Essential Insights On Treating Fifth Metatarsal Fractures

Start Page: 76

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

A Guide To Common Fifth Metatarsal Fractures
The site of the fracture, the fracture pattern and one’s understanding of the fifth metatarsal anatomy gives the podiatric physician an adequate amount of information related to the force producing the fracture. In regard to these fractures, there have been a number of classification systems to help clinicians better understand specific fracture patterns within a given region of the bone and their common outcomes.
Capital fractures. Fractures to the head of the fifth metatarsal generally occur from direct impact (in the vertical direction) or trauma from projectiles. Fractures due to compression may also occur but these tend to be quite stable and only involve minor displacement. When significant displacement does occur, it tends to be in a plantar and lateral direction.
One must pay careful attention with these fractures due to their intraarticular involvement and possible unwanted sequelae of arthritis and joint stiffness. These injuries may require open reduction with pinning if closed reduction fails to restore an appropriate articular surface. Another surgical option may include metatarsal head resection with conversion into an arthroplasty if one cannot reconstruct/realign the articular surface.
Cervical fractures. The most common neck fracture of the fifth metatarsal is the spiral fracture. The spiral fracture tends to be displaced medially along the shearing axis of the fracture. In most cases, these fractures are caused by a torque force mediated by bending and loading the lateral aspect of the foot (i.e. rolling over on the outer border) while the foot is in a plantarflexed and inverted position. This is known as the demi-pointe position in relation to dancing. This type of fracture tends to require open reduction and internal fixation, which one may accomplish with crossed K-wires or 2.0 lag screws.
Other types of fractures that can occur along the metatarsal neck include flexural transverse fractures and buckling impaction fractures. Most have acceptable alignment and heal well with four to six weeks of cast immobilization.

Shaft fractures. Fractures along the shaft of the metatarsal tend to be the result of direct violence or impact. Comminuted fractures are the most common result and one may occasionally see a concurrent open wound and a segmental defect. Alternatively, indirect forces, such as a twisting fall, will result in a spiral fracture of the metatarsal shaft. In either case, in the absence of considerable displacement, both types of fractures tend to heal quite well with conservative non-weightbearing care.
When ORIF is required, a one-third tubular plate with 2.7 or 3.5 screws is the recommended fixation for comminuted, displaced diaphyseal fractures. One may use bone graft as an adjunct if a severe defect is present after fixation is in place. For spiral shaft fractures with significant displacement, the surgical options include IM nail, lag screw with neutralization plate or cerclage wire. Another surgical option for shaft fractures in patients with open injuries or osteopenia is external fixation via a mini rail system.

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