Essential Insights On Treating Fifth Metatarsal Fractures

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Continuing Education Course #140 — April 2006

I am pleased to introduce the latest article, “Essential Insights On Treating Fifth
Metatarsal Fractures,” in our CE series. This series, brought to you by the North American Center for Continuing Medical Education (NACCME), consists of regular CE activities that qualify for one continuing education contact hour (.1 CEU). Readers will not be required to pay a processing fee for this course.

The incidence of fifth metatarsal fracture is somewhat common in active patients and such fractures can be complicated in nature. With this in mind, Nicholas Romansky, DPM, and Todd Becker, DPM, provide an essential guide to classification systems for these types of fractures. They also review key diagnostic pearls and pertinent treatment considerations for facilitating optimal outcomes.

At the end of this article, you’ll find a 10-question exam. Please mark your responses on the enclosed postcard and return it to NACCME. This course will be posted on Podiatry Today’s Web site (www.podiatrytoday.com) roughly one month after the publication date. I hope this CE series contributes to your clinical skills.

Sincerely,

Jeff A. Hall
Executive Editor
Podiatry Today

INSTRUCTIONS: Physicians may receive one continuing education contact hour (.1 CEU) by reading the article on pg. 77 and successfully answering the questions on pg. 82. Use the enclosed card provided to submit your answers or log on to www.podiatrytoday.com and respond via fax to (610) 560-0502.
ACCREDITATION: NACCME is approved by the Council on Podiatric Medical Education as a sponsor of continuing education in podiatric medicine.
DESIGNATION: This activity is approved for 1 continuing education contact hour or .1 CEU.
DISCLOSURE POLICY: All faculty participating in Continuing Education programs sponsored by NACCME are expected to disclose to the audience any real or apparent conflicts of interest related to the content of their presentation.
DISCLOSURE STATEMENTS: Drs. Romansky and Becker have disclosed that they have no significant financial relationship with any organization that could be perceived as a real or apparent conflict of interest in the context of the subject of their presentation.
GRADING: Answers to the CE exam will be graded by NACCME. Within 60 days, you will be advised that you have passed or failed the exam. A score of 70 percent or above will comprise a passing grade. A certificate will be awarded to participants who successfully complete the exam.
TARGET AUDIENCE: Podiatrists.
RELEASE DATE: April 2006.
EXPIRATION DATE: April 30, 2007.
LEARNING OBJECTIVES: At the conclusion of this activity, participants should be able to:
• demonstrate a thorough knowledge of fifth metatarsal fractures;
• discuss common causes and diagnostic characteristics of cervical fractures, capital fractures and shaft fractures of the fifth metatarsal;
• review the Delee and Torg classification systems for Jones fractures;
• review key treatment considerations with Jones fractures; and
• discuss the diagnosis and treatment of tuberosity fractures of the fifth metatarsal.

Sponsored by the North American Center for Continuing Medical Education.

This is a spiral shaft fracture that resulted from a twisting injury. Note the medial displacement and shortening of the distal fragment.
Here one can see a spiral shaft fracture after open reduction internal fixation. The large surface area along the fracture site lends itself to healing. The authors used two 2.7 mm lag screws and standard AO technique with cerclage wire to reinforce the f
Here one can see an acute Jones fracture following intramedullary screw fixation with a 4.0 mm partially threaded cancellous screw. This treatment maintains periosteal blood supply and allows for rigid fixation and earlier weightbearing.
(Illustration courtesy of Maria McBride)
82
Author(s): 
By Nicholas Romansky, DPM, and Todd Becker, DPM

Podiatric physicians commonly see fifth metatarsal fractures when treating active patients. The actual rate of occurrence is unknown but some estimate the rate at somewhere between 0.7 and 1.9 percent of all foot fractures. Fractures of the fifth metatarsal can occur at a number of locations and while some of these respond well to conservative treatment, other fractures have been notoriously hard to heal with high rates of nonunion and other complications.
Proper classification of these fractures and a strong understanding of the mechanism of injury will help guide the podiatric physician in establishing a proper prognosis and treatment. It is also helpful to have a thorough understanding of fifth metatarsal anatomy (see “A Primer On Fifth Metatarsal Anatomy” below).

How To Ensure An Appropriate Diagnosis
The accurate diagnosis of fifth metatarsal fractures begins with a thorough history and physical exam. In many cases, the patient may not relate a specific traumatic event during the history portion of the exam, making the physical exam and subsequent studies imperative to an accurate diagnosis. In the acute setting, the patient may present with symptoms of localized pain on the outside or bottom of the midfoot. These symptoms can be insidious in nature or exacerbated by weightbearing. The physical exam may reveal ecchymosis, edema, point tenderness and/or pain against resistance.
Radiographs are invaluable in the diagnosis. It is important to get multiple views of the affected foot, including AP, lateral and medial oblique views for proper assessment of the fracture for location, the amount of displacement, angulation and comminution. One should also obtain radiographs after the patient’s affected extremity has been immobilized for two to three weeks. Fracture healing is dependent on location of the fracture and the specific blood supply to that area of violation.

Open reduction with internal fixation is generally indicated when the fracture is non-reducible and one notes residual displacement of 3 to 4 mm or 10 degrees of angulation in the sagittal plane. When these fractures go unrecognized, a painful plantar keratosis might develop anywhere along the fifth metatarsal. Cortical disruption or thickening, periosteal callus formation and the presence of intramedullary sclerosis may all be visible on X-rays.
Other modalities one may employ for diagnosing fifth metatarsal fractures include CT, MRI, bone scan, ultrasound and tuning fork.
The differential diagnosis for lateral foot pain should include stress fracture, apophysitis in adolescents, accessory bones (i.e., os vesalianum or os peroneum), herniated disc, neoplasm and tendonitis.

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