|

Fractures of the Base of the Fifth

Metatarsal Bone
A Critical Analysis Review
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Kamila Bušková, MD Abstract

Jan Bartonı́ček, MD, DSc
Stefan Rammelt, MD, PhD
» Fractures of the proximal fifth metatarsal (PFMT) are one of the most
common foot injuries, accounting for 61% to 78% of all foot fractures,
but full consensus on their classification, diagnosis, and treatment has
not yet been reached.

» The most commonly accepted classification is that of Lawrence and

Botte, who divided the location of PFMT fractures into 3 zones with
respect to their healing potential.

» Avulsion fractures of the tuberosity of the base (zone 1) generally

heal well, and nonoperative treatment is commonly recommended.

» Internal fixation may be considered for displaced fractures that

extend into the fourth-fifth intermetatarsal joint (zone 2) as well as for
nondisplaced fractures in athletes or high-demand patients, with the
aims of reducing the healing time and expediting return to sport or
work.

» Stress fractures of the proximal diaphysis (zone 3) are preferably

treated operatively, particularly in the presence of signs of delayed
union. With nonoperative treatment, supportive measures such as
ultrasonography or external/extracorporeal shockwave therapy have
been demonstrated to have limited potential for the enhancement of
fracture-healing.

M
anagement of fractures of
the proximal fifth meta-
tarsal (PFMT) has been
intensively debated in
the literature since the 1970s1-6. Although
the first case series of PFMT fractures was
published .100 years ago7,8, no universal
consensus has yet been reached on their
classification, diagnosis, and treatment9-23.
In 1847, Malgaigne was probably the
first surgeon who briefly mentioned a
PFMT fracture24. In 1902, Robert Jones
described 6 such fractures according to
radiographs, including his own injury that
he had sustained while dancing; hence, the
eponym a “Jones (or dancer) fracture.”7 In
1927, Carp25 found delayed union in 4 of
21 cases of PFMT fracture and proposed an
association with the particular blood supply
of the fifth metatarsal as described in detail
by Lexer et al. in 190426. In 1960, Stewart
published a series of 51 patients with a
PMFT fracture1. Several larger studies fol-
lowed between 1975 and 19842-6. In 1993,
Lawrence and Botte divided the location of
PFMT fractures into 3 zones with respect to
their healing potential27, a system that has
been commonly accepted since.
Anatomy
The fifth metatarsal forms the lateral border
of the forefoot. Its robust proximal aspect

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 | Fractures of the Base of the Fifth Metatarsal Bone
receives the attachments of multiple
ligaments and muscles, and it is the end
part of Hellpap’s so-called “supination
line”28-31. The fifth metatarsal is formed
by the base, the shaft, the neck, and the
head32. The base is the prominent
proximal part that forms a tuberosity on
its lateral aspect, also called the styloid
process. The tuberosity markedly over-
laps the lateral aspect of the cuboid. The
proximal part of the base carries a tri-
angular articular facet for the cuboid. On
the medial surface, there is an oval
articular facet that articulates with the
lateral articular facet of the fourth met-
atarsal base. A groove for the abductor
digiti minimi muscle lies on the plantar
surface. The joint capsule to the cuboid
is reinforced by relatively thin dorsal and
plantar tarsometatarsal ligaments33,34.
The joint to the fourth metatarsal base is
stabilized by dorsal, interosseous, and
plantar intermetatarsal ligaments35.
Recently, a lateral Lisfranc ligament has
been described; it spans from the fifth to
the second metatarsal base on the plantar
aspect and blends with the long plantar
ligament, thus stabilizing both the longi-
tudinal and transverse arches of the foot36.
All 3 of the articulating bones are part of
the lateral pillar of the foot (Fig. 1).
The peroneus brevis tendon atta-
ches to the dorsolateral surface of the
tuberosity. The peroneus tertius tendon
attaches to its dorsal surface, just distal to
the peroneus brevis tendon27,33,34. The
plantar surface receives insertions of the
lateral band of the plantar aponeurosis
and the terminal fibers of the long
plantar ligament and is the site of origin
of the flexor digiti minimi. The lateral
Fig. 1
Figs. 1-A and 1-B Anatomy of the fifth meta-
tarsal base. Fig. 1-A Attachments of the pero-
neal muscles. Fig. 1-B Articulations of the
base of the fifth metatarsal. Cu 5 cuboid,
PB 5 peroneus brevis, PT 5 peroneus tertius,
4. mtt 5 fourth metatarsal, 5. mtt 5 fifth
metatarsal, red arrow 5 cuboid-metatarsal liga-
ment, and yellow arrow 5 intermetatarsal
ligament.
2 OCTOBER 2021
plantar (Lisfranc) ligament originates the tuberosity with respect to radio-
from the fifth metatarsal base in 62% of graphic appearance and healing poten-
patients37. tial, which was divided into 3 types
The fifth metatarsal base is sup- without explicitly using the term stress
plied by the terminal branches of the fracture6:
anterior and posterior tibial arteries,
1. Type I: early (a narrow fracture
specifically through dorsal metatarsal
line and absence of intramedullary
arteries arising from the lateral plantar
sclerosis or cortical reaction),
artery and the plantar metatarsal arteries
2. Type II: delayed union (widening
that are derived from the arcuate artery
of the fracture line with bone
or the dorsalis pedis artery26,38,39. The
resorption and sclerosis), and
tuberosity is supplied by the metaphy-
3. Type III: nonunion (a wide frac-
seal arteries. The shaft is supplied by a
ture line, a periosteal reaction,
nutrient artery arising from the fourth
and complete obliteration of the
plantar artery. This artery enters the fifth
medullary canal).
metatarsal from the medioplantar
aspect, which is approximately 2 cm In 1993, Lawrence and Botte27
distal to the tuberosity, and provides a published a classification based on the
retrograde blood supply to the proximal location of the fracture line (Fig. 2):
metaphysis. This creates a vascular
1. Tuberosity avulsion fracture (zone
watershed area in the metaphyseal-
1): an acute fracture exiting
diaphyseal region that is considered a
proximal to the fourth-fifth
predisposition for delayed fracture-
intermetatarsal joint, frequently
healing in this zone40,41. The base of the
involving the cuboid-metatarsal
fifth metatarsal is the site of ramification
joint,
of the sural nerve42,43.
2. Jones fracture (metaphyseal-
Fractures and nonunions of the
diaphyseal: zone 2): an acute
fifth metatarsal base must be distin-
fracture passing transversely or
guished from accessory bones such as the
obliquely through the fifth met-
os peroneum44 and the os vesalianum45.
atarsal base to the fourth-fifth
intermetatarsal joint, and
Classification
3. Proximal diaphyseal stress fracture
In 1916, Tanton developed the first
(zone 3): a transverse fracture line
binary classification, dividing PFMT
passing distal to the fourth-fifth
fractures into fractures of the base (1°)
intermetatarsal joint.
and fractures of the styloid (2°)46. Sim-
ilar classifications were subsequently At the proximal metaphyseal-
presented by Stewart in 19601 and diaphyseal junction, this classification
Dameron in 19752. distinguishes between traumatic (zone
In 1984, Torg et al. published a 2) and stress (zone 3) fractures. As both
classification of PFMT fractures distal to are typically nondisplaced and have a
· VOLUME 9, ISSUE 10 · e 21.00010

similar poor healing potential, many
authors have called this discrimination
into question and refer to all fractures of
the metaphysis and proximal shaft as
Jones fractures, thereby returning to the
simple classifications of Tanton and
Dameron46-50. Others hold that acute
fractures (zones 1 and 2) have a similar
prognosis and therefore need not be
differentiated51,52.
Overall, there is considerable con-
fusion about the nomenclature of
PFMT fractures, particularly the term
“Jones fracture,” which is frequently
used for acute fractures in zone 2 and
stress fractures in zone 3, thereby mak-
ing multiple studies difficult to interpret
and compare. In the original report by
Jones7, the 4 images demonstrated at
least 2, if not 3, different fracture pat-
terns50,53. In our article, we use the term
“Jones fracture” exclusively for acute
fractures that are in zone 2.
Fractures and dislocations at the
fifth metatarsal base may also occur in
the wake of tarsometatarsal (Lisfranc)
injuries and must be classified accord-
ingly54. Injuries to the lateral tarsomet-
atarsal joints are beyond the scope of this
review and discussions may be found
elsewhere55.
OCTOBER 2021 · VOLUME 9, ISSUE 10 · e21.00010
Fractures of the Base of the Fifth Metatarsal Bone
Epidemiology
PFMT fractures account for 61% to
78% of all foot fractures56-63. The
reported rates range from 46% to 73%
in zone 1, 14% to 39% in zone 2, and
8% to 15% in zone 3. In professional
football players, the incidence of PFMT
stress fractures has been calculated to be
0.04 injuries per 1,000 hours of expo-
sure. Therefore, a team of 25 players
might expect such a fracture to occur
every fifth season64.
Mechanism of Injury
Tuberosity fractures (zone 1) are caused
by avulsion resulting from the pull of the
lateral band of the plantar fascia29,33,65.
These “tennis fractures” typically occur
after a misstep or a fall with the foot in
supination, adduction, and plantar
flexion2,3,49,58,66. The pull of the per-
oneus brevis tendon may further dis-
place these fractures33,67.
Jones fractures (zone 2) are acute
injuries that are believed to be caused
mainly by an adduction force to the
forefoot with the ankle in plantar flex-
ion. The result is a transverse fracture,
sometimes with medial comminution1,
27
. In a case-control study of 51 athletes,
Karnovsky et al. identified a long,
straight, narrow fifth metatarsal and
|
Fig. 2
Lawrence and Botte classification of fractures
of the proximal fifth metatarsal on a radio-
graph (Fig. 2-A) and an anatomical specimen
(Fig. 2-B). I 5 zone 1 (tuberosity fractures), II
5 zone 2 (Jones fractures), and III 5 zone 3
(stress fractures of the fifth metatarsal base).
forefoot adduction as risk factors for
sustaining a Jones fracture68.
Fractures of the metaphyseal-
diaphyseal junction beyond the fourth-
fifth intermetatarsal joint (zone 3) are
typically stress fractures. During normal
walking, the lateral aspect of the foot is
exposed to a substantial load; the con-
centration of the load at the
metaphyseal-diaphyseal junction also is
enhanced by the attachment of the per-
oneal muscles and the hinge that is
provided by the fourth-fifth intermeta-
tarsal ligaments2,5,33,66. Risk factors
include hindfoot varus alignment69,70,
metatarsus adductus68, and pes cavus, as
well as neuropathic conditions71-73.
Diagnosis
There are several steps in the diagnosis of
a PFMT fracture, which may include a
detailed history and physical examina-
tion, radiographs, computed tomogra-
phy (CT), magnetic resonance imaging
(MRI), ultrasonography, and bone
scintigraphy.
During the history-taking, patients
are questioned about the injury mecha-
nism, any previous injuries, the intensity
of previous activities, and the nature and
onset of pain. Systemic metabolic, neu-
rologic, rheumatologic, or oncologic
disease should be ruled out.
3
 | Fractures of the Base of the Fifth Metatarsal Bone

TABLE I Recommendations for Care

Recommendation
Recommendation Grade*

MRI is highly efficient in diagnosing stress fractures before they are visible on radiographs. A
Avulsion fractures of the tuberosity (zone 1) have good healing potential, and nonoperative treatment is generally B
recommended.
Internal fixation may be considered for displaced fractures extending into the fourth-fifth intermetatarsal joint (zone 2) B
and for nondisplaced fractures in athletes or high-demand patients, with the aim to reduce the time to heal and
expedite return to sport or work.
Stress fractures at the proximal metaphysis (zone 3) are preferably treated operatively. The most commonly used B
method is implantation of an intramedullary screw.
With nonoperative treatment, supportive measures like ultrasonography and external/extracorporeal shockwave B
therapy have demonstrated some value for the enhancement of fracture-healing.

*According to Wright190, grade A indicates good evidence (Level-I studies with consistent findings) for or against recommending intervention; grade B,
fair evidence (Level-II or III studies with consistent findings) for or against recommending intervention; grade C, poor-quality evidence (Level-IV or V
studies with consistent findings) for or against recommending intervention; and grade I, insufficient or conflicting evidence not allowing a recom-
mendation for or against intervention.

With acute fractures, the clinical
findings include limping with offloading
of the lateral edge of the foot, pain on
weight-bearing and inversion, swelling,
hematoma, and tenderness on palpation
at the fifth metatarsal base.
The basic radiographic examina-
tion consists of anteroposterior, 30°
oblique, and lateral radiographs of the
foot. Stress fractures are usually seen as
radiolucent zones on radiographs at a
minimum of 10 days after the onset of
symptoms. Only 9% of cases are
detected on the initial radiographs74,75.
CT is indicated with complex
intra-articular fractures, including lat-
eral Lisfranc injuries. CT also may be
used to evaluate the phase of healing of
these fractures76.
MRI is highly efficient in diag-
nosing stress fractures before they are
visible on radiographs and in assessing
the surrounding tissues74,75.
Ultrasonography is less demanding
to perform and more readily available
than MRI. In addition to associated soft-
tissue alterations, ultrasonography may
demonstrate early periosteal reactions
that accompany a stress fracture77,78.
Bone scintigraphy, using the radi-
onuclide isotope technetium-99m
(99mTc), was a former gold standard in
the diagnosis of stress fractures, but has a
lower sensitivity and specificity,
although a lower cost, than MRI79.
Principles of Treatment
Despite an ever-increasing number of
clinical studies, there is limited eviden-
tial guidance regarding the choice of
PFMT fracture treatment (Table I). A
wide array of nonoperative and operative
methods is available. Treatment must
be tailored individually to the fracture
pattern, the displacement, the local con-
ditions, and the health status and func-
tional demand of each patient. Abnormal
metabolic or hormonal conditions like
vitamin D deficiency, osteoporosis,
poorly controlled diabetes, and thyroid
hormone deficiency should be treated
simultaneously to improve the chance
of healing80-83. In cases of severe
underlying foot and ankle deformities,
especially cavovarus or equinovarus in
recalcitrant PFMT nonunions, correc-
tive osteotomies or fusions should be
considered70,84.
Treatment of Tuberosity Fractures—
Zone 1
Nonoperative Treatment
Avulsion fractures of the tuberosity have
good healing potential, and nonopera-
tive treatment is generally recom-
mended53. This is particularly true for
extra-articular and nondisplaced frac-
tures2,12,51,85-97. In the nonathletic
population, excellent results with union
rates of 100% have been reported for
displaced fractures and fractures involv-
ing the articular facet to the cuboid13,52,
94,98-100
. One prospective randomized
study comparing nonoperative and
operative treatment in zone-1 fractures
with displacement of $2 mm did not
reveal any significant difference in visual
analog scale (VAS) pain and American
Orthopaedic Foot & Ankle Society
(AOFAS) scores98. Another prospective
randomized study in young adults and
athletes found significantly higher (p ,
0.05) AOFAS scores at 6 weeks, lower
VAS scores at 12 months, and an earlier
return to work after minimally invasive
screw fixation when compared with
nonoperative treatment in a cast101.
Similar results were seen in a non-
randomized prospective cohort study in
athletes102. Nonunion after nonopera-
tive treatment that required revision
surgery has been reported repeatedly in
athletes103-105. Based on these data,
operative treatment has been advocated
for athletes and young high-demand
patients with displaced tuberosity
fractures.
Nonoperative treatment is based
on the RICE (rest, ice, compression, and
elevation) regimen. Most authors allow
weight-bearing as tolerated immedi-
ately after the injury. The foot is pro-
tected with various types of bandages,
braces, hard-soled or cast shoes, air-
cast walking boots, or below-the-knee
casts2,52,86,89,91,93,95-97. Better

4 OCTOBER 2021 · VOLUME 9, ISSUE 10 · e 21.00010

 Fractures of the Base of the Fifth Metatarsal Bone |

Fig. 3
Figs. 3-A through 3-D Internal fixation of tuberosity (zone-1) fractures with tension-band wiring (Fig. 3-A), a locking compression plate (LCP, or hook plate) for the distal aspect
of the ulna (Fig. 3-B), an intramedullary screw (Fig. 3-C), and a headless screw (Fig. 3-D).

functional outcomes have been
achieved with the use of an elastic ban-
dage or a walking brace than with
immobilization in a short leg cast56,87,88,
92,96,97,106
. In a recent prospective ran-
domized trial, the time to return to
preinjury activity was significantly
shorter when patients were treated with
use of a hard-soled shoe than after
treatment with a short leg cast107.
Operative Treatment
Numerous authors have proposed
operative treatment for intra-articular
tuberosity fractures with a displacement
exceeding 2 to 3 mm or separation of
.30% of the joint surface between the
cuboid and fifth metatarsal, particularly
in athletes and high-demand patients
and in fractures with wide fragment
displacement, resulting in soft-tissue
incarceration56,76,85,101,103,108-110.
Options for internal fixation include
Kirschner wires111,112, simple intraosse-
ous wire fixation30,113, and tension-band
wiring alone76,109,114 or in combination
with interfragmentary lag screws115,116.
Several custom or preshaped plates for
tuberosity fractures117-121, various types
of screws101,120-124 (Fig. 3), and,
recently, anchors125 are available. In a
biomechanical study, a single 4.0-mm
bicortical partially threaded cancel-
lous screw was significantly (p , 0.02)
more stable than a tension-band
wire construct for avulsion fracture
fixation109. A bicortical screw is bio-
mechanically more stable than an
intramedullary screw126.
Opinions vary on postoperative
protection and weight-bearing. Hei-
neck et al. recommended partial
weight-bearing while wearing an elas-
tic ankle orthosis for 6 weeks127.
A below-the-knee cast is not required.

Fig. 4
Figs. 4-A, 4-B, and 4-C Internal fixation of a
Jones fracture with an intramedullary screw.
Fig. 4-A Postinjury radiograph. Fig. 4-B Fixa-
tion with an intramedullary 4.0-mm cancellous
screw that breached the distal aspect of the
cortex during insertion but had no impact on
the course of healing. Fig. 4-C Radiographic
evidence of complete bone-healing at 6 weeks
after surgery.

OCTOBER 2021 · VOLUME 9, ISSUE 10 · e21.00010 5

 | Fractures of the Base of the Fifth Metatarsal Bone
Fig. 5
Figs. 5-A through 5-G Intramedullary fixation by different types of screws, including a cortical 3.5-mm screw (Fig. 5-A), a cortical 4.5-mm screw (Fig. 5-B), a cancellous 6.5-mm
screw (Fig. 5-C), a 4.5-mm locking compression plate (LCP) screw (Fig. 5-D), a cancellous 4.0-mm screw (Fig. 5-E), a cannulated cancellous 4.0-mm screw (Fig. 5-F), and a cannulated
cancellous 6.5-mm screw (Fig. 5-G).
Treatment outcomes have been excel-
lent, regardless of the implant that
was used101,111,112,118-125.
Treatment of Jones Fractures—Zone 2
Nonoperative Treatment
Nonoperative treatment for non-
displaced true zone-2 fractures (i.e., an
acute transverse or short oblique fracture
exiting through the fourth-fifth inter-
metatarsal joint) is generally indicated in
the nonathletic population27,49,56,86,89,
94,95,99,128
. There is no evidence that
nonoperative treatment substantially
increases the risk of refracture49,53,99,
129
. However, the time to heal and re-
turn to full activities can be decreased
with operative treatment, which is of
particular interest for athletes and young
high-demand patients47,64,130. In a
recent systematic review, pooled out-
comes for nonoperative versus operative
treatment of zone-2 fractures revealed
union rates of 77% versus 96% and
mean time to union of 11 versus 9
weeks129.
Recommendations differ for the
postoperative protocol. Numerous
authors have reported union rates
between 96% and 100% with full
weight-bearing as tolerated by the
patient for 6 to 8 weeks with the use of an
elastic bandage or a hard-soled shoe52,89,
94,95,99,128
. Others recommend off-
6 OCTOBER 2021
loading or partial weight-bearing (20 kg)
for 6 to 8 weeks in a boot or a cast27,49,56,
86
. One study reported delayed union in
18% of patients with non-weight-
bearing for 4 to 6 weeks49. The patient-
reported outcomes are uniformly good
and similar to those with tuberosity
fractures49,86,99,119,128.
Operative Treatment
Operative treatment is generally favored
with zone-2 fractures that are displaced
by .2 mm49,76,99. Internal fixation also
has been advocated for nondisplaced
zone-2 fractures in athletes, high-demand
patients, and young active patients, with
the aim of reducing the healing time
and expediting return to sport or
work6,27,49,50,56,76,85,86,108,110,129-132.
The method of choice for most
authors is an intramedullary screw27,49,
123,131,133,134
(Fig. 4). Various types of
cortical, cancellous, and locking (solid or
cannulated) screws of appropriate
diameters, thread length (partially or
fully threaded screws), and materials are
available40,71,135-144 (Fig. 5). Other
types of internal fixation include a bi-
cortical screw123, tension-band wiring,
Kirschner wires120, and plates118,119,
145
. The latter are preferred for commi-
nuted fractures, and designs include
ulnar locking compression119 and hook
plates145.
Multiple studies have been con-
ducted to optimize internal fixation of
PFMT fractures with an intramedullary
screw142,143,146,147. In CT-based stud-
ies, the medullary canal diameter aver-
aged 4.0 mm at the apex of the curvature
and 5.0 mm at the isthmus142,143. As
most authors have proposed using the
largest possible screw diameter, the most
frequently recommended diameter is
4.5 mm, with recommendations rang-
ing from 4.0 to 6.5 mm in a systematic
review148. Larger screw diameters have
greater bending fatigue strength144 and
pullout strength136. In some biome-
chanical investigations, this did not
translate into relevant differences in
clinical studies regarding nonunion,
refracture, or screw breakage71,140.
Porter et al. found bending in 3 of
twenty 4.5-mm screws and no bending
in twenty-three 5.5-mm screws71. Horst
et al. found an equal torsional stiffness
with 5.0 and 6.5-mm screws149. How-
ever, to achieve stability, the 5.0-mm
screw had to reach the metatarsal neck.
The required screw length tended to
straighten the normally curved fifth
metatarsal bone and caused lateral gap-
ping of the fracture. Solid screws have a
higher fatigue bending strength than
cannulated screws144, but, again, to our
knowledge, no correlation between
screw design and nonunion rate has been
· VOLUME 9, ISSUE 10 · e 21.00010

found in clinical studies140. Neverthe-
less, variable-pitch headless compression
screws, although they generate 30% less
compression150 and have inferior fatigue
strength144 than partially threaded
constant-pitch screws, led to excellent
outcomes in a study of 60 Japanese
athletes, with a 97% union rate and no
refractures139. Indication-specific
screws have improved biomechanical
properties over traditional screws144,151,
152
, with less adverse events demon-
strated in 1 clinical study141.
Another important parameter is
screw length, which should be neither
too short, resulting in insufficient sta-
bility, nor too long, risking medial cortex
perforation, straightening of the meta-
tarsal, and lateral opening of the frac-
ture136,142,143,149. When using partially
threaded screws, the threads should be
situated completely in the distal frag-
ment in order to achieve compression
across the fracture. In CT-based studies,
DeSandis et al.143 measured an average
distance of 42.6 mm from the apex to the
base in the anteroposterior view, and
Ochenjele et al.142 measured an average
straight segment length of 52 mm. In a
cadaveric study, van Dijk et al. calcu-
Fig. 6
Figs. 6-A, 6-B, and 6-C A stress fracture that
was treated by an intramedullary 4.5-mm
cortical screw. Fig. 6-A Postinjury radiograph.
Fig. 6-B Postoperative radiograph. Fig. 6-C The
healed fracture at 2 months after surgery.
OCTOBER 2021 · VOLUME 9, ISSUE 10 · e21.00010
Fractures of the Base of the Fifth Metatarsal Bone
lated a clinically achievable screw length
of 48 mm and a thread length of
28 mm153. They also found that the
screw path compromised the peroneus
brevis and plantar fascia insertions in
33% and 62% of cases, respectively153.
The optimal site for screw insertion is
10.5 mm dorsal to the inferior margin
and 5.3 mm medial to the lateral margin
of the tuberosity, just medial to the
insertion of the peroneus brevis ten-
don154. The screw should be directed
upward at an angle of ,10°5,85. Khur-
ana et al. found that lateral and inferior
insertion was associated with fracture
site distraction155. Patients with a plan-
tar gap had an increased risk of delayed
union17,156.
There is evidence from numerous
studies that minimally invasive intra-
medullary screw fixation allows early
postoperative weight-bearing, with
union rates ranging from 89% to 100%
and no need for bone-grafting3,5,49,50,99,
133,137,157-159
. The main disadvan-
tages of intramedullary screws are a
demanding insertion technique, the risk
of irritation of the sural nerve, and
symptomatic prominence of the screw
head3,5,49,122,130,133,158,160-163.
|
Most of the recent literature has
recommended postoperative weight-
bearing as tolerated in a brace50,131,159,
163,164
, while earlier studies favored
partial or no weight-bearing for 5 to 12
weeks49,56,85,109,123,133. Return to sport
on a professional level is achieved after 6
to 8 weeks50,131,159,163.
The reported results have been
good, but the problem with several
studies is that they included stress frac-
tures131,134 or tuberosity fractures119,
123
in the category of Jones fractures.
Treatment of Stress Fractures—
Zone 3
Nonoperative Treatment
The treatment of stress fractures is the
subject of lively debate. Torg et al. rec-
ommended nonoperative treatment of
type-I and II fractures, except in young
athletes (type II)6. Operative treatment
was recommended for type-III frac-
tures6,85. Historically, nonoperative
treatment of these fractures is associated
with a prolonged period of immobiliza-
tion, a long healing time4,6,27,110,165, a
higher incidence of delayed healing and
nonunion in 25% to 67% of cases3,4,6,
13,49,53,56
, and refracture rates of up to
7
 | Fractures of the Base of the Fifth Metatarsal Bone
Fig. 7
Figs. 7-A through 7-E Nonunion of a stress fracture after intramedullary screw fixation. Fig. 7-A A stress fracture (with pain persisting for 5 months).
Fig. 7-B Fixation with a 4.5-mm cortical screw (the patient refused non-weight-bearing after surgery). Fig. 7-C Migration of the screw at 5 months after
surgery. Fig. 7-D Refixation with an intramedullary 6.5-mm cancellous screw. Fig. 7-E Healed fracture at 3 months after refixation.
50% if the patients are followed for a
longer time period3,49,53,85,130. Inter-
pretation of these data is difficult since
most of these studies combined the
results of zone-2 and 3 fractures under
the term “Jones fracture.”
Nonoperative treatment usually
consists of non-weight-bearing on the
foot and protection in a short leg cast6,49,
130,165
. Other authors have recom-
mended limited weight-bearing, or full
weight-bearing as tolerated, in a hard-
soled shoe, a walking cast, or a molded
orthosis, or with strapping47,52. How-
ever, if patients fail to comply with the
protocol of limited or non-weight-
bearing, the risk of delayed healing or
nonunion is markedly higher6. The
period of immobilization is 6 to 12
weeks, the time to return to sport activ-
ities is 15 to 26 weeks, and the period of
radiographic healing is 3.1 to 8.4
months4,6,49,130,165.
Several methods have been em-
ployed to enhance fracture-healing in
fifth metatarsal stress fractures and de-
layed unions, including ESWT
(external/extracorporeal shockwave
therapy), LIPUS (low-intensity pulsed
ultrasound), and PEMF (pulsed elec-
tromagnetic field) therapy. Good out-
comes after ESWT, with healing rates
similar to screw fixation, have been
8 OCTOBER 2021
published by Furia et al.166, Albisetti
et al.167, Alvarez et al.168, and Taki
et al.169. Nolte et al. used LIPUS in 594
metatarsal fractures, of which 161 were
Jones fractures, and achieved a healing
rate of 97.3%170. Holmes reported that
9 fifth metatarsal stress fractures healed
with the use of PEMF therapy171.
Operative Treatment
From the available evidence, operative
treatment is recommended for Torg
type-II and III stress fractures of the
PFMT3-5,49,71,76,130,131,157,159,172. In
professional athletes and other high-
demand patients, operative treatment is
recommended for all zone-3 fractures
because it reduces the time to return to
unlimited sporting activities3-5,71,130,
131,148,157,159,172,173
.
Currently, the most commonly
used method is insertion of an intra-
medullary screw3,5,71,131,137,158,159,174
(Fig. 6). Plates175,176 or tension-band
wiring114,115 are used less frequently.
Some authors practice minimally inva-
sive screw fixation (e.g., in zone-2 frac-
tures) without surgical preparation of
the nonunion site177. Drilling of the
medullary canal has been advocated in
cases of cortical thickening, with partial
obliteration of the canal (Torg type-II
fractures) in order to enhance bone-
healing76,132. Plate fixation has been
successfully employed for Torg type-II
and III fractures176,178. In cases of de-
layed healing or nonunion (Torg type-II
and III fractures), several authors have
combined internal fixation with the
application of bone marrow aspirate
concentrate (BMAC) to the fracture
site134,141,161,172,179 or cancellous bone-
grafting from the calcaneus, the tibia, or
the iliac crest6,40,56,141,162,175,178-182.
Popovic et al. found less refractures
(0 versus 27%) in professional football
players with Torg type-I and II fractures
when 4.5-mm screw fixation was sup-
plemented by local bone-grafting40.
Bone grafts may be applied as
sliding (local) grafts from the fifth met-
atarsal2,4,6 or as corticocancellous grafts
that have been harvested from the iliac
crest, the calcaneus, or the tibia40,141,162,
175,179,181,182
.
The time to clinical healing is
reported to be between 3 and 13 weeks5,
40,49,131,137,157-159
. The time to radio-
graphic union ranges from 6 to 24
weeks3,5,40,49,131,134,157,161,172,175.
Patients returned to full activities,
including sports, within 8 to 15 weeks5,
71,131,134,137,157,159,172
. A delay of full
weight-bearing, and a delay of return to
sport, did not seem to have a relevant
· VOLUME 9, ISSUE 10 · e 21.00010

impact on radiographic healing127,159,
172
. intramedullary screw fixation5,130,133
Several authors recorded excellent
results after use of a single screw3,5,40,71,
122,131,137,157-159,174
, use of a screw in
combination with BMAC134,161,172,
and use of a screw in combination with
cancellous bone-grafting or a solid bone
graft40,141,162,175,179,181,182. Reported
union rates after operative treatment of
zone-3 fractures and nonunions have
ranged between 86% and 100%5,49,50,
133,158,172,175
. Lee et al. found a longer
time to union if a preoperative plantar
gap of 1 mm was present17,156.
Complications
Intraoperative complications comprise
injuries to the sural nerve or the lateral
dorsal cutaneous nerve99,111,119,122,134,
159,160
, injuries to the peroneus brevis
tendon with difficult insertion of the
intramedullary screw3,162, breakage of
the drill bit162, straightening of the
metatarsal136,142,143, perforation of the
medial cortex40, breakage of the metatar-
sal136, suboptimal insertion of the im-
plant that is potentially associated with
the risk of damage of the cortex distal to
the fracture3,40, and fracture of the base158.
Postoperative complications
include wound-healing disorders
(seroma, hematoma, superficial infec-
tion)99,162,172, paresthesia99,111,119,
122,134,159
, painful prominence of the
implant3,5,49,122,130,134,159,161, screw
breakage 3,22 , a ruptured wire
band 123 , and fracture of the medial
cortex distal to the fracture line 40.
Sural neuritis has been reported
in 5% to 25% of cases after open
exposure of the PFMT, but mostly
resolves spontaneously within 6
weeks 178 .
Delayed healing was observed after
both operative99,119,121,134,137,172,174
and nonoperative treatment3,4,47,49,93,
99,130
. Refractures were seen after both
operative40,115,134,156,161,162,172,175,
182-184
and nonoperative3,4,47,130
treatment.
Prominent implants may be
removed after union of the bone has
been achieved. This is reported to be
OCTOBER 2021 · VOLUME 9, ISSUE 10 · e21.00010
Fractures of the Base of the Fifth Metatarsal Bone
required in up to 30% of cases after
and in up to 31% of cases following plate
fixation175,185. Prominence of the screw
head can be prevented by countersink-
ing it into the bone. After removal of the
plating, screw holes will remain as a
stress riser and may lead to refracture in
athletes50,175. Screw breakage, nonun-
ion, and refracture require reoperation
(Fig. 7).
Refractures or nonunions have
been successfully treated with larger-
diameter screws and additional aug-
mentation with either BMAC or
bone-grafting48,179,186,187 or with
plantar plating and autograft178. Exci-
sion of small tuberosity fragments
has been successfully employed for
painful nonunion after a zone-1 frac-
ture103,104,188,189 as well as for sympto-
matic accessory bones44,45.
Source of Funding
There was no source of external funding
for this study.
Kamila Bušková, MD1,
Jan Bartonı́ček, MD, DSc1,2,
Stefan Rammelt, MD, PhD3
1Department
of Orthopaedics, First
Faculty of Medicine Charles University and
Military University Hospital Prague,
Prague, Czech Republic
2Department
of Anatomy, First Faculty of
Medicine, Charles University Prague,
Prague, Czech Republic
3University Center of Orthopaedics and
Traumatology, University Hospital Carl
Gustav Carus Dresden, Dresden, Germany
Email for corresponding author:
kamila.buskova@uvn.cz
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