Evolution Of A Jones Fracture

In an earlier blog (http://tinyurl.com/285eurj ), I discussed the common lateral foot and ankle pain syndromes in the foot. I recently stumbled on a great case, which is applicable to that theme.

Stress fractures are common in the foot and they most often affect the metatarsal bones. The distal second metatarsal neck is the most common site of a stress fracture in the foot. Stress fractures of the third or fourth metatarsals are less frequent. I think we can all agree that stress fractures of the first and fifth metatarsal bones are relatively rare.

I had a 67-year-old woman patient see me recently with pain on both feet with the right foot worse than the left. She complained of pain for about a year on and off. She had previous treatment by another podiatrist who told her that she had bone spurs on the top of her feet. She had one cortisone injection but it did not help much.

Her examination was remarkable for pain with palpation of the dorsal bony prominence of the tarsometatarsal joints. There was also generalized tenderness over the base of the fourth and fifth metatarsal bases. Bilateral X-rays revealed an old stress fracture of the left second metatarsal. Mild to moderate degenerative joint disease of the tarsometatarsal joints was present. There was an underlying metatarsus adductus.

At the patient’s first office visit, my working diagnosis was osteoarthritis of the tarsometatarsal joints with exostosis and lateral stress syndrome of the foot secondary to metatarsus adductus. I call this condition metatarsal periostitis. Her treatment included shoe gear modification to avoid flimsy shoes, which increase stress to the foot. I recommended a stiff soled athletic shoe and alternating her lacing pattern to avoid pressure to the dorsal exostosis. I prescribed diclofenac 75 mg BID PC #60. She initiated an icing protocol TID x 15 minutes. I instructed her to follow up in three weeks.

On her return visit, she was not getting better and, in fact, stated that she was worse. She tried wearing better shoes and she even went to an orthotist to have a pair of orthotics made but these did not help either. Upon re-examination of the patient, it seemed as if the pain was more on the lateral side of the right foot.

At this point, I dispensed a fracture boot to immobilize the foot and advised her to wear it during all weightbearing activities. I gave her a prescription for diclofenac patches (the oral medication caused gastrointestinal upset) and hydrocodone (Vicodin, Abbott Laboratories). She was to follow up in two weeks.

On her following visit, she was approximately 80 percent better. Repeat X-rays revealed a stress fracture of the fifth metatarsal, which was now quite obvious.

What I find very interesting about this case is that I have always believed in the theory that a Jones fracture was a "stress fracture in the making." Since most Jones fractures that we see in practice are a result of an injury (foot plantarflexed with an inversion torque), it is hard to prove the stress fracture theory. I think this is a perfect case in point to illustrate this.

This patient also has a metatarsus adductus. You will see lateral foot and ankle pathology over and over again in the pes cavus and/or metatarsus adductus foot type.

Fig. 1. This X-ray depicts a typical stress fracture of the second metatarsal. This type is usually seen in active younger patients.
Fig 2. In this X-ray, one can see a metatarsal stress fracture at the base. This is more typical for geriatric patients.
Fig. 3. Here one can see a classic stress fracture of the calcaneus.
Fig. 4. A stress fracture in the third metatarsal is less common.
Fig. 5. Pediatric stress fractures also occur occasionally.
Fig. 6. Here one can see multiple stress fractures in a geriatric patient.
Fig. 7. This is a tibial stress fracture in a runner.
Fig. 8. This X-ray shows a fibula stress fracture in a geriatric patient
Fig 9. Here one can see a classic Jones fracture. Note the underlying metatarsus adductus.
Fig. 10. A 67-year-old female had dorsal and dorsolateral foot pain, worse in the right foot. Note osteoarthritis of the tarsometatarsal joints and metatarsus adductus, an old left 2nd metatarsal stress fracture and mild periostitis on the right 5th met.
This is a lateral view of the same patient on initial presentation.
Fig. 12. This is a follow-up right lateral x-ray of the same patient. Note the now obvious stress fracture of the fifth metatarsal at the site of a "Jones" fracture.


Anonymoussays: October 12, 2010 at 11:14 am

I will typically order a bone scan if I'm uncertain of a stress fracture. It is probably the only justifiable reason to order a simple 3 phase bone scan anymore.

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Anonymoussays: October 12, 2010 at 8:42 pm

I personally do not order 3 phase bone scans for this condition. The delay in diagnosis was a couple of weeks and the treatment protocol did not change. Moreover, the outcome of the treatment will not change. I simply tell the patient that "clinically you have a stress fracture, despite a negative x-ray." If it were me, I would not want an injection of a radioisotope and x-rays for "confirmation."

William D. Fishco

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Anonymoussays: October 14, 2010 at 5:14 pm

There was a delay of three weeks in diagnosis. Bone scan would have showed that within 2 days and the patient would have been called back to the office for Cast Boot dispensing. I think treatment would have been initiated faster in this case. If she had gone on to frank fracture due to her age within this time frame, a bone scan would have been helpful.

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Anonymoussays: October 25, 2010 at 11:30 am

Why did she go elsewhere for orthotics?

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Anonymoussays: October 25, 2010 at 11:52 pm

The patient's daughter is a physical therapist and was giving her mother advice. The orthotics were made by an orthotist that had a professional relationship with the daughter.

William D. Fishco

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