Epidemiology
Metatarsal fractures 5 - 6% of all fractures
- 70% of these involve 5th metatarsal
Types
Base of 5th - Zone 1 / 2 / 3
Metatarsal shaft - spiral fracture
Metatarsal neck fractures
Base Shaft Neck
Base of 5th metatarsal fractures
Classification
Dean et al Foot Ankle Spec 2012
- systematic review
- in the literature there is poor differentiation between Zone 2 and Zone 3
| Zone 1 | Zone 2 | Zone 3 |
|---|---|---|
|
Tuberosity avulsion fractures
|
Metaphyseal-diaphyseal junction Involves the 4th / 5th MT articulation |
Proximal diaphysis Distal to the 4th / 5th MT articulation |
| Inversion injuries |
Jones fracture Acute adduction injury |
Repetitive tress fracture Athletes |
 |
 |
 |
| 93% | 4% | 3% |
Blood supply
Watershed area in the proximal metaphysis
Correlates to area of poor healing
Zone 1 Metatarsal Fracture
Definition
Tuberosity avulsion fracture
Usually extra-articular but may extend into cuboid-metatarsal joint
Etiology
Peroneus brevis contracture following inversion
Xray
Differential diagnosis
| Apophysis | Os peroneum | Os Vesalianum |
|---|---|---|
|
Longitudinal Does not enter cuboid-MT joint
Iselin's disease Traction apophysiits |
Accessory bone - well rounded shape
Within peroneus longus tendon |
Accessory bone - well rounded shape
Within peroneus brevis |
|
Appears - female 9 - 11 - male 11 - 14 Fuses 3 years later |
Lateral aspect of the cuboid Common - in up to 25% of feet |
Very uncommon Usually asymptomatic
|
 |
 |
|
| BMJ case report | www.boneschool.com/os-peroneum | Literature review |
Nonoperative management
- systematic review of 627 zone 1 fractures
- union rate nonoperative: 93%
- union rate operative: 95%
Valkier et al J Foot Ankle Surg 2020
- 20 avulsion fractures treated with surgery
- 30 treated nonoperative
- nonoperative: 36% asymptomatic nonunion
- no functional difference between two groups at 1 year
Operative management
Indications
- intra-articular > 30% cuboid joint
- displaced > 2 mm
Options
- IM screw
- hook plate
- suture anchor
Zone 2 / 3 Metatarsal Fracture
Definition
Zone 2 Jones fracture
- transverse fracture of 5th MT shaft 1.5cm from base
- diaphysis / metaphysis junction
- extends 4th/5th MT joint
Zone 3 Metatarsal Fracture
- diaphyseal stress fracture
- distal to 4/5 MT joint
- secondary to repetitive distraction force
Xray
Zone 2 fractures
Zone 2 fractures
Progression to nonunion of zone 2 fracture with nonoperative care
Zone 3 Fractures
Torg Classification
| Type I | Type II | Type III |
|---|---|---|
| Acute | Delayed union | Nonunion |
|
Narrow fracture line No sclerosis No cortical reaction No periosteal hypertrophy |
Increased fracture line Both cortices Some sclerosis Some periosteal hypertrophy |
Significant sclerosis Significant cortical hypertrophy |
|
|
 |
CT
Management
Operative versus non operative
- systematic review of 600 zone 2 / Jones fractures
- union rate nonoperative: 77%
- union rate operative: 96%
- refracture rate 2% in both groups
- systematic review of 400 5th metatarsal stress fractures
- operative union rate: nonunion 4%, refracture 7%
- nonoperative: nonunion 33%, refracture 12%
Operative management
Indications
- displaced
- athlete
- nonunion
Displaced fracture Nonunion
Options
- intramedullary screw
- plate fixation - comminuted fractures
- systematic review of 10 studies and 300 patients
- screw versus plate
- no difference in outcomes or complications
IM Screw Technique
Entry point
- 5th metatarsal is not straight
- high and medial to get straight shot
- avoids planar insertion peroneus brevis
- screw diameter 3.5 / 4.5 / 5.5
Screw fixation Zone 2 nonunion
Screw fixation Zone 2 nonunion
Screw fixation Zone 3 nonunion
Biological augmentation
Biologics - autograft, bone marrow aspirate
- systematic review ORIF +/- biological augmentation
- ORIF + biologics: union 98%
- ORIF alone: union 94%
5th Metatarsal Shaft Fractures
Definition
Spiral fracture of the shaft of the 5th metatarsal
Dancer's fracture
Gonzalez et al Foot Ankle Spec 2024
- 37 spiral 5th metatarsal fractures
- 78% women, average age 50
Nonoperative management
Gonzalez et al Foot Ankle Spec 2024
- 37 spiral 5th metatarsal fractures
- treated weight bear as tolerated
- all healed by 3 months
- 27% mild pain
- 3% significant pain
- 33 shaft fractures treated nonoperatively
- faster return to function with shoe versus boot
Operative management
- systematic review of management spiral 5th metatarsal fractures in athletes
- union rate nonoperative and operative 99%
- return to sport: nonoperative 15 weeks, operative 22 weeks
