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

In Conclusion
Podiatric physicians commonly see fractures of the fifth metatarsal when treating active patients. Choosing between conservative and surgical treatment is imperative because conservative treatment can sometimes lead to an extremely slow recovery or long-term problems. Both competitive and recreational athletes should be geared to a more rapid recovery. Accordingly, intramedullary screw fixation may be a more suitable option. In addition, long-term immobilization and rest can lead to muscle atrophy and stiffness, thus leading to a long recovery before the patient can achieve full athletic participation.
In the athletic and active population, one must consider ORIF as a primary treatment option for Jones type fractures whereas cast immobilization may be more appropriate for the elderly and sedentary population. Late bone grafting may be necessary for avascular nonunions and severe comminution with autogenous grafting from the tibia or calcaneus. Fractures of the base of the fifth metatarsal may require ORIF only in the presence of articular involvement or distraction.
It is also important postoperatively to consider the use of orthotics or shoe gear modifications to decrease the possibility of recurrent fracture. Some have also proposed that low-intensity ultrasound or other forms of bone stimulation may be beneficial in accelerating the healing time for delayed and non-unions but further research is still necessary in this area.

Dr. Romansky is a Fellow of the American College of Foot and Ankle Surgeons and is a Diplomate of the American Board of Podiatric Surgery. He is a team physician for the United States Olympic and World Cup Men’s and Women’s soccer teams. Dr. Romansky is in private practice in Media and Phoenixville, Pa.

Dr. Becker is a third-year resident at Crozer Keystone Health System in Pennsylvania.

References
1. Ebraheim NA, Haman SP, Lu J, Padanilam TG, Yeasting RA. Anatomical and radiographical considerations of the fifth metatarsal. Foot Ankle International. 2000; 21:212-215.
2. Donley BG, McCollum MJ, Murphy A, Richardson G. Risk of sural nerve injury with intramedullary screw fixation of fifth metatarsal fractures: a cadaver study. Foot Ankle International. March 1999; 20(3):182-184.
3. Delee JC, Evans JP, Julian J. Stress fracture of the fifth metatarsal. Am J Sports Med. 1983; 11:349-353.
4. Torg JS. Fractures of the base of the fifth metatarsal distal to the tuberosity. Orthopedics. 1990; 13:731-737.
5. Jones R. Fractures of the base of the fifth metatarsal by indirect violence. Annals Surg. 1902; 35:697-702.
6. Stewart IM. Jones’ fractures: fractures of the base of the fifth metatarsal. Clin Orthopedics. 1960; 16:190-198.
7. Yu WD, Shapiro MS. Fractures of the fifth metatarsal. The Physician and Sports Medicine. Feb.1998; 26(2).
8. Kavanaugh JH, Brower TD, Mann RV. The Jones fracture revisited. J Bone Joint Surg. 1978; 60(A):776-782.
9. Portland G, Kelikian A, Kodros S. Acute surgical management of Jones Fractures. Foot Ankle International. Nov. 2003: 24(11)
10. Pietropaoli MP, Wnorowski DC, Werner FW, Fortino MD. Intramedullary screw fixation of Jones fractures: a biomechanical study. Foot Ankle International. September 1999; 20(9):560-563.
11. Shah SN, Knoblich GO, Lindsey DP, Kreshak J, Yerby SA, Chou LB. Intramedullary screw fixation of proximal fifth metatarsal fractures: a biomechanical study. Foot Ankle Int. 2001 Jul;22(7):581-4.
12. Kelly IP, Glisson RR, Fink C, Easley ME, Nunley JA. Intramedullary screw fixation of Jones fractures. Foot Ankle International. July 2001; 22(7):585-589.
13. Husain ZS, DeFronzo DJ. A Comparison of bicortical and intramedullary screw fixations of Jones fractures. J Foot Ankle Surg. May/June 2002; 41:146-153.

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