A 14-year-old female came to clinic with right foot pain. The pain began approximately 5 months earlier after a fall on ice. Radiographs at that time were negative. Since that time, there usually was no pain, but pain would return and increase with more activity. Over the past 2 weeks, she began recreational league soccer practices and would have pain that initially occurred at the end of practice and now occurs when she begins running at the beginning of practice. She also complains that it is more painful when she is going up stairs or just at the end of a regular day. She denies any other trauma. The review of systems was negative.
The pertinent physical exam revealed a healthy female with normal vital signs and growth parameters. Her extremity examination revealed pain over the proximal 5th metatarsal with palpation and also with supination and flexion of the foot. There was no erythema, bruising or edema. There was no other point tenderness and range of motion was normal in ankle and toes. The radiologic evaluation showed the diagnosis of a fracture of the proximal 5th metatarsal. The family was told by the pediatrician that this could represent a new fracture, one that hadn’t healed or a refracture and therefore the fracture may require surgical intervention. Orthopaedics was consulted and recommended a weight-bearing boot be placed for the next 3 weeks after which they would re-evaluate the patient.
Figure 110 – AP and oblique radiographs of the left foot demonstrate 2 corticated fragments at the base of the fifth metatarsal, felt to represent a non-united chronic fracture.
Fifth metatarsal fractures are a common fracture of the foot and are the most common metatarsal fracture in children > 5 years of age and adults. There is a peak age distribution in the second and fifth decades of life. Teenage boys in organized sports are one of the most common groups affected. In acute fractures, acute pain and inability to walk are common presentations, whereas in a stress fracture an increase in activity, or chronic repetitive forces are at play. Fifth metatarsal fractures have various classifications. Fracture locations from proximal to distal include avulsion fractures (a common acute fracture because of torque forces in the proximal diaphysis), Jones fracture, metaphyseal fractures (common location for stress fractures) and neck and head fractures. The Jones fracture is a specific type of 5th metatarsal fracture first described in 1902 by Sir Robert Jones. He described it in his own foot after dancing and in 4 other patients. It occurs at the diaphyseal-metaphyseal interface which has a watershed blood supply and therefore is prone to delayed or non-union fractures.
Treatment for 5th metatarsal fractures varies and includes non-operative management such as wraps, casts, boots, hard soled shoes with or without weight bearing and also electromagnetic field treatment or ultrasound. Operative management is usually by screw fixation, but also by tension band wiring and/or bone grafts. The prognosis is good overall for these fractures. Depending on several factors (including the initial treatment) and the end point used (i.e. clinical fracture union, return to sports) treatment may take weeks to months.
has been described as the “incomplete healing of a fracture where the cortices of the bone fragments do not reconnect.” Some people will also use the term delayed union. Malunion is a fracture that has healed with a deformity such as rotation, angulation or an incongruent joint surface. Common reasons for malunion include poor blood supply, poor bone fixation (i.e. too much movement) or apposition (i.e. fragments are too far away from each other), behaviors (e.g. smoking, excessive alcohol ingestion, and noncompliance with treatment) and underlying medical problems. Medications may impair healing of fractures. Certain body sites are more common for nonunion because of poor blood supply including the fifth metatarsal, tibia, hamate and scaphoid bones.
Fracture complications include:
- Injuries to adjacent structures
- Other organs
- Compartment syndrome
- Fracture blisters of the skin
- Fat embolism
- Open fracture
- Thromboembolic disease
- Injuries to adjacent structures
- Arthritis, post-traumatic
- Complex regional pain syndrome
- Delayed union
- Thromboembolic disease
Questions for Further Discussion
1. How does the presence of a wound or bone infection affect the risk for delayed or of fractures?
2. What are indications for orthopaedic consultation?
- Symptom/Presentation: Foot Pain
- Specialty: Orthopaedic Surgery and Sports Medicine |
Radiology / Nuclear Medicine / Radiation Oncology
- Age: Teenager
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Zwitser EW, Breederveld RS. Fractures of the fifth metatarsal; diagnosis and treatment. Injury. 2010 Jun;41(6):555-62.
Roche AJ, Calder JD. Treatment and return to sport following a Jones fracture of the fifth metatarsal: a systematic review. Knee Surg Sports Traumatol Arthrosc. 2013 Jun;21(6):1307-15.
Howe, AS. General Principles of Fracture Management: Early and Late Complications. UpToDate. Rev. 1/21/2014, cited 2/3/2014.
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
5. Patients and their families are counseled and educated.
6. Information technology to support patient care decisions and patient education is used.
7. All medical and invasive procedures considered essential for the area of practice are competently performed.
8. Health care services aimed at preventing health problems or maintaining health are provided.
9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.
24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital