant Professor, Rush University Medical Center, Rockford Orthopedic Associates, Rockford, IL
3
Department of Orthopaedic Surgery, University of Southern California Keck School of Medicine, Los Angeles, CA
4
Associate Professor, Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL

a r t i c l e i n f o a b s t r a c t

Level of Clinical Evidence: 4 Jones fractures are reportedly prone to nonunion and generally treated with a period of non-weightbearing or
operative treatment. Extended non-weightbearing can have adverse effects, and operative treatment poses various
Keywords:
fifth metatarsal risks. We report the clinical results of patients treated without weightbearing restriction. All patients treated for
Jones fracture metatarsal fractures by a single surgeon from January 1, 2000 to December 31, 2009 were identified through the
trauma clinical billing records by International Classification of Diseases, ninth revision, code. Through a radiographic and
weightbearing medical record review, 27 consecutive patients with acute Jones fractures treated without weightbearing restriction
were identified. The demographic information and clinical and radiographic results were recorded. Of the 27 patients,
24 (89%) had achieved clinical union at a mean of 8.0
2.6 weeks. Complete radiographic union was noted in 13 (48%)
patients, and 13 (48%) others had made significant progress toward radiographic union but had not yet reached it. Two
(8.3%) patients were lost to follow-up. One patient (4%) developed nonunion. Patients with acute Jones fractures can
be treated without weightbearing restriction. This protocol results in rapid clinical union and a low rate of nonunion.
Ó 2016 by the American College of Foot and Ankle Surgeons. All rights reserved.

Fractures at the base of the fifth metatarsal pose many challenges for
the treating surgeon. Although they are the most common of all foot
fractures (1), considerable disagreement still exists regarding the
optimal treatment method for these injuries. In 1902, Sir Robert Jones (2)
described a proximal fifth metatarsal fracture from indirect trauma. The
term Jones fracture has been variously ascribed to fractures at the distal
extent of the fourth to fifth intermetatarsal articulation (3), proximal
avulsion fractures (4), and the proximal metadiaphyseal junction (5).
Many investigators have described the inherent difficulty in
treating proximal fifth metatarsal fractures (3–10). The reported rates
of nonunion have ranged from 20% to 28% (4,8,11,12), with delayed
union rates of 20% to 59% (4,6,8,13). Early reports suggested that the
method of treatment did not matter (3,6,9); however, a landmark
study by Torg et al (8) demonstrated decreased rates of nonunion with
a strict non-weightbearing (NWB) protocol. However, patients might
be unwilling to comply with NWB restrictions (14). Moreover, pro-
longed NWB has been associated with worse functional outcomes
Financial Disclosure: A grant from the Goldberg Family Charitable Trust was
provided to allow presentation of our report at a national academic meeting.
Conflict of Interest: Geoffrey S. Merk is a consultant for Stryker Orthopaedics and
is a speaker on behalf of Stryker Orthopaedics and DePuy Synthes.
Address correspondence to: Geoffrey S. Marecek, MD, Department of Orthopaedic
Surgery, University of Southern California Keck School of Medicine, 1200 North State
Street, GNH 3900, Los Angeles, CA 90033.
E-mail address: marecek@usc.edu (G.S. Marecek).
(15), muscle atrophy (16), decreases in bone mineral density (17), and
ankle stiffness (15). Operative treatment has been proposed to avoid
these problems, in particular, in athletes (12,18–21).
After observing these issues in his patients, the senior author
(B.R.M.) has permitted weightbearing as tolerated (WBAT) for pa-
tients with acute Jones fractures. The purpose of the present study
was to describe the results of this treatment protocol.
Patients and Methods
The institutional review board at our institution approved the present study. Using
billing rosters of patients with the International Classification of Diseases, ninth revi-
sion, diagnosis code of 825.25 (closed fracture, metatarsal), we identified all patients
with fractures at the base of the fifth metatarsal treated by the senior author (B.R.M.)
from January 1, 2000 to December 31, 2009. The potential subjects were identified
through a review of the written medical record. The specific mention of a Jones fracture
or proximal metadiaphyseal fracture merited inclusion in the present study.
Fractures treated with the WBAT protocol were further screened using plain radio-
graphs. The fractures were defined as a Jones fracture if the fracture line did not extend
distally to the fourth to fifth intermetatarsal articulation or enter the metatarsocuboid
joint (3,5), corresponding to zone 2 in the classification system of Lawrence and Botte (5)
and Quill (7) (Fig.). Two of us (G.S.M., J.S.E.) independently reviewed all the radiographs
for inclusion. In cases of disagreement, a senior author (B.R.M.) adjudicated.
Patients were excluded from the study if they had concomitant lower extremity
injuries that prevented WBAT, previous surgery on the fifth metatarsal, previous
treatment of the current injury by a different surgeon, incomplete medical records, if
the fracture was not acute in nature (e.g., reporting a prodrome of pain or evidence of
stress fracture), or if they had chosen primary surgical treatment.

1067-2516/$ - see front matter Ó 2016 by the American College of Foot and Ankle Surgeons. All rights reserved.
http://dx.doi.org/10.1053/j.jfas.2016.04.013
2 G.S. Marecek et al. / The Journal of Foot & Ankle Surgery xxx (2016) 1–4

Fig. Oblique radiographs of a 42-year-old female who had sustained a twisting injury to her right foot. A fracture line entering the fourth to fifth intermetatarsal articulation is visible at
injury (A) and had subsequently healed approximately 7 weeks later (B). The solid black lines in (A) denote the region of interest for the present study.

The medical records were reviewed for demographic information, such as age, 27.6
4.8 kg/m2 (mean
standard deviation). No patient had diabetes mellitus, 1
gender, mechanism of injury, body mass index, the use of tobacco, and the presence of reported steroid use, and 1 reported tobacco use. Concomitant injuries included a
medical comorbidities. We specifically noted the time to clinical union, alterations in lateral malleolar fracture in 1 patient and fractures at the base of the third and fourth
the treatment plan, repeat fracture, and the follow-up length. Foot alignment was not metatarsals in 1 patient. The patient characteristics are listed in Table 1.
regularly noted in the medical record but was recorded when available. Information
about bone health (e.g., vitamin D or bisphosphonate use) was not available. Clinical
union was defined as the absence of tenderness to palpation and painless ambulation. If Results
the medical notes mentioned a “healed” fracture, this was recorded. Radiographic
union was defined as bridging in 2 of 3 (medial, lateral, plantar) cortices by 2 of us
Of the 27 patients, 24 (89%) had achieved clinical union at a mean of
(G.S.M., J.S.E.). In cases of disagreement, a senior author (B.R.M.) adjudicated.
The patients were placed into a removable walking boot and prescribed WBAT in
8.0
2.6 weeks. Complete radiographic union was noted in 13 patients
which they were allowed to resume ambulation as it became comfortable. Follow-up
Table 1
examinations were performed at the discretion of the treating surgeon, usually at 4-
Demographic information
to 6-week intervals until healing had occurred. Follow-up examinations were not
routinely performed in patients with clinically united, but radiographically incomplete, Variable Value
fractures if progress toward union was evident.
Patients 27 (100)
The initial review using the International Classification of Diseases, ninth revision,
Female gender 21 (78)
code revealed 328 patients. The clinical and radiographic review yielded 49 patients
Right foot 18 (67)
with acute Jones fractures. Of these, 2 records had no specific mention of weightbearing
Age (y)
protocol, 8 had undergone a restricted (partial or NWB) weightbearing protocol, 9 were
Median 49
seen only for a single visit, 1 had bilateral fractures, 1 had a radiation-related fracture,
Range 25 to 80
and 1 had a subacute fracture. No patient underwent primary surgery. This left 27
Mean body mass index (kg/m2) 27.6
4.8
patients with 27 fractures for review.
Steroid use 1 (3.7)
Of the 27 patients, 6 (22%) were male and 21 (78%) were female. The median age
Tobacco use 1 (3.7)
was 49 (range 25 to 80) years. Of the 27 fractures, 18 (67%) were right- and 9 (33%) were
Diabetes mellitus 0
left-sided injuries. The mechanism of injury was reported to be mechanistically as a
twist in 15, inversion in 4, and the result of a fall in 8. The mean body mass index was Data presented as n (%) or mean
standard deviation, unless otherwise noted.
 G.S. Marecek et al. / The Journal of Foot & Ankle Surgery xxx (2016) 1–4
Table 2
Outcomes of treatment of acute Jones fractures without weightbearing restriction
(n ¼ 27)
Variable
Clinical union
Mean time to union (wk)
Nonunion
Data presented as n (%) or mean
standard deviation.
(48%) at a mean of 10.9 weeks, and 13 patients (48%) had made sig-
nificant progress toward radiographic union but had not yet reached
full union. Two patients were lost to follow-up at 7 and 14 weeks after
injury, with radiographic evidence of healing and progress toward
clinical union. The outcomes are summarized in Table 2.
One patient (4%) had not reached union by 3 months after injury.
He was a 55-year-old male who was a tobacco user and had a sig-
nificant cavovarus foot deformity. He was referred for treatment of the
nonunion and corrective osteotomy and ultimately healed.
Discussion
In 1984, Torg et al (8) published a landmark study that has had
long-lasting influence on the treatment of fractures at the base of the
fifth metatarsal. Of the 46 fractures in their study, only 25 were
classified as acute. Of the 25 acute fractures, 15 were treated with
below-the-knee casts and NWB. The other 10 were allowed WBAT
with various forms of immobilization. Of the 15 fractures treated with
NWB, 14 had healed at a mean of 6 (range 3 to 12) weeks. In the other
group, 4 had asymptomatic delayed union and had healed at a mean
of 11.5 months, 2 had symptomatic delayed union, and 4 had symp-
tomatic nonunion. All these patients were treated with bone grafting
using a technique described in their report and ultimately healed (8).
On the basis of these findings, Torg et al (8) concluded that a period of
cast immobilization with NWB was the treatment of choice for acute
Jones fractures.
Other investigators have reached similar conclusions (22); however,
prolonged NWB is not without drawbacks. One study reported lower
ankle scores and increased patient-reported stiffness with longer pe-
riods of NWB for fractures at the base of the fifth metatarsal, including
Jones fractures (15), and another noted similar findings for avulsion
fractures alone (23). Muscle atrophy (16) and decreased bone mineral
density (17) have also been reported. Many patients prefer to avoid NWB
(14), and early operative treatment has gained popularity among those
seeking earlier WBAT (12,14,18,20). However, repeat fracture remains a
risk (21), and medullary screw fixation carries the attendant risks of
sural nerve injury (24,25) and the need for implant removal (20).
Lawrence and Botte (5) and Quill (7) later distinguished between
true Jones fractures at the metadiaphyseal junction and proximal
diaphyseal stress fractures, noting that the fractures in the study by
Torg et al (8) were mainly in the latter group. Drawing meaningful
conclusions from early data is difficult because no specific distinction
was made among fracture types or inclusion of heterogeneous groups
Table 3
Summary of available published data for Jones fractures treated without weightbearing restriction
Investigator Patients (n) Treatment
Present study 27 CAM orthosis
Josefsson et al (18) 24 Elastic bandage
Bigsby et al (29) 24 Compressive dressing
Konkel et al (13) 10 Various
Van Aaken et al (30) 8 Elastic bandage
Gosele et al (31) 2 Orthopedic boot
Summary 95 d d
Abbreviations: CAM, controlled ankle motion; FFI, Foot Function Index; NR, not reported.
3
of fractures (26). Recently, some investigators have suggested that
differentiating between Jones and proximal diaphyseal stress frac-
tures is not necessary because they have similar healing potential and
Value results (27). We theorized that the important distinction is between
24 (89) acute fractures and stress fractures. Fractures that occur without
8.0
2.6 prodrome owing to trauma, rather than overuse, might have a more
1 (4)
forgiving biologic and mechanical environment and will respond well
to nonoperative treatment, regardless of the weightbearing protocol.
To our knowledge, the present study also included the largest
cohort of patients treated with WBAT for acute Jones fractures. Other
investigators have previously explored this treatment protocol.
Josefsson et al (28) reported their results of the treatment of 40 Jones
fractures after a minimum of 11 years. The 24 acute fractures were
treated with an elastic bandage and WBAT, resulting in 2 repeat
fractures and 1 delayed union. One of the patients with a repeat
fracture and the patient with delayed union continued with WBAT,
and the other was treated operatively. However, the investigators did
not specify how they defined a Jones fracture (28). Another series of
24 Jones fractures reported on the functional outcomes after treat-
ment with a compressive dressing and WBAT protocol (29). The in-
vestigators included a cohort of patients similar to those in our study
but did not report the rates of union. The investigators reported that
11% of patients had activity limitations at 4 months and the median
Foot Function Index scores were 0 by 4 months after injury.
Several smaller series have reported similarly good results. One
series of 66 patients with fractures at the base of the fifth metatarsal
who were permitted to bear weight as tolerated included 10 with
Jones fractures (13). Of these, only 2 experienced delayed union, and
the remainder had healed at a mean of 3.5 months. All patients were
satisfied with their treatment. Another series of 23 patients reported
good results in 8 Jones fractures treated with an elastic bandage, with
100% union at a mean of 7.1 weeks (30). Yet another series reported
the results of functional treatment of 50 proximal fifth metatarsal
fractures, 2 of which were Jones fractures, with 100% union (31). The
available data on Jones fractures with WBAT is summarized in Table 3.
Our results are comparable to those from these smaller series.
Given 2 patients who had nearly reached union but were lost to
follow-up were from the WBAT group, our rate of clinical union
ranged from 89% at worst to 96% if they were included. These results
are similar to, or better than, the reported historical rates of 72% to
80% (4,8,11,12). It is unclear what role, if any, the use of a controlled
ankle motion type orthosis had on the ability of patients to WBAT,
because this type of device might have more favorable loading char-
acteristics compared with other devices used (32).
We documented complete radiographic union in 48% of our pa-
tients. Another 11 (41%) had incomplete radiographic healing at the
final follow-up visit (mean 6.6 weeks). These patients had achieved
clinical union. It is possible that these patients might have ultimately
developed delayed union or asymptomatic nonunion; however, we do
not routinely intervene in such cases. All had documented progres-
sion toward union that was nearly complete in most cases. Although
we do not typically classify Jones fractures as “delayed” at <7 weeks,
this group is consistent with previously reported rates of delayed
Union Rate (%) Complications (n) Other (n)
89 1 Nonunion 2 Lost to follow-up
88 2 Repeat fractures; 1 nonunion
NR Median FFI of 0 at 4 mo
100 2 Delayed union
100
100
2 Nonunion; 2 delayed union; 1 repeat fracture
4 G.S. Marecek et al. / The Journal of Foot & Ankle Surgery xxx (2016) 1–4
union ranging from 20% to 59% (4,6,8,13). All patients were instructed
to return if any symptoms or problems developed, although it is
possible they might have presented to a different hospital.
The 1 nonunion in the present series was diagnosed in a patient
with several risk factors for nonunion, who was rapidly referred for
operative treatment. It is possible that with time or nonoperative
interventions such as smoking cessation and bone stimulator use that
the patient might have ultimately healed. It is difficult to draw com-
parisons because the timing before diagnosis of a nonunion has varied
widely or has not been routinely disclosed in published studies.
Our study had several limitations. The present study was subject to
the limitations of any retrospective review. Our patient population
was older than that typically reported in the published data, and our
results might be less applicable to young, athletic patients. Further-
more, we made no specific assessment of function and did not use a
validated outcome measure to facilitate comparisons with the pub-
lished data.
In conclusion, we believe that patients with acute Jones fractures can
be treated with WBAT. This protocol results in rapid clinical union and a
low rate of nonunion. Future investigations to compare outcomes be-
tween various weightbearing protocols and operative treatment
methods would help further guide clinical decision-making.
References
1. Petrisor BA, Ekrol I, Court-Brown C. The epidemiology of metatarsal fractures. Foot
Ankle Int 27:172–174, 2006.
2. Jones R. I. Fracture of the base of the fifth metatarsal bone by indirect violence.
Ann Surg 35:697–700, 1902.
3. Stewart IM. Jones’s fracture: fracture of base of fifth metatarsal. Clin Orthop
16:190–198, 1960.
4. Dameron TB Jr. Fractures and anatomical variations of the proximal portion of the
fifth metatarsal. J Bone Joint Surg Am 57:788–792, 1975.
5. Lawrence SJ, Botte MJ. Jones’ fractures and related fractures of the proximal fifth
metatarsal. Foot Ankle 14:358–365, 1993.
6. Kavanaugh JH, Brower TD, Mann RV. The Jones fracture revisited. J Bone Joint Surg
Am 60:776–782, 1978.
7. Quill GE Jr. Fractures of the proximal fifth metatarsal. Orthop Clin North Am
26:353–361, 1995.
8. Torg JS, Balduini FC, Zelko RR, Pavlov H, Peff TC, Das M. 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 66:209–214, 1984.
9. 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
7:95–101, 1979.
10. Carp L. Fracture of the fifth metatarsal bone. Ann Surg 86:308–320, 1927.
11. Clapper MF, O’Brien TJ, Lyons PM. Fractures of the fifth metatarsal: analysis of a
fracture registry. Clin Orthop Relat Res:238–241, 1995.
12. Mologne TS, Lundeen JM, Clapper MF, O’Brien TJ. Early screw fixation versus
casting in the treatment of acute Jones fractures. Am J Sports Med 33:970–975,
2005.
13. Konkel KF, Menger AG, Retzlaff SA. Nonoperative treatment of fifth metatarsal
fractures in an orthopaedic suburban private multispeciality practice. Foot Ankle
Int 26:704–707, 2005.
14. Nunley JA. Fractures of the base of the fifth metatarsal: the Jones fracture. Orthop
Clin North Am 32:171–180, 2001.
15. Vorlat P, Achtergael W, Haentjens P. Predictors of outcome of non-displaced
fractures of the base of the fifth metatarsal. Int Orthop 31:5–10, 2007.
16. Psatha M, Wu Z, Gammie FM, Ratkevicius A, Wackerhage H, Lee JH, Redpath TW,
Gilbert FJ, Ashcroft GP, Meakin JR, Aspden RM. A longitudinal MRI study of muscle
atrophy during lower leg immobilization following ankle fracture. J Magn Reson
Imaging 35:686–695, 2012.
17. Ceroni D, Martin X, Delhumeau C, Rizzoli R, Kaelin A, Farpour-Lambert N. Effects of
cast-mediated immobilization on bone mineral mass at various sites in adoles-
cents with lower-extremity fracture. J Bone Joint Surg Am 94:208–216, 2012.
18. Josefsson PO, Karlsson M, Redlund-Johnell I, Wendeberg B. Jones fracture: surgical
versus nonsurgical treatment. Clin Orthop Relat Res:252–255, 1994.
19. Leumann A, Pagenstert G, Fuhr P, Hintermann B, Valderrabano V. Intramedullary
screw fixation in proximal fifth-metatarsal fractures in sports: clinical and
biomechanical analysis. Arch Orthop Trauma Surg 128:1425–1430, 2008.
20. Portland G, Kelikian A, Kodros S. Acute surgical management of Jones’ fractures.
Foot Ankle Int 24:829–833, 2003.
21. Wright RW, Fischer DA, Shively RA, Heidt RS Jr, Nuber GW. Refracture of proximal
fifth metatarsal (Jones) fracture after intramedullary screw fixation in athletes. Am
J Sports Med 28:732–736, 2000.
22. Zogby RG, Baker BE. A review of nonoperative treatment of Jones’ fracture. Am J
Sports Med 15:304–307, 1987.
23. Wiener BD, Linder JF, Giattini JF. Treatment of fractures of the fifth metatarsal: a
prospective study. Foot Ankle Int 18:267–269, 1997.
24. Donley BG, McCollum MJ, Murphy GA, Richardson EG. Risk of sural nerve injury
with intramedullary screw fixation of fifth metatarsal fractures: a cadaver study.
Foot Ankle Int 20:182–184, 1999.
25. Johnson JT, Labib SA, Fowler R. Intramedullary screw fixation of the fifth meta-
tarsal: an anatomic study and improved technique. Foot Ankle Int 25:274–277,
2004.
26. Polzer H, Polzer S, Mutschler W, Prall WC. Acute fractures to the proximal fifth
metatarsal bone: development of classification and treatment recommendations
based on the current evidence. Injury 43:1626–1632, 2012.
27. Chuckpaiwong B, Queen RM, Easley ME, Nunley JA. Distinguishing Jones and
proximal diaphyseal fractures of the fifth metatarsal. Clin Orthop Relat Res
466:1966–1970, 2008.
28. Josefsson PO, Karlsson M, Redlund-Johnell I, Wendeberg B. Closed treatment of
Jones fracture: good results in 40 cases after 11-26 years. Acta Orthop Scand
65:545–547, 1994.
29. Bigsby E, Halliday R, Middleton RG, Case R, Harries W. Functional outcome of fifth
metatarsal fractures. Injury 45:2009–2012, 2014.
30. Van Aaken J, Berli M, Noger M, Gambirasio R, Frischy D. Traitement symptoma-
tique des fractures non deplacees de la base du cinquieme metatarse: etude
prospective. Rev Med Suisse 3:1792–1794, 2007.
31. Gosele A, Schulenburg J, Ochsner PE. [Early functional treatment of a 5th meta-
tarsal fracture using an orthopedic boot]. Swiss Surg 3:81–84, 1997.
32. Hunt KJ, Goeb Y, Esparza R, Malone M, Shultz R, Matheson G. Site-specific loading
at the fifth metatarsal base in rehabilitative devices: implications for Jones frac-
ture treatment. PM R 6:1022–1029, 2014.