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

Sorting Through The Different Classifications Of Jones Fractures
The classic metaphyseal-diaphyseal fracture, also known as a Jones fracture, is 1.5 cm to 3 cm distal to the tuberosity. Typically, this fracture can either be stress-induced or acute. The anatomic site of the cortical shaft to the proximal metaphyseal expansion creates an area predisposed to load failure.This fracture is typically an incomplete fracture with a wider gap on the lateral cortex. If weightbearing continues, one will see widening of the lateral cortex on a radiographic series.
Many classification systems have attempted to simplify fractures to the fifth metatarsal metaphyseal-diaphyseal junction. Delee classified these fractures based on fracture pattern and acuity.3 Type I fractures are defined as acute fractures and heal well with conservative means. Type II fractures are defined as stress fractures of the proximal diaphysis and have a high propensity for nonunion that necessitate surgical intervention. Vertical or medial lateral forces cause these first two types. Type III fractures involve acute fractures of the tuberosity and will be discussed in detail below.
Torg developed a classification system for proximal diaphyseal stress fractures based on radiographic findings.4 Stage I is an acute fracture with periosteal reaction, a planar-based fracture line and no medullary sclerosis. Stage II shows a similar process but medullary sclerosis and widening of the fracture line are similar to what one would see in delayed unions. Stage III shows complete obliteration of the medullary canal consistent with non-unions.
In 1902, Sir Robert Jones described a transverse diaphyseal fracture that occurred approximately 1.5 to 3.0 cm distal to the tuberosity of the fifth metatarsal.5 Since that time, two different subsets have been termed Jones fractures.
The first, defined by Stewart, occurs at the metaphyseal-diaphyseal junction and does not extend into the metatarsocuboid joint.6 This acute type of injury tends to occur with plantarflexion and adduction of the forefoot, most commonly as a result of landing on the outside of the foot. The second subset applies to proximal diaphyseal stress (aka acute on chronic) fractures. The prevailing thinking is that these fractures are the result of repetitive high bending stresses with an increase in activity. This injury is quite common in athletes who participate in such activities as running and soccer. According to Yu, et. al., these injuries are relatively refractory to conservative treatment and yield less than acceptable outcomes.7
Treatment for these fractures varies from six to eight weeks of non-weightbearing immobilization to primary surgical repair. For a Type I fracture with no displacement or comminution, the treatment of choice is cast immobilization for six to eight weeks. However, even with non-weightbearing immobilization, many of theses fractures will go on to nonunion after 10 or 12 weeks with rates as high as 28 percent being reported in the literature.

Type II fractures also tend not to heal and many go on to non-union after the eight to 12 weeks of cast immobilization. Kavanaugh and Delee advocated percutaneous insertion of a cannulated screw, which one would place longitudinally down the intramedullary canal, as the primary treatment of choice for active patients with Type I fractures and all Type II fractures.3,8 They noted that active patients tend to have a much faster recovery from this surgery and can begin earlier weightbearing (usually within days) with cross-training.

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