by Al Kline DPM¹

Podiatry Internet Journal  1 (1): 12

Introduction 

The Jones fracture describes a fracture to the base of the fifth metatarsal. It was named after Sir Robert Jones, who in 1902, sustained this fracture while dancing around a maypole at a garden dance. The injury is caused by stress plantarflexion and inversion. While there are a number of techniques used to fix the fracture, a case report is highlighted that presents an open reduction and internal fixation using a Synthese 3.0 cannulated screw. This report highlights the ideal placement for the screw in a Type 3 (Stewart Classification) fracture. Special emphasis is placed on screw head placement along the inferior depression of the metatarsal tuberosity. In an earlier article, we discussed the anatomy of the fifth metatarsal. The anatomical outline of the fifth metatarsal will be repeated in this article.

 

Anatomy

It is important to review the anatomy to the base of the fifth metatarsal. The metatarsal is divided into the metatarsal head, distal metaphysis, central diaphysis and proximal body of the fifth metatarsal base and its most proximal styloid process or tuberosity. Cadaveric studies by Theodorou et al showed how the anatomical attachments of the plantar aponeurosis and the peroneal tendons can influence fracture pathogensis at the tuberosity.

The entire styloid process and body of the base of the metatarsal is encompassed by broad fibrous bands formed by fibers converging from the lateral component of the plantar aponeurosis (PAL) and fibers of the peroneal brevis tendon (PB). There are also ligamentous structures inserting into the proximal portion of the tuberosity. There is an anterior frenular ligament extending from the long peroneal tendon to the base of the fifth metatarsal. This would suggest strong ligamentous and tendonous structures that can cause spontaneous avulsion of the styloid process or even body fractures to the fifth metatarsal base on stress. Because of these stresses , it is the authors opinion that any fracture to the styloid process or base of the fifth metatarsal should be fixated or reduced surgically. It is also my opinion that metatarsal stress fractures involving the fifth metatarsal distal to the body of the fifth metatarsal base, should also be repaired surgically.

When we look closer at the base of the fifth metatarsal, the fracture region of the metatarsal is divided into three distinct regions: 1) the most proximal tuberosity or styloid process (T), 2) the body to the base of the fifth metatarsal (B) and 3) the tubular surface just distal to the body of the base of the fifth metatarsal extending into the diaphysis (D).

In reviewing the literature, these ‘zones’ differ and some are delineated by distance from the end of the bone. For instance, fractures that are within 1.5 cm to the end of the styloid process is considered a ‘avulsion’ fracture. Anything distal to that is a ‘metatarsal’ fracture.

 

There has also been 3 zones of fracture descrbed in metatarsal base fractures: 1) zone of tuberosity fracture, 2) zone of Jones fracture and 3) zone of diaphyseal stress fracture.

For our simplified classification, it is fractures that involve the styloid process that are considered true ‘avulsion’ fractures (T). Fractures to the body of the fifth metatarsal base are considered ‘base fractures’ (B) and fractures distal to the body of the fifth metatarsal base are considered ‘metatarsal’ or diaphyseal fractures (D). In most of the literature, this is also the most common region for stress fractures associated with a Jones fracture.

 

 

Case Presentation

A 28 year old female presents post 1 week Jones fracture. She was sent to our office from the emergency room. She presented on crutches and was still experiencing significant pain, even after fracturing the bone one week prior. Initial radiographic evaluation reveals a Type 3 Stewart Classification fracture or Stage 3 (Simple Classification) fracture to the body of the base of the proximal fifth metatarsal. Radiographic indications would suggest that open reduction and internal fixation (ORIF) of the fracture is necessary. The patient is health and was scheduled for outpatient surgery that week. We discussed fixation of this fracture with the patient and her postoperative course. This will include non weightbearing for an additional 4 to 6 weeks after surgery.

 

 

Surgical Technique

We make our initial incision directly over the fifth metatarsal tuberostiy. It is interesting to note the amount of bruising that occured after this fracture.

 

 

The periosteum is incised and some fibers of the PAL is reflected plantarly. Here, the fracture site is easily seen. A small curett can be used to debride the fracture edges. A small bone clamp can then be used to reduce the fracture. It is important during your dissection to not disturb the attaching fibers of the peroneal brevis tendon. In this dissection, some of the fibers are split, but the main body of attachement of the tendon is not disturbed.

 

In this photographic sequence, you can see how the fracture fragment is clamped down and reduced. At this stage, I like to insert a cannulated screw system using simple k-wire directional placement of the screw. It is to place the screw so the screw head is not on the weightbearing surface. There is a small depression just inferior to the PB attachement that is ideal for screw placement.

A small k-wire is used to cross the fracture site. As you can see, there is a small depression along the inferior aspect of the tuberosity that is ideal for screw head placement. If this area is not involved in the fracture site, this is an ideal placement for a screw in a fifth metatarsal base body fracture. Once the wire is in place it is ready for screw compression of the fracture.

The screw is then driven over the k-wire by simple canulated technique. The inset shows the screw length. In this case, it is roughly 22mm in length. The 3.0 mm cannulated screw is ideal for reduction and compression of the fracture site. The screw is angulated in a proximal-plantar to distal-dorsal direction.

The screw is placed with a washer. This will prevent loss of screw head compression to the fracture site. Here you can see the screw head lies in a small depression along the plantar-posterior aspect of the fifth metatarsal base tuberosity.

On the operative radiographs, you can see the orientation of the cannulated screw. It crosses the osteotomy site in an oblique fashion and compresses the fracture site. Be sure to leave one or two threads just outside the cortex for adequate compression. The threads should not pose any problem with the fourth metatarsal. You can also see here how the washer and screw head abute nicely against the cortex and the small depression just under the tuberosity. This orientation of the screw allows the patient, once the fracture is healed, to walk on the foot without screw irritation. Of course, elimination of fixation pain is never a garauntee. If the screw head becomes painful, the screw can simply be removed.

These postoperative views are non-weightbearing. I will try and have a follow-up weightbearing radiograph once the fracture is healed. On this lateral non-weightbearing view, you can see how the fracture cortices is aligned with real sign of fracture. This should allow for proper healing in its anatomical position. In the preoperative xray, the fracture fragment is actually somewhat dorsiflexed. During the reduction phase of this fracture, care was taken to align the cortex in its anatomical positioning.

 

 

Conclusion

 

A simple case study is discussed which outlines the proper fixation technique for a base fracture of the fifth metatarsal or Stage 3 Jones fracture. Proper understand of fifth metatarsal anatomy is discussed describing the anatomical orientation of the PAL and PB tendon. A small plantar-posterior depression is identified that allows for proper placement of a 3.0mm cannulated screw head with washer. The depression is oriented in such a manner as to allow weight-bearing without screw irritation or pain. Certainly, painful fixation can’t always be eliminated, but I believe this technique will decrease those chances.

 

 

References

Malogne, TS: Early Screw Fixation Versus casting in the Treatment of Acute Jones Fractures. The American Journal of Sports Medicine 33:970-975. 2005

Ortiguera, C, et al: A Review of the Current Treatment for Fracture of the Proximal Fifth Metatarsal as First Described by Jones Orthopedic Technology Review 2 (4), 2000

Strayer, S. et al: Fractures of the Proximal Fifth Metatarsal American Family Physician 59: 9 , 1999. Jones, R. Fractures of the Fifth Metatarsal Bone,Liverpool med. Surg. J. 42: 103-107,1902

Jones, R. Fracture of the Base of the Fifth Metatarsal Bone by Indirect Violence, Ann. Surg. 35: 697-700, 1902

Stewart, I.M. Jone’s Fracture: Fracture of Base of Fifth Metatarsal Clini. Orthop. 16:190-198, 1960

Dameron, T.B. Fracture and Anatomical Variations of the Proximal Portion of the Fifth Metatarsal JBJS 57A: 788-792, 1975.

Kavanaugh, J.H., et al. The Jones Fracture Revisited JBJS 60A: 776-782, 1978

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Peltier, L.F. Eponymic Fractures: Robert Jones and Jone’s Fracture, Surgery 71: 522-526, 1972.

Stone, M.M. Avulsion Fracture of the base of the Fifth metatarsal, Am.J. Orthop. Surg. 10: 190-193, 1968.

Torg, J.S., et al Fracture of the Base of the Fifth Metatarsal Distal to the Tuberosity: Classification and Guidelines for Nonsurgical and Surgical management. JBJS 66A: 209-214, 1984.

Zelko, R.R. et al Proximal Diaphyseal Fracture of the Fifth Metatarsal: Treatment of the Fractures and their Complications in Athletes. Am. J. Sports. Med. 7: 95-101, 1979.

Pritsch, M., et al An Unusual Fracture of the Base of the Fifth Metatarsal Bone J. Trauma 20: 530-531, 1980

Soufflet, M. Fracture of the Base of the 5^th Metatarsal (Jone’s Fracture) Radiologic Classification (After I.M. Stewart) translated from Courrier des Pedicures Romands, Chiropodist, April 1983.

Lehman RC, et al Fractures of the base of the fifth metatarsal distal to the tuberosity: a review. Foot Ankle 1987;7:245-52.

Torg JS. Fractures of the base of the fifth metatarsal distal to the tuberosity. Orthopedics 1990.

Parkinson, D.E. et al Biomechanical Principals of Tension Band Wiring Applied to Fractures of the Distal Fibular and Fifth Metatarsal Base JFS 27(2) : 149-156, 1988.

Lee, P. et al: Musculoskelatal Collloquialisms: How Did We Come Up with These Names? Radiographics 24: 1009-1027, 2004

Theodorou, D.J. et al: Fractures of Proximal Portion of Fifth Metatarsal Bone: Anatomic and Imaging Evidence of a Pathogenesis of Avulsion of the Plantar Aponeurosis and the Short Peroneal Muscle Tendon. Radiology (http://radiology.rsnajnls.org/cgi/content/figsonly/226/3/857).

 

 

 

 

 

 

 

 

 

¹Dr. Kline is in private practice in Corpus Christi, Texas.  He can be reached by email at al@kline.net.

© Podiatry Internet Journal , 2006