460197

IXXX10.1177/1071100712460197Foot & Ankle

InternationalShahid et al
2013
FA

Foot & Ankle International

Aircast Walking Boot and Below-Knee 34(1) 75­–79

© The Author(s) 2013
Reprints and permission:
Walking Cast for Avulsion Fractures sagepub.com/journalsPermissions.nav
DOI: 10.1177/1071100712460197

of the Base of the Fifth Metatarsal:

http://fai.sagepub.com

A Comparative Cohort Study

Mohammad Kamran Shahid, MBChB, MRCS1,

Shahid Punwar, MBChB, MRCS, FRCS1,
Caroline Boulind, MBChB, MRCS1, and
Gordon Bannister, MBChB, MCh(Orth), MD, FRCSEd, FRCSEdOrth2

Abstract
Background: Acute avulsion fractures of the base of the fifth metatarsal are common and are treated in a variety of ways.
The aims of this study were to compare pain, functional outcome, and time taken off work after treatment with a walking
boot or a short-leg cast.
Methods: Of 39 patients with acute avulsion fractures of the base of the fifth metatarsal, 23 were treated with a short-
leg cast and 16 with a walking boot, according to the preference of the consultant present at outpatient clinic. Functional
outcome was assessed by the Visual Analogue Scale Foot and Ankle Questionnaire (VAS FA), pain, and other complaints on
presentation and at 3, 6, 9, and 12 weeks after injury. The VAS FA scores were compared between the 2 groups by a paired
Student t test.
Results: The mean time to return to the level of pain and function before injury was approximately 9 weeks after treatment
in the walking boot group and 12 weeks with a short-leg cast. Patients with walking boots reported less pain between 3 and
12 weeks than did those with short-leg casts after 6 (P = .06), 9 (P = .020), and 12 weeks (P = .33). Function was significantly
better with Aircast walking boots after 3 (P = .006), 6 (P = .002), and 9 weeks (P = .002) but not after 12 weeks (P = .09).
Patients returned to their preinjury level of driving after 6 weeks with walking boots and 12 weeks with short-leg casts
(P = .006). Employed patients took a mean of 35.8 days off work (range, 28-42 days), fewer with boots (31.5 days) than with
short-leg casts (39.2 days).
Conclusion: The walking boot was better treatment than a short-leg cast for avulsion fractures of the base of the fifth
metatarsal. Patients had an improved combined level of pain and function 3 weeks earlier, at 9 weeks post injury, when
managed in a walking boot.
Level of Evidence: Level II, prospective comparative series.

Keywords: fifth metatarsal, function, pain,Visual Analogue Scale Foot and Ankle Questionnaire, walking boot, short-leg
cast

Avulsion fracture of the base of the fifth metatarsal is com- Materials and Methods
mon and is usually treated conservatively. An avulsion frac- Patients
ture is a zone 1 fracture defined as involving a variably sized Between May 6 and December 22, 2010, 43 patients with
portion of the tuberosity or styloid process (Figure 1).6,13 an avulsion fracture of the fifth metatarsal who attended the
Conservative management of avulsion fractures is by pro-
tected weightbearing. Two methods of protected weight- 1
Department of Orthopaedics and Traumatology, Yeovil District
bearing are a short-leg cast and a walking boot.3 There has Hospital, Yeovil, UK
been no comparison of the outcome of treatment of the 2
Avon Orthopaedic Centre, Southmead Hospital, Bristol, UK
avulsion fracture of the base of the fifth metatarsal with a
walking boot or short-leg cast. The primary aim of the study Corresponding Author:
Mohammad Kamran Shahid, Specialty Registrar Trauma and
was to compare pain and functional outcome following
Orthopaedic Surgery, Department of Orthopaedics and Traumatology,
such fractures treated in a walking boot or short-leg cast. Yeovil District Hospital, 46 Pereira Road, Harborne, Birmingham, B17
The secondary aim was to establish time lost from work and 9JN UK
the cost of the 2 treatments. Email: kamren35@hotmail.com

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76 Foot & Ankle International 34(1)
Figure 1. Classification of metatarsal base fractures into 3 zones.13
fracture clinic of a district general hospital were treated
with either a short walking boot (DJO Aircast Walker,
Vista, CA) or a short-leg cast, according to consultant pref-
erence, and weightbearing with crutches for 5 weeks. Seven
consultants were independently involved in determining
their preferred type of immobilization (short-leg cast
or walking boot) for the patients attending their clinic. Four
patients declined to complete the questionnaire. Of the
43 patients who met the study criteria, 39 (13 males,
26 females) provided written consent. Twenty-three patients
received a short-leg cast and 16 a walking boot for 5 weeks.
The patients’ ages ranged from 18 to 81 years (median 56)
(Table 1). The boot was removable, and patients were
advised they could remove it at night for comfort only. The
short-leg cast comprised an underlying cotton stockinette,
padding, and 3 layers of polyester casting tape. Both
extended approximately halfway up the leg.
Outcome Measures
At the initial clinic visit and after 3, 6, 9, and 12 weeks, the
Visual Analogue Scale Foot and Ankle Questionnaire (VAS
FA) was administered (Figure 2).6 We used the VAS FA
because we believed that it was the best validated scale of
the available foot and ankle outcome measures.9,11 The pri-
mary outcome measure was time taken to reach preinjury
level of pain and function for the 2 methods of immobiliza-
tion. Secondary outcome measures included time taken off
work, cost of the boot or casting material, and ability to
drive a vehicle.
The VAS FA is based on 20 questions and requires sub-
jective answers that can be subdivided into 3 distinct cate-
gories. It is designed to add more weighting toward function
than pain or other complaints. There are 11 questions on
function, 4 on pain, and 5 on other complaints.9 Each VAS
was measured to give a score out of 100 for each question
and a combined maximum score of 2000. To assess the time
taken for a return to preinjury function or pain, a mean score
greater than 90 out of 100 was interpreted as a return to
preinjury level. “Other complaints” data recorded in the
VAS FA include gait, perception of unilateral leg weakness,
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presence of callosity, problems finding appropriate foot-
wear, and sensory disturbance in the foot.
Statistical Analysis
Data were normally distributed and compared using paired
Student t test. A P value of .05 or less was considered signifi-
cant.
Results
The VAS FA was significantly less in patients for reaching
preinjury level of function wearing the walking boot after
3 (P = .006), 6 (P = .002), and 9 weeks (P = .002). By
12 weeks there was no significant difference (P = .09). The
VAS FA was significantly less in patients for reaching prein-
jury level of pain wearing the walking boot after 9 weeks (P =
.02). At 3, 6, and 12 weeks, there was no significant difference
(P = .11, .06, and .33, respectively). Time taken to achieve
preinjury level of pain and function was 9 weeks using the
walking boot and 12 weeks with the short-leg cast. All
patients with the boot confirmed they were compliant with
wearing the boot and removed it only at night (Table 2).
Radiographs were taken only on initial presentation to
the clinic and in those patients with a great deal of pain
clinically at the fracture site at the 6-week stage. Eight
patients from the short-leg cast group and 5 patients from
the boot group had radiographs at 6 weeks, all of which
showed presence of callus but not union. Fracture union
was defined radiographically by bridging bone on at least
3 of 4 cortices.3 Further radiographs in the patients were not
indicated, as all had clinically united by 12 weeks.
Eighteen patients were employed and missed a mean of
35.8 days (range, 28-42 days) from work. Patients with the
boot missed 31.5 days and those with the short-leg cast
missed 39.2 (P = .002). Four patients who were self-
employed missed work for a mean of only 28 days and
explained that they returned to work early for financial rea-
sons. They described pain on walking but were sufficiently
mobile to work. One patient returned to work after 28 days
due to pressure from the workplace. The remaining patients
all felt that they returned to work at a satisfactory time and
all took at least 35 days off. The mean time to return to the
preinjury level of driving was 6 weeks with a boot and
12 weeks with a short-leg cast (P = .006) (Table 3).
The walking boots cost £62 and were used for the dura-
tion of treatment. The total cost of materials to apply a sin-
gle short-leg cast was estimated at £9, and all patients
required at least 1 further cast change.
Discussion
There is paucity of literature regarding avulsion fractures of
the fifth metatarsal base. Only 3 prospective studies have
Shahid et al 77

Table 1. Patient Demographics With Short-Leg Casts (SLC) and Walking Boots (WB)

Mean Age, y Males:Females, n Smokers, n Mean Treatment, d Mean Time to Work, d

SLC 51.5 6:17 0 32.2 39.2
WB 47.9 7:9 18.8 34.6 31.5

Figure 2. The Visual Analogue Scale Foot and Ankle Questionnaire (VAS FA) used to assess pain, functional outcome, and other
complaints.9

examined pain and functional outcome following such dressing12; the third investigated functional outcome with a
avulsion fractures.3,5,12 Two were comparative studies hard-soled shoe.3
that compared functional outcome after plaster slipper Other studies have combined avulsion with Jones frac-
and Tubigrip support5 and short-leg cast and soft Jones tures and other variants of fractures of the proximal fifth

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78 Foot & Ankle International 34(1)

Table 2. Mean Scoresa on the Visual Analogue Scale Foot and Ankle Questionnaire for the Short-Leg Cast (SLC) and Walking Boot
(WB) at Different Times

Clinic Review (Average = 3 Weeks 6 Weeks 9 Weeks 12 Weeks

Preinjury 6.6 Days Post Injury) Post Injury Post Injury Post Injury Post Injury
Pain
 SLC 100 32 62 77 86 95
 WB 100 39 67 85 94 97
Function
 SLC 100 22 38 63 83 93
 WB 100 37 62 85 93 96
Other
 SLC  99 43 58 57 85 94
 WB 100 51 70 89 96 97
a
Scores shown are correct to 2 significant figures. Mean score range, 0 to 100.

Table 3. Average Scoresa on the Visual Analogue Scale Foot and Ankle Questionnaire for Driving a Car With the Short-Leg Cast (SLC)
and Walking Boot (WB) at Different Times

Clinic Review (Average = 3 Weeks 6 Weeks 9 Weeks 12 Weeks

Preinjury 6.6 Days Post Injury) Post Injury Post Injury Post Injury Post Injury
SLC 100 6.2 29 46 79 93
WB 100 25 65 93 96 96
a
Scores shown are correct to 2 significant figures. Mean score range, 0 to 100.

metatarsal and universally report clinical union of fractures
of the fifth metatarsal base.1,6,10,11 There has been no previ-
ous comparison study investigating pain and functional out-
come following treatment with a short-leg cast and a
walking boot, and this is the first study to use a validated
foot specific outcome measure.9
This study demonstrated that pain and function recov-
ered earlier in patients treated with a walking boot than in
those with a short-leg cast. The literature suggests that less
rigid immobilization leads to better pain and functional out-
come. Our study showed that all patients achieved clinical
union by 12 weeks, which is supported by the literature.5,12
Gray et al5 found that patients had better improvement of
both pain and function after 2 weeks with a plaster slipper
than with Tubigrip support. Wiener et al12 reported that
patients returned to preinjury activity by 33 days with a soft
Jones dressing compared with 43 days for patients who had
a short-leg cast. However, Egol et al3 reported that clinical
union was achieved in only 20% of their patients by 12 weeks
when treated with a hard-soled shoe. This suggests that a
less rigid form of immobilization than a short-leg cast gives
better early results following such fractures. The walking
boot group took their boot off at night, allowing ankle move-
ment, similar to movement achievable in a Jones dressing,
which may have improved early functional outcome. Analysis
of the fracture registry by Clapper et al1 showed that all 68
avulsion fractures in military personnel healed uneventfully
in an average of 4.7 weeks with no difference between
results with a hard-soled shoe or a cast.1,3
The present study found that fractures of the fifth meta-
tarsal base are a source of lost work productivity. Egol et al3
reported on 52 similar patients treated with a hard-soled
shoe who lost an average of 22 days from work; 47% took
up to 10 days off and 37% more than 10 days. Gosele et al4
reported on a series of 52 patients with such fractures treated
with an orthopedic shoe and found an average of 19 days
taken off work. The present data show that a mean of
35.8 days were missed from work, and this number was
lower with walking boots (31.5 days) than with short-leg
casts (39.2 days). Perhaps it is because a short-leg cast pre-
vents ankle movement, and thus, additional rehabilitation
time is required to overcome stiffness. Although Egol et al3
reported fewer mean days lost from work with a hard-soled
shoe than was found in our treatment groups, only 20.4%
of their patients returned to preinjury functional status by
3 months. This suggests either that the patients returned
to work early, involving an increased level of weightbearing
activity, or that a hard-soled shoe did not provide adequate
treatment. The occupations of patients in both of our
treatment groups were similar in terms of the level of
weightbearing activity required during the working day. In
this study, 5 of the 18 patients who returned to work after 28
days for financial reasons and workplace pressure did not
feel ready to return to work, because of continuing pain.

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Shahid et al 79
Thirteen patients felt well enough to go to work from at
least 35 days post injury.
Cost of treatment is a very important consideration
given the continued increased pressure by health care orga-
nizations to reduce spending. The walking boot (DJO
Aircast Walker) cost was estimated at £62 each and should
cover the duration of treatment. The total cost of materials
to apply a single short-leg cast was estimated at £9, and all
patients required at least 1 further cast change. A plaster
slipper was estimated to cost £7.50 and a Tubigrip support
bandage to cost £1.50. Although treatment is much more
expensive with a walking boot, patients in this study recov-
ered 3 weeks earlier and returned to work 8 days earlier
than after cast immobilization. State benefits as an
Employment Support Allowance to individuals who cannot
be paid following absence from work because of injury are
approximately £67.50 per week for single males over 25
years old with no dependents.2 This suggests that the boot
is cost-effective. Konkel et al7 pointed out that closed treat-
ments give predictable bone healing with minimal cost and
a high satisfaction, but medical fees, radiographs, and
orthopedic equipment in North America range from
$692.50 to $2820.50, with an average total fracture care
medical cost of $1414.09.7 A walking boot is not reusable
in the United Kingdom; were that permitted, their cost
would decrease.
There is no formal guidance from the literature regarding
when patients should return to driving following metatarsal
base avulsion fractures. This study found that walking boots
allow patients to return to their preinjury level of driving
after 6 weeks compared with 12 weeks with a short-leg cast.
Orr et al8 reported that the total brake-response time for
people wearing a controlled-ankle motion boot or a short-
leg cast was greatly increased or worsened in comparison to
wearing normal footwear, suggesting that it is unsafe to
drive with any of these devices.
The strengths of our study lie in its prospective and stan-
dardized nature with regard to treatment and follow-up
questionnaires scheduled at regular time intervals. The use
of the VAS FA was subjective and did not require clinical
examination, and it was completed independently by each
patient without any external influence. Limitations of our
study are that the design would have been better as a ran-
domized controlled trial; it evaluated only 2 treatment
modalities and administered the VAS FA at 3-week inter-
vals for a total of 12 weeks post injury, when recovery
tended to be maximal in the first 6 weeks. We also did not
have radiographic evaluation beyond 6 weeks, so we cannot
comment on the incidence of true nonunion.
Conclusion
Avulsion fractures of the fifth metatarsal base treated con-
servatively require support during healing beyond that
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provided by a Tubigrip but not as rigid as with a short-leg
cast. The walking boot was more expensive but was effec-
tive, providing earlier recovery and return to work.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
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. Directgov. Benefits adviser, 2011. http://www.direct.gov.uk/
en/Diol1/DoItOnline/DoItOnlineByCategory/DG_172666.
Accessed August 19, 2011.
  3. Egol K, Walsh M, Rosenblatt K, Capla E, Koval KJ. Avulsion
fractures of the fifth metatarsal base: a prospective outcome
study. Foot Ankle Int. 2007;28(5):581-583.
  4. Gosele A, Schulenburg J, Oschsner PE. Early functional treat-
ment of a fifth metatarsal fracture using an orthopaedic boot.
Swiss Surg. 1997;3(2):81-84.
  5. Gray AC, Rooney BP, Ingram R. A prospective comparison of
two treatment options for tuberosity fractures of the proximal
fifth metatarsal. Foot (Edinb). 2008;18(3):156-158.
 6. Holubec KD, Karlin JM, Scurran BL. Retrospective study
of fifth metatarsal fractures. J Am Podiatr Med Assoc.
1993;83(4):215-222.
  7. Konkel KF, Menger AG, Retzlaff SA. Nonoperative treatment
of fifth metatarsal fractures in an orthopaedic suburban private
multispecialty practice. Foot Ankle Int. 2005;26(9):704-707.
  8. Orr J, Dowd T, Rush JK, Hsu J, Ficke J, Kirk K. The effect
of immobilization devices and left-foot adapter on brake-
response time. J Bone Joint Surg Am. 2010;92(18):2871-
2877.
  9. Richter M, Zech S, Gearing J, Frank M, Knoblauch K, Retek C:
A new foot and ankle outcome score: questionnaire based,
subjective, visual analogue scale, validated and computerised.
Foot Ankle Surg. 1996;12:191-199.
10. Torg JS, Balduini FC, Zalco RR, Pavlov H, Peff TC, Das M.
Fractures of the base of the fifth metatarsal distal to the tuber-
osity: classification and guidelines for non-surgical and surgi-
cal management. J Bone Joint Surg Am. 1984;66(2):209-201.
11. Vorlat P, Achtergael W, Haentjens P. Predictors of outcome of
non-displaced fractures of the base of the fifth metatarsal. Int
Orthop. 2007;31:5-10.
12. Wiener BD, Linder JF, Giattini JF. Treatment of fractures of
the fifth metatarsal: a prospective study. Foot and Ankle Inter-
national. 1997;18(5):267-269.
13. Zwitzer EW, Breederveld RS. Fractures of the fifth metatar-
sal; diagnosis and treatment. Injury. 2010;41(6):555-562.