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Clinical lead, Mr James Calder
Should all 5th metatarsal fractures undergo surgical fixation?

 

Avulsion fractures of the base of 5th metatarsal may be successfully treated non-operatively. Gray, Rooney and Ingram1 reported on 37 patients and found they were more comfortable in a plaster slipper than tubigrip at 2 months but there was no difference in satisfaction at 6 months whilst Egol et al2 reported that 86% of his 57 patients had returned to normal activities by 6 months and Vorlat, Achtergael and Haentjens3 found that a poorer outcome was associated with longer non weight-bearing.

However, fractures at the metaphyseal-diaphyseal junction behave differently and ever since Sir Robert Jones fractured his 5th metatarsal whilst dancing debate has continued regarding the most appropriate method for treatment.4 The problem lies in their relatively high rate of non-union. A recent meta-analysis has demonstrated a pooled non-union rate for acute fractures of 21% following non-operative treatment  compared to 97% union with intra-medullary screw fixation.5 However, as is common in orthopaedic trauma, this is mainly reliant upon Level 4 evidence - in fact there is only one Level 1 study randomising screw fixation with non-operative treatment (8 weeks non weight-bearing cast) - this reported a much higher non-union rate with in the cast group (94% vs 67% union) with a mean return to sports at 8 weeks with surgery and 15 weeks with a cast (p < 0.01).6 There does not appear to be any evidence to support or refute the use of bone graft at the time of surgery or to guide the surgeon as to the size of screw - Wright7 reported on 6 re-fractures despite clinical and radiographic union and recommended using larger diameter screws in bigger athletes and also the use of orthoses past-operatively to reduce the risk of re-fracture. It is interesting to note that re-fractures are more common in the elite athlete probably as a result of increased team pressure for an early return to play - Larson8 reported that 83% of those patients who “failed” to heal were elite athletes returning to training at a mean of 6.8 weeks compared with the “healed” group in which only 11% were athletes and returned to sports at a mean of 9 weeks. There was also frequently incomplete radiographic union on the radiographs of those in the failure group immediately prior to their return to sports.

Therefore in view of the relatively high non-union rate for metaphyseal-diaphyseal fractures intramedullary screw fixation is indicated especially in the elite athlete. This reduces the risk of non-union, re-fracture and enables a quicker return to sporting activities. As a non-elite athlete I know which method I would prefer should I fracture! Elite athletes should however be told that no matter what the newspapers may say it is more likely they will be back to playing at 3 months than the usual journalistic optimism of 6 weeks and surgeons should ensure there is good progression towards radiographic union prior to that return.

Mr James Calder, Consultant Orthopaedic Surgeon, Chelsea and Westminster Hospital, London, UK
February 2013

References
1.  Gray A, Rooney B, Ingram R
. A prospective comparison of two treatment options for tuberosity fractures of the proximal fifth metatarsal. Foot 2008;18:156–58.
2.  Egol K, Walsh M et al. Avulsion Fractures of the Fifth Metatarsal Base: A Prospective Outcome Study. Foot Ankle Int 2007;28:581-3.
3.  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
4.  Jones R. Fracture of the Base of the Fifth Metatarsal Bone by Indirect Violence. Ann Surg 1902;35:697-702
5.  Roche A, Calder JD.  Treatment and return to sport following a Jones fracture of the fifth metatarsal – A systematic review. Knee Surg Sports Traumatol Arthrosc 2012;Sep 6. [Epub ahead of print].
6.  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;33:970-975.
7.  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.
8.  Larson CM, Almekinders LC, Taft TN, et al. Intramedullary screw fixation of Jones fractures. Analysis of failure. Am J Sports Med 2002;30:55-60.


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