Acute fractures to the proximal fifth metatarsal bone: development of classification and treatment recommendations based on the current evidence

Management of zone 2 fifth metatarsal fractures varies based on treating specialty

Aims

This study evaluated the effect of treating clinician speciality on management of zone 2 fifth metatarsal fractures.

Methods

This was a retrospective cohort study of patients with acute zone 2 fifth metatarsal fractures who presented to a single large, urban, academic medical centre between December 2012 and April 2022. Zone 2 was the region of the fifth metatarsal base bordered by the fourth and fifth metatarsal articulation on the oblique radiograph. The proportion of patients allowed to bear weight as tolerated immediately after injury was compared between patients treated by orthopaedic surgeons and podiatrists. The effects of unrestricted weightbearing and foot and/or ankle immobilization on clinical healing were assessed. A total of 487 patients with zone 2 fractures were included (mean age 53.5 years (SD 16.9), mean BMI 27.2 kg/m2 (SD 6.0)) with a mean follow-up duration of 2.57 years (SD 2.64).

Results

Overall, 281 patients (57.7%) were treated by orthopaedic surgeons, and 206 patients (42.3%) by podiatrists. When controlling for age, sex, and time between symptom onset and presentation, the likelihood of undergoing operative treatment was significantly greater when treated by a podiatrist (odds ratio (OR) 2.9 (95% CI 1.2 to 8.2); p = 0.029). A greater proportion of patients treated by orthopaedic surgeons were allowed to immediately bear weight on the injured foot (70.9% (178/251) vs 47.3% (71/150); p < 0.001). Patients treated by podiatrists were immobilized for significantly longer (mean 8.4 weeks (SD 5.7) vs 6.8 weeks (SD 4.3); p = 0.002) and experienced a significantly longer mean time to clinical healing (12.1 (SD 10.6) vs 9.0 weeks (SD 7.3), p = 0.003).

Conclusion

Although there was considerable heterogeneity among zone 2 fracture management, orthopaedic surgeons were less likely to treat patients operatively and more likely to allow early full weightbearing compared to podiatrists.

[Surgical treatment of forefoot and midfoot fractures : Minimally invasive fixation of metatarsal fractures]

OBJECTIVE

Minimally invasive stabilization of metatarsal fractures to enable adequate fracture healing in a correct position to restore anatomy and biomechanics of the foot.

INDICATIONS

A. Dislocated diaphyseal and subcapital fractures of the second to fifth metatarsal (> 3 mm, > 10° dislocation). B. Fifth metatarsal fracture at the metadiaphyseal junction (Lawrence and Botte type III).

CONTRAINDICATIONS

High grade soft tissue damage or infection at the implant insertion site.

SURGICAL TECHNIQUE

A. Fluoroscopically assisted closed reduction and antegrade intramedullary fixation of diaphyseal and subcapital fractures of the second to fifth metatarsal. B. Fluoroscopically assisted wire-guided intramedullary screw fixation of fifth metatarsal fractures at the metadiaphyseal junction.

POSTOPERATIVE MANAGEMENT

A. Mobilization with partial weight bearing (20 kg) for 6 weeks wearing a stiff sole; implant removal under local anesthesia after 6-8 weeks, followed by a free range of movement and weight-bearing as tolerated (WBAT). B. Early mobilization with weight-bearing as tolerated (WBAT); removal of the orthosis after 6 weeks, implant removal optional.

RESULTS

A. Antegrade nailing of subcapital and shaft fractures of metatarsals II-V achieves good clinical results with low complication rates both when using prepared Kirschner wires or elastically stable intramedullary nails (ESIN). B. According to current literature, intramedullary screw osteosynthesis of proximal metatarsal V fractures of zone II and III according to Lawrence and Botte leads to faster bony healing with a lower nonunion rate compared with conservative treatment. It is recommended especially, but not only, for active athletes.

Zone 2 Fifth Metatarsal Fractures Treated Nonoperatively Have Similar Time to Healing to Those Treated Operatively

OBJECTIVES

To quantify the rate of union and time to clinical and radiographic healing in Zone 2 proximal fifth metatarsal (MT) fractures and compare these outcomes between Zone 2 fractures treated operatively and nonoperatively.

METHODS

DESIGN

Retrospective cohort study.

SETTING

Academic Level I Trauma Center.

PATIENT SELECTION CRITERIA

Patients with fifth MT fractures who presented between December 2012 and April 2022 and confirmed to have Zone 2 fractures (defined as fractures entering the proximal 4-5 MT articulation on the oblique radiographic view) were included in the study analysis in either the operative or nonoperative cohort.

OUTCOME MEASURES AND COMPARISONS

Nonunion, time to clinical healing by, and time to radiographic healing between operative and nonoperative treatment.

RESULTS

Among the 499 included patients, 475 patients (95.2%) were initially treated nonoperatively and 24 patients (4.8%) were treated operatively. Both groups were similar in demographics. There was no difference in the proportion of patients with nonunions between groups (6.1% in the nonoperative group vs. 3.8% in the operative group, P = 1.000). In addition, there was no statistically significant difference between groups with respect to the time to clinical healing (9.9 ± 8.3 weeks for the nonoperative group vs. 15.4 ± 15.0 weeks for the operative group, P = 0.117) or the time to radiographic healing (18.7 ± 12 weeks for the nonoperative group vs. 18.5 ± 16.6 weeks for the operative group, P = 0.970).

CONCLUSIONS

Zone 2 fifth MT base fractures were successfully treated with nonoperative management. There was no evidence in this study that operative treatment leads to significantly faster clinical or radiographic healing.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

New Classification for Pediatric Proximal Fifth Metatarsal Fractures

Proximal fifth metatarsal fractures are the most common foot fractures in children. Attempts to classify these injuries are misapplied and inadequately predict outcomes. This is the first study to identify factors associated with healing in pediatric fifth metatarsal fractures. In this retrospective cohort study (N = 305), proximal fifth metatarsal fractures were classified on radiographs by location on the bone, alignment (transverse or oblique), displacement (>2 mm), and completion through the bone. Based on the literature, they were secondarily sorted by category: apophyseal, intra-articular metaphyseal, extra-articular metaphyseal, and diaphyseal. Primary outcomes included times to healing, indicated by clinical symptoms, immobilization, and return to sports, as well as radiographic callus formation, bridging, and remodeling. Healing times were compared by ANOVA and linear regression. Location had a significant effect on times of immobilization and return to sports, but alignment, displacement, and completion were not associated with healing. When re-classified, the categories were also associated with immobilization and return to sports. Apophyseal fractures healed fastest and diaphyseal fractures required the most time to heal. There was no difference between extra- and intra-articular fractures. For every year of age, symptoms resolved about 2 days sooner. Neither gender nor body mass index (BMI) was positively or negatively associated with healing times. In conclusion, classifying fractures by apophyseal, metaphyseal, and diaphyseal is the most concise, accurate, and useful system. This is the largest series of nonoperatively treated proximal fifth metatarsal fractures in children and a robust standard to which surgical management can be compared.

Short term clinical and patient reported outcomes following Virtual Fracture Clinic management of fifth metatarsal fractures

INTRODUCTION

Fracture clinics are experiencing increased referrals and decreased capacity. Virtual fracture clinics (VFC) are an efficient, safe, and cost-effective solution for specified injury presentations. There is currently a lack of evidence to support the use of a VFC model in the management of 5th metatarsal base fractures. This study aims to assess clinical outcomes and patient satisfaction with the management of 5th metatarsal base fractures in VFC. We hypothesise that it is both safe and cost effectiveness.

METHODS

Patients presenting to VFC at our major trauma centre with a 5th metatarsal base fracture, between January 2019 and December 2019, were included. Patient demographics, clinic appointments, complication and operative rates were analysed. Patients received standardised VFC treatment; walker boot/full weight bearing, rehabilitation information and instructions to contact VFC if symptoms of pain persist after 4 months. Minimum follow-up was one year; Manchester-Oxford Foot Questionnaires (MOXFQ) were distributed. A basic cost analysis was performed.

RESULTS

126 patients met inclusion criteria. Mean age was 41.6 years (18-92). Average time from ED attendance to VFC review was 2 days (1 - 5). Fractures were classified according to the Lawrence and Botte Classification with 104 (82%) zone 1 fractures, 15 (12%) zone 2 fractures and 7 (6%) zone 3 fractures. At VFC, 125/126 were discharged. 12 patients (9.5%) arranged further follow-up after initial discharge; pain the reason in all cases. There was 1 non-union during the study period. Average MOXFQ score post 1 year was 0.4/64, with only 11 patients scoring more than 0. In total, 248 face-to-face clinic visits were saved.

CONCLUSION

Our experience demonstrates that the management of 5th metatarsal base fractures in the VFC setting, with a well-defined protocol, can prove safe, efficient, cost effective and yield good short term clinical outcomes.

Reliability of Fifth Metatarsal Base Fracture Classifications and Current Management

BACKGROUND

Classification of fifth metatarsal base fractures has been a source of confusion since originally described by Jones in 1902. Zone classifications have been described but never evaluated for reliability. The most recent classification, metaphyseal vs meta-diaphyseal, may be unknown to many surgeons. The purpose of this study was to evaluate reliability of American Orthopaedic Foot & Ankle Society (AOFAS) members classifying fifth metatarsal base fractures and current management of these fractures.

METHODS

A survey was emailed to AOFAS members including radiographs of 18 fifth metatarsal base fractures. Demographic information was collected in addition to evaluation of the radiographs. Interrater reliability was assessed for each measurement: presence of Jones fracture, zone classification, and metaphyseal vs metaphyseal-diaphyseal, using Fleiss kappa. After 3 weeks, a second email was sent to the members asking to retake the survey to evaluate intrarater reliability. Respondents were asked which region is a Jones fracture, which classification is used, if symptomatic zone 2 and 3 fractures are treated similarly, and what fractures are operative in healthy symptomatic acute fractures.

RESULTS

A total of 223 AOFAS members, with a median time in practice of 12 years (range 0-50), completed the initial survey. Eighty members (36%) repeated the survey for intrarater comparison. Interrater reliability was moderate for Jones and zone classification but substantial for the 2-zone metaphyseal/meta-diaphyseal classification. The median intrarater kappa was 0.78, 0.75, and 0.78 for Jones, zone, and metaphyseal/meta-diaphyseal respectively. Seventy percent of respondents treat zones 2 and 3 similarly, and approximately 60% consider an acute symptomatic fracture identified as Jones, zone 2 or zone 3 operative.

CONCLUSION

A 2-zone system may be the best available classification for fifth metatarsal base fractures given high interrater reliability and 70% of AOFAS members treat zones 2 and 3 in similar fashion.

LEVEL OF EVIDENCE

Level III, diagnostic study.

What Is the Interrater and Intrarater Reliability of the Lawrence and Botte Classification System of Fifth Metatarsal Base Fractures?

BACKGROUND

Fractures of the proximal fifth metatarsal are common, and often they are classified using a three-part scale first proposed by Lawrence and Botte. A clear consensus on prognosis and treatment for these fractures is lacking, particularly for fractures in the middle classification, Zone 2; the reliability of the classification scheme itself may be partly at fault for this. The intra- and interrater reliability of the classification itself has never been established, and it remains unclear whether the three-part classification of fifth metatarsal fractures can be applied consistently enough to guide treatment.

QUESTIONS/PURPOSES

When used by experienced orthopaedic surgeons, (1) What is the overall interrater reliability of the three-part Lawrence and Botte classification of fifth metatarsal base fractures? (2) What is the overall intrarater reliability of the three-part Lawrence and Botte classification of fifth metatarsal base fractures? (3) What are these same metrics for the individual transitions within the classification (Zone 1-2 and Zone 2-3)?

METHODS

Thirty sets of initial presentation radiographs representing an equal number of fractures originally diagnosed by treating clinicians as Zone 1, Zone 2, and Zone 3 were evaluated and classified by three orthopaedic surgeons specializing in foot and ankle surgery and eight foot and ankle fellows to determine interrater reliability. Two weeks later, the same set of radiographs were reevaluated in random order to determine intrarater reliability. Kappa values for interrater and intrarater reliability were calculated. Additionally, the individual transitions between zones were separately analyzed by calculating kappa values for a hypothetical two-part classification based on each transition.

RESULTS

The three-part Lawrence and Botte classification of fifth metatarsal fractures demonstrated an overall interrater agreement of κ = 0.66 (observed agreement 77% versus chance agreement 33%). Intrarater reliability for the 11 surgeons ranged from κ = 0.60 to κ = 0.90. A two-part scheme divided by the transition between Zone 1 and Zone 2 demonstrated an interrater agreement of κ = 0.83, and a two-part scheme divided by the transition between Zone 2 and Zone 3 demonstrated a much lower interrater reliability of κ = 0.66.

CONCLUSION

The three-part Lawrence and Botte classification system demonstrated a concerningly low level of interrater reliability with an observed agreement of 77% compared with a chance agreement of 33%. The primary source of concern is the assessment of the interface between Zone 2 and Zone 3, which proved much less reliable than that between Zone 1 and Zone 2. This suggests that previous studies of isolated Zone 1 fractures likely contain a homogeneous fracture cohort, whereas studies of Zone 2 or Zone 3 fractures are likely to include a mixture of fracture types. In practice, the consensus treatment of fifth metatarsal fractures differs based on whether they represent a more proximal, avulsive injury or a more distal injury from indirect trauma. Our data suggest that the Lawrence and Botte classification should be abandoned. Further work should focus on developing a new classification scheme that demonstrates improved interobserver reliability and more directly corresponds to this treatment paradigm.

LEVEL OF EVIDENCE

Level III, diagnostic study.

Surgical Management of Jones Fractures in Athletes: Orthobiologic Augmentation: A Systematic Review and Meta-analysis of 718 Fractures

BACKGROUND

The use of orthobiologics is expanding. However, the use of orthobiologic augmentation in primary fracture fixation surgery remains limited. Primary fracture fixation of the fifth metatarsal (Jones) in athletes is one of the rare situations where primary orthobiologic augmentation has been advocated.

PURPOSE

To determine the effect of orthobiologic augmentation on the outcome of surgically managed Jones fractures in athletes.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, 2 independent team members searched several databases including PubMed, MEDLINE, Embase, Google Scholar, Web of Science, Cochrane Library, and ClinicalTrials.gov through March 2021 to identify studies reporting on surgically managed Jones fractures of the fifth metatarsal exclusively in athletes. The primary outcomes were the return to play (RTP) rate and time to RTP, whereas the secondary outcomes were time to union, union rate, and refractures. Data were presented by type of treatment (biologically augmented fixation or fixation alone).

RESULTS

In the biologically augmented fixation group, successful RTP was reported in 195 (98.98%) of 197 fractures (odds ratio [OR], 97.5%; 95% CI, 95.8%-100%; I² = 0), with a mean time to RTP of 10.3 weeks (95% CI, 9.5-11.1 weeks; I² = 99%). In the group that received fixation without biological augmentation, successful RTP was reported in 516 (99.04%) of 521 fractures (OR, 98.7%; 95% CI, 97.8%-99.7%; I² = 0], with a mean time to RTP of 9.7 weeks (95% CI, 7.84-11.53 weeks; I² = 98.64%]. In the biologically augmented fixation group, fracture union was achieved in 194 (98.48%) of 197 fractures (OR, 97.6%; 95% CI, 95.5%-99.7%; I² = 0%), with a mean time to fracture union of 9.28 weeks (95% CI, 7.23-11.34 weeks; I² = 98.18%). In the group that received fixation without biological augmentation, fracture union was achieved in 407 (93.78%) of 434 fractures (OR, 97.4%; 95% CI, 96%-98.9%; I² = 0%), with a mean time to fracture union of 8.57 weeks (95% CI, 6.82-10.32 weeks; I² = 98.81%).

CONCLUSION

Orthobiologically augmented surgical fixation of Jones fractures in athletes is becoming increasingly common, despite the lack of comparative studies to support this practice. Biologically augmented fixation of Jones fractures results in higher fracture union rates than fixation alone but similar rates of RTP and time to RTP. Although the current evidence recommends primary surgical fixation for the management of Jones fractures in athletes, further high quality comparative studies are required to establish the indication for orthobiologic augmentation.

Proximal Fifth Metatarsal Fractures: A Retrospective Study of 834 Fractures With a Minimum Follow-up of 5 Years

BACKGROUND

Proximal fifth metatarsal fractures are common fractures. Treatment strategies have been debated. We wanted to investigate whether Lawrence and Botte's classification has prognostic value because of time to fracture union, and evaluate if weightbearing as tolerated (WBAT) and nonweightbearing (NWB) treatment strategy had effect on time to fracture union in nonoperatively treated fractures.

METHODS

Computerized database search, patients diagnosed between January 1, 2003, and December 31, 2015.

RESULTS

We identified 834 fractures; 510 (61.2%) zone 1, 157 (18.8%) zone 2, and 167 (20.0%) zone 3. Most (94.4%) were treated nonoperatively; time to fracture union was 7.5 (SD 7.7), 7.7 (5.6), and 9.2 (8.1) weeks for zone 1, 2, and 3, respectively, which gave a significant longer time to union for zone 3 compared to zone 1 fractures (P = .04). There was no difference in time to fracture union when comparing WBAT and NWB for all fracture zones. Failure to union, defined as crossover to surgery and/or delayed union, was found in 13 (2.7%) zone 1, 5 (3.2%) zone 2, and 6 (3.8%) zone 3 fractures. Refracture during follow-up was found in 3 (0.6%) zone 1 and 14 (8.9%) zone 3 fractures.

CONCLUSION

Proximal fifth metatarsal fractures have high union rates with nonoperative treatment. No difference in time to union could be found between WBAT and NWB treatment strategies for all fracture zones. We observed a significantly longer time to fracture union for zone 3 fractures compared to zone 1 fractures. Refracture occurs in a nonnegligible share of nonoperatively treated zone 3 fractures.

[Functional outcome of 111 metatarsal fractures following conservative in comparison to operative treatment]

BACKGROUND

Fractures of the metatarsal bones are common injuries of the foot and particularly occur in patients aged 40-50 years. Especially multiple metatarsal fractures can lead to permanent limitations. Therefore, the aim of this study was to investigate the functional outcome of metatarsal fractures after conservative and surgical treatment using a validated self-reported patient-based outcome questionnaire.

MATERIAL AND METHODS

All patients suffering from metatarsal fractures between 2003 and 2015 were enrolled in this retrospective analysis. The following data were collected: demographic data, AO classification, treatment, reoperation rate and the foot and ankle outcome score (FAOS). For outcome analysis, the nonparametric Mann-Whitney U‑test and Fisher's exact test were performed.

RESULTS

In total the functional outcome of 111 patients with metatarsal fractures were analyzed, 81 patients suffered of an isolated metatarsal fracture and 30 of multiple fractures. The mean age of the patients was 45 ± 15.2 years with a total of 48 men (43%) and 63 women (57%). Patients with an isolated metatarsal fracture had an FAOS of 88 ± 17.1, while patients with multiple metatarsal fractures achieved an FAOS of 78 ± 17.7 (p = 0.046). In the group of isolated metatarsal fractures 43 patients (53%) were surgically treated and of these 36 patients showed a type C fracture (84%). In the group of multiple metatarsal fractures 16 patients (53%) underwent operative treatment.

CONCLUSION

Overall, the functional outcome of isolated metatarsal fractures following operative as well as conservative treatment is good to very good. Simple fractures can be successfully treated conservatively and complex multifragment fractures can be safely managed surgically. If more than one metatarsal bone is fractured, the functional outcome is significantly worse with patients reporting lasting limitations involving the range of motion and stiffness.

Conservative management of Jones fractures with immediate weight-bearing in a walking boot demonstrates healing

Jones fractures, or proximal metatarsal fractures at the level of the fourth and fifth intermetatarsal junction, have a high risk for nonunion due to a vascular watershed region. Classically, treatment consists of weight bearing restrictions in a cast or surgical fixation. Some studies have assessed immediate weight bearing following a Jones fracture. Due to conflicting results, the most appropriate treatment method remains unclear. This study analyzes outcomes after treating adults with acute Jones fractures non-operatively without weight bearing restrictions in a walking boot. This study hypothesizes that patients will not require future operative intervention following functional treatment. A retrospective review of 55 adult patients who sustained acute, closed Jones fractures was conducted. 47 were treated weight bearing as tolerated (WBAT) in a walking boot and eight were treated non-weight bearing (NWB) in a cast. They were followed radiographically by an orthopedic surgeon for an average of 6.4 and 15.5 months, respectively. Three patients in each group (6.4% WBAT, 37.5% NWB) developed painful nonunion leading to surgical fixation. Thirty (66.7%) patients in the WBAT group demonstrated radiographic union on final radiographs. Only two (13.3%) of the 15 patients with partial union were seen at least six months from time of injury, one of whom had ongoing pain but declined surgery. The remaining 13 patients were asymptomatic at their final clinic appointment. Controversy still exists as to the best treatment methodology for acute Jones fractures. Due to a lack of clear guidelines, it can be difficult for the multiple medical specialties involved to evaluate and treat this injury. Our study suggests that non-operative management of minimally displaced Jones fractures, in the adult, low demand population, without weight bearing restrictions in a walking boot offers similar outcomes to cast immobilization with weight bearing restrictions, resulting in bony union or asymptomatic fibrous nonunion.

Functional outcome of 103 fractures of the proximal fifth metatarsal bone

Background

Metatarsal fractures are common skeletal injuries of the lower extremity in adults. The majority involves the proximal fifth metatarsal bone. In the current literature, there still exists controversy regarding treatment recommendations for the different fracture entities.

Methods

All patients suffering from single fractures to the proximal fifth metatarsal bone between 2003 and 2015 were enrolled in this retrospective analysis. Only patients with a minimum follow-up of 12 months were included. The fractures were classified according to Lawrence and Botte (L&B). Data were collected via patient registry, radiographs and a standardized questionnaire (Foot and Ankle Outcome Score = FOAS). For outcome analysis, the nonparametric Mann–Whitney U test was performed and Spearman’s rank correlation coefficient calculated.

Results

In total, the functional outcomes of 103 patients suffering from fractures to the proximal fifth metatarsal bone were analyzed. L&B type I fractures (n = 13) had a FAOS score of 91 ± 23, L&B type II (n = 67) presented a score of 91 ± 15 and L&B type III (n = 23) a score of 93 ± 11. Surgically treated patients with an L&B type II fracture had no statistically significant better functional outcome in comparison to conservative management (p = 0.89). Operatively treated L&B type III fractures tended to have a better functional score (p = 0.16). The follow-up time was 58 (min: 15; max: 164) months.

Conclusions

Overall, the functional outcome following fractures to the proximal fifth metatarsal bone is satisfactory. Conservatively treated L&B type II fractures showed an equivalent functional outcome compared to surgical management. Patients with an L&B type III fracture mainly were treated surgically, but difference in FAOS score did not reach level of significance.

Fifth metatarsal fractures in skeletally immature patients do not need routine orthopedic surgeon assessment and follow-up

Objectives

The aim of this study was to determine the rate of delayed or nonunion of fifth metatarsal fractures in skeletally immature patients. Using this information, we sought to develop an evidence-based clinical care pathway in order to mitigate unnecessary patient radiation exposure, costs to families, and costs to the health system.

Methods

We retrospectively reviewed the charts and radiographs of patients who presented to an academic tertiary-care paediatric hospital between 2009 and 2014 with isolated fifth metatarsal fractures.

Results

A total of 114 patients (61 males and 53 females) with mean age of 11.2 (SD 3.0) years old were included in the study. No patients required operative management. There was one case of delayed union and no cases of nonunion. There was no association of these complications with fracture type, location, or mechanism of injury. There was no association of complications with immobilization type or immobilization period. Despite the low complication rate and need for surgery, fracture clinic resource utilization was significant. Fractures were managed with a mean number of 3.1 (SD 0.89) clinic visits and a mean number of 2.7 (SD1.0) radiology department visits where a mean total of 7.9 (SD 3.4) x-rays were performed.

Conclusions

Based on our retrospective review, skeletally immature patients presenting with isolated fifth metatarsal fractures have a very low rate of delayed or nonunion. A selective follow-up strategy will decrease radiation exposure, reduce costs to families and the healthcare system, without compromising clinical outcomes.

Fractures of the Base of the Fifth Metatarsal Bone: A Critical Analysis Review

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Fractures of the proximal fifth metatarsal (PFMT) are one of the most common foot injuries, accounting for 61% to 78% of all foot fractures, but full consensus on their classification, diagnosis, and treatment has not yet been reached.

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The most commonly accepted classification is that of Lawrence and Botte, who divided the location of PFMT fractures into 3 zones with respect to their healing potential.

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Avulsion fractures of the tuberosity of the base (zone 1) generally heal well, and nonoperative treatment is commonly recommended.

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Internal fixation may be considered for displaced fractures that extend into the fourth-fifth intermetatarsal joint (zone 2) as well as for nondisplaced fractures in athletes or high-demand patients, with the aims of reducing the healing time and expediting return to sport or work.

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Stress fractures of the proximal diaphysis (zone 3) are preferably treated operatively, particularly in the presence of signs of delayed union. With nonoperative treatment, supportive measures such as ultrasonography or external/extracorporeal shockwave therapy have been demonstrated to have limited potential for the enhancement of fracture-healing.

Avulsion injuries: an update on radiologic findings

Avulsion injuries result from the application of a tensile force to a musculoskeletal unit or ligament. Although injuries tend to occur more commonly in skeletally immature populations due to the weakness of their apophysis, adults may also be subject to avulsion fractures, particularly those with osteoporotic bones. The most common sites of avulsion injuries in adolescents and children are apophyses of the pelvis and knee. In adults, avulsion injuries commonly occur within the tendon due to underlying degeneration or tendinosis. However, any location can be involved in avulsion injuries. Radiography is the first imaging modality to diagnose avulsion injury, although advanced imaging modalities are occasionally required to identify subtle lesions or to fully delineate the extent of the injury. Ultrasonography has a high spatial resolution with a dynamic assessment potential and allows the comparison of a bone avulsion with the opposite side. Computed tomography is more sensitive for depicting a tiny osseous fragment located adjacent to the expected attachment site of a ligament, tendon, or capsule. Moreover, magnetic resonance imaging is the best imaging modality for the evaluation of soft tissue abnormalities, especially the affected muscles, tendons, and ligaments. Acute avulsion injuries usually manifest as avulsed bone fragments. In contrast, chronic injuries can easily mimic other disease processes, such as infections or neoplasms. Therefore, recognizing the vulnerable sites and characteristic imaging features of avulsion fractures would be helpful in ensuring accurate diagnosis and appropriate patient management. To this end, familiarity with musculoskeletal anatomy and mechanism of injury is necessary.

Return to Play and Fracture Union After the Surgical Management of Jones Fractures in Athletes: A Systematic Review and Meta-analysis

BACKGROUND

Proximal fifth metatarsal fractures are among the most common forefoot injuries in athletes. The management of this injury can be challenging because of delayed union and refractures. Intramedullary (IM) screw fixation rather than nonoperative management has been recommended in the athletic population.

PURPOSE

To provide an updated summary of the return-to-play (RTP) rate and time to RTP after Jones fractures in athletes with regard to their management, whether operative or nonoperative, and to explore the union rate and time to union as well as the rate of complications such as refractures.

STUDY DESIGN

Meta-analysis.

METHODS

Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, 2 independent team members searched several databases including PubMed, MEDLINE, Embase, Google Scholar, Web of Science, Cochrane Library, and ClinicalTrials.gov through November 2019 to identify studies reporting on Jones fractures of the fifth metatarsal exclusively in athletes. The primary outcomes were the RTP rate and time to RTP, whereas the secondary outcomes were the number of games missed, time to union, and union rate as well as the rates of nonunion, delayed union, and refractures.

RESULTS

Of 168 studies identified, 22 studies were eligible for meta-analysis with a total of 646 Jones fractures. The overall RTP rate was 98.4% (95% CI, 97.3%-99.4%) in 626 of 646 Jones fractures. The RTP rate with IM screw fixation only was 98.8% (95% CI, 97.8%-99.7%), with other surgical fixation methods (plate, Minifix) was 98.4% (95% CI, 95.8%-100.0%), and with nonoperative management was 71.6% (95% CI, 45.6%-97.6%). There were 3 studies directly comparing RTP rates with surgical versus nonoperative management, which showed significant superiority in favor of surgery (odds ratio, 0.033 [95% CI, 0.005-0.215]; P < .001). The RTP rate according to type of sport was 99.0% (95% CI, 97.5%-100.0%) in football, 91.1% (95% CI, 82.2%-99.4%) in basketball, and 96.6% (95% CI, 92.6%-100.0%) in soccer. The overall time to RTP was 9.6 weeks (95% CI, 8.5-10.7 weeks). The time to RTP in the surgical group (IM screw fixation) was 9.6 weeks (95% CI, 8.3-10.9 weeks), which was significantly less than that in the nonoperative group of 13.1 weeks (95% CI, 8.2-18.0 weeks). The pooled union rate in the operative group (excluding refractures) was 97.3% (95% CI, 95.1%-99.4%), whereas the pooled union rate in the nonoperative group was 71.4% (95% CI, 49.1%-93.7%). The overall time to union was 9.1 weeks (95% CI, 7.7-10.4 weeks). The time to union with IM screw fixation (8.2 weeks [95% CI, 7.5-9.0 weeks]) was shorter than that with nonoperative treatment (13.7 weeks [95% CI, 12.7-14.6 weeks]). The rate of delayed union was 2.5% (95% CI, 1.2%-3.7%), and the overall refracture rate was 10.2% (95% CI, 5.9%-14.5%).

CONCLUSION

The RTP rate and time to RTP after the surgical management of Jones fractures in athletes were excellent, regardless of the implant used and type of sport. IM screw fixation was superior to nonoperative management, as it led to a higher rate of RTP, shorter time to RTP, higher rate of union, shorter time to union, and improved functional outcomes. We recommend surgical fixation for all Jones fractures in athletes.

Fifth Metatarsal Fracture-A Systematic Review of the Treatment of Fractures of the Base of the Fifth Metatarsal Bone

BACKGROUND

Metatarsal fractures are among the most common foot and ankle injuries, with an annual incidence of 6.7 per 100 000 persons. Approximately 30% of metatarsal fractures affect the base of the fifth metatarsal bone. Nevertheless, no evidence-based treatment recommendations are available to date.

METHODS

The three fracture localizations according to Lawrence and Botte (zone I, proximal to the intermetatarsal joint between the fourth and fifth metatarsal bones; zone II, in the area of the joint; zone III, at the distal end of the joint) are analyzed on the basis of a systematic literature search. Studies were included that compared the treatment of two types of fracture in the same manner, or that compared two different treatments for a single type of fracture.

RESULTS

Nine studies compared different treatments of zone I fractures. Two of these were randomized controlled trials (RCTs); in one RCT, patients given functional therapy returned to work much sooner than those treated with immobilization (11 vs. 28 days; p = 0.001), with otherwise similar outcomes. The non-randomized studies revealed a faster return to full function (33 vs. 46 days; p<0.05) with early functional therapy, and similar outcomes for immobilization and surgery. One RCT that compared functional therapy with immobilization for zone II fractures revealed no statistically significant difference. Five studies compared fractures in zones I and II that were treated in the same manner, revealing similar outcomes. One RCT compared surgery and immobilization for zone III fractures: surgery led to statistically significant improvement of the outcome in all of the measured parameters.

CONCLUSION

Fractures in zones I and II should be treated with early functional therapy. There seems to be no reason to consider zone I and II fractures as two separate entities, as the outcomes in the two groups are similar. In contrast, fractures in zone III should primarily be treated surgically.

Conservative Versus Surgical Management of Fifth Metatarsal Avulsion Fractures

Fifth metatarsal avulsion fractures are among the most common fractures seen by foot and ankle surgeons. Studies have centered around classification systems, but debate continues regarding surgical versus conservative treatment modalities. The present study focused on quantifying the time for healing fifth metatarsal base avulsion fractures. Specifically, we compared healing time, displacement, and incidence of nonunion among surgically managed and conservatively managed avulsion fractures. Surgically managed patients underwent either open reduction with internal fixation or closed reduction with percutaneous fixation. Conservatively managed fractures were immobilized with a below-knee cast or pneumatic walking boot. Fifty-one patient records (51 feet) were retrospectively compared for basic demographics, smoking, and diabetes status, presence of peripheral neuropathy, Stewart classification, amount of displacement, rate of nonunion, and radiographic healing time. The groups did not differ significantly based on age, sex, or the remaining clinical characteristics including time to consolidation. However, among the 31 conservatively managed patients, 11 (35.5%) developed an asymptomatic nonunion versus none among the 20 patients treated surgically (p = .004). All patients were asymptomatic at 1 year. This study provides insight into the time required for fifth metatarsal avulsion fractures to heal or become asymptomatic. The surgical management of these fractures helped to eliminate the risk of nonunion and helped ensure a timely return to preinjury activity. We recommend surgical management of any fifth metatarsal avulsion fracture displaced >2 mm. Both patients and physicians should have realistic expectations when making decisions regarding treatment modalities for fifth metatarsal avulsion fractures.

Early Results of a Novel Intramedullary Fixation Device for Proximal Fifth Metatarsal Fractures

BACKGROUND

Proximal fifth metatarsal fractures are commonly treated surgically due to their poor healing capacity. While intramedullary screws may be the most popular operative treatment choice, newer fixation methods continue to develop. We present a case series utilizing a novel intramedullary fixation device for proximal fifth metatarsal fractures. To our knowledge, no other study in the literature has assessed the safety and efficacy of this fixation method.

METHODS

A retrospective analysis was performed for 16 patients with proximal fifth metatarsal fractures who underwent fixation with the same novel intramedullary device. Patient charts were reviewed for fracture union, plantar fracture gapping, time to weight-bearing, refracture, perioperative complications, and secondary surgeries.

RESULTS

Sixteen patients with an average age of 43.3 years underwent fixation with this novel device from 2015 to 2020. Mean follow-up was 32.4 weeks. Fifteen of the 16 patients achieved radiographic union at a mean of 8.9 weeks. One patient suffered a nonunion. Mean time to full weight-bearing in, and out of, a walking boot was 6.4 and 9.8 weeks, respectively, for healed fractures. Mean plantar fracture gap improved from 1.22 mm to 0.88 mm following surgery. There were zero infections, refractures, or hardware complications. Three patients suffered iatrogenic fracture during implant insertion.

CONCLUSION

To our knowledge, this is the first report of early results for this novel intramedullary device. Excellent union rates, acceptable time to weight-bearing, and a low complication profile can be achieved. Based on our findings, we propose a safe and effective treatment option for proximal fifth metatarsal fractures.

LEVELS OF EVIDENCE

Level IV: Clinical case series.

Conservative treatment of refractures after modified tension band wiring of fifth metatarsal base stress fractures in athletes

OBJECTIVE

Recurrent fifth metatarsal base stress fractures (MT5-BSF) in athletes present a challenging problem. The aim of this study was to evaluate the result of conservative treatment for the refracture of MT5-BSF after modified tension band wiring (MTBW).

MATERIALS AND METHODS

The outcomes of 15 elite athletes undergoing conservative treatment for refracture of MT5-BSF after MTBW were retrospectively reviewed. They were instructed to avoid weight-bearing with short leg cast for 6 weeks. After that, they started partial weight with a postop shoe. Stepwise exercise followed bone union by radiographs.

RESULTS

Thirteen cases (86.6%) had a complete bone union after a mean of 18.9 ± 8.6 weeks. Twelve cases (80%) returned to their previous activity level and maintained for at least two consecutive seasons.

CONCLUSION

Eighty percent of all athletic patients with the conservative treatment for refractures with healed MT5-BSF after MTBW on the plantar-lateral side could maintain and return to their previous sports activity for at least 2 years.

Early functional treatment or trivialization? - current treatment strategies in lateral ligament injuries of the ankle

Introduction: Ankle injuries are common in daily orthopaedic trauma practice, with a high incidence of lateral ligament complex (lat-lig-com) injuries of the ankle joint (AJ). Primarily, these lat-lig-com injuries heal sufficiently, although there is a risk of developing chronic ankle instability. However, there is a lack of knowledge about the clinical application and routine for rehabilitation strategies so as to prevent chronic instability. This study investigates the current rehabilitation concepts in clinical routine after ligament injuries of the AJ. Methods: Rehabilitation protocols, provided by orthopaedic and trauma surgery institutions in German speaking countries, were analysed in terms of weight-bearing, range of motion (ROM), physiotherapy and choice of orthosis. All protocols for operatively and non-operatively (nop) treated ligament ruptures of the AJ were included. Results: 120 of 213 institutions provided protocols of lat-lig-com injuries of the AJ. Regarding the orthosis, the nop-treatment group mainly used ankle braces; in contrast, the operative group preferred the use of an ankle boot. The operative group recommends 6-12 weeks for duration of orthosis in contrast to only 6 weeks in the nop group. Significant differences prevail in ROM, with free ROM in non-operative treatment from the first day after trauma (p<0.001) in contrast to a careful increase in ROM in the first 6 weeks post-operatively. Conclusion: Early functional treatment is clinical standard in rehabilitation after lat-lig-com injuries of the ankle. Regarding current literature the differences of restrictions in ROM and orthosis treatment after lat-lig-com injuries suggest a trivialization of conservative treatment in the first period after trauma compared to post-operative aftercare.

Hard-Soled Shoe Versus Short Leg Cast for a Fifth Metatarsal Base Avulsion Fracture: A Multicenter, Noninferiority, Randomized Controlled Trial

BACKGROUND

The purpose of this study was to determine whether tolerated weight-bearing in a hard-soled shoe was noninferior to the use of a short leg cast for the treatment of a fifth metatarsal base avulsion fracture, as assessed with use of a 100-mm visual analog scale (VAS) for pain at 6 months after the fracture.

METHODS

A total of 145 patients were assessed for eligibility. Of these, 96 patients were randomly assigned to either the hard-soled shoe group (46 patients) or the cast group (50 patients). The primary outcome measure was the mean difference on the 100-mm VAS between groups at 6 months after the fracture. Secondary outcome measures included the time to return to preinjury activity and patient-reported satisfaction. Analysis was performed according to both an intention-to-treat basis (i.e., patients were included in the assessment of their assigned treatment arm, even if they crossed over to the other treatment arm prior to completing the 6-month follow-up) and a per-protocol basis (i.e., patients who completed the 6-month follow-up were analyzed according to the treatment they received).

RESULTS

At 6 months after the fracture, the mean 100-mm VAS was 8.6 ± 7.0 mm in the hard-soled shoe group and 9.8 ± 7.3 mm in the cast group (p = 0.41) according to intention-to-treat analysis. The mean difference in 100-mm VAS between the 2 groups was -1.3 mm (95% confidence interval, -4.3 to 1.8 mm). The upper limit of the 95% confidence interval did not exceed the noninferiority margin of 10 mm, indicating that treatment with the hard-soled shoe was noninferior to treatment with the short leg cast. The proportion of patients who reported satisfaction with their treatment was similar between the hard-soled shoe and cast groups (89.5% compared with 87.5%, respectively; p = 0.79), but the time to return to preinjury activity was significantly shorter in the hard-soled shoe group (37.2 ± 14.4 days compared with 43.0 ± 11.1 days in the cast group; p = 0.04). There were no cases of nonunion in either group.

CONCLUSIONS

Weight-bearing as tolerated in a hard-soled shoe for a fifth metatarsal base avulsion fracture was noninferior to the use of a short leg cast as assessed with use of a 100-mm VAS at 6 months after the fracture. Patient-reported satisfaction was similar between groups, but the time to return to preinjury activity was shorter in the hard-soled shoe group.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Jones Fracture in the Nonathletic Population

Fractures of the proximal fifth metatarsal are common injuries with a unique history. Treatment of these fractures is controversial partly because of confusion regarding fracture subtype nomenclature. Today "Jones fracture" refers to proximal fifth metatarsal fracture in zones 2 or 3. Zone 2 fractures are acute injuries, and their optimal treatment is unclear. Zone 3 fractures commonly occur in the presence of a chronic stress reaction. Because of poor healing potential, zone 3 fractures typically require operative treatment. Zone 1 fractures have excellent healing potential and may be treated nonoperatively with a weightbearing as tolerated protocol.

How useful are virtual fracture clinics?: a systematic review

Background

Due to the overwhelming demand for trauma services, resulting from increasing emergency department attendances over the past decade, virtual fracture clinics (VFCs) have become the fashion to keep up with the demand and help comply with the BOA Standards for Trauma and Orthopaedics (BOAST) guidelines. In this article, we perform a systematic review asking, “How useful are VFCs?”, and what injuries and conditions can be treated safely and effectively, to help decrease patient face to face consultations. Our primary outcomes were patient satisfaction, clinical efficiency and cost analysis, and clinical outcomes.

Methods

We performed a systematic literature search of all papers pertaining to VFCs, using the search engines PubMed, MEDLINE, and the Cochrane Database, according to the Preferred Reporting Items for Systematic review and Meta-Analysis (PRISMA) checklist. Searches were carried out and screened by two authors, with final study eligibility confirmed by the senior author.

Results

In total, 21 records were relevant to our research question. Six orthopaedic injuries were identified as suitable for VFC review, with a further four discussed in detail. A reduction of face to face appointments of up to 50% was reported with greater compliance to BOAST guidelines (46.4%) and cost saving (up to £212,000).

Conclusions

This systematic review demonstrates that the VFC model can help deliver a safe, more cost-effective, and more efficient arm of the trauma service to patients.

Cite this article: Bone Joint Open 2020;1-11:683–690.

Surgical versus conservative management of fifth metatarsal fractures in adults: A protocol of retrospective study

BACKGROUND

At present, the treatment of base fractures of the fifth metatarsal, especially the area I fractures, is still a controversial topic. The objective of our work was to assess the radiological and clinical outcomes of displaced avulsion fractures of the fifth metatarsal base after treated with conservative treatment or intramedullary screw.

METHODS

All of the fifth metatarsal fractures patients underwent surgery by the senior authors in our hospital from January 2017 to December 2019 were reviewed. Institutional Review Board in the Subsidiary Hospital of Guizhou Medical University approved this study. Patients with the following conditions can be included:Patients with the following conditions will be excluded: follow-up less than 6 months; open fracture; pathological fracture; osteoporotic fracture; patients have the history of ankle or foot surgery. Radiographs were taken at 1, 3, 6 and 12 months in outpatient follow-up. The following outcomes were assessed in the follow-up: functional outcomes, the score of patient satisfaction, as well as the motion range, and complications. All the statistical analyses were implemented via applying the software of SPSS Version 12 (SPSS Inc, Chicago, IL).

RESULTS

We hypothesized that there was no remarkable difference between two groups in the outcomes after operation.

TRIAL REGISTRATION

This study protocol was registered in Research Registry (researchregistry6024).

Jones Fracture Management in Athletes

Jones fractures in both elite and recreational athletes are best treated with surgical fixation, given superior results as compared to nonoperative management. While screw specifics remain controversial, intramedullary screw fixation is established as the standard surgical technique. Plate fixation also has shown excellent outcomes. Complications of refracture, nonunion, and delayed union require careful evaluation for contributions of early return to play, implant characteristics, and anatomic/metabolic abnormality. Revision fixation with autograft and biologic augmentation is supported in the literature, with ongoing inquiry to optimizing specific implants and adjuvants.

Results of Functional Treatment of Epi-Metaphyseal Fractures of the Base of the Fifth Metatarsal

BACKGROUND

Fractures of the fifth metatarsal base (5th MT) are common foot injuries, but their treatment remains a subject of debate. The aim was to assess the midterm outcome of functionally treated epi-metaphyseal fractures (Lawrence and Botte types I and II) of the 5th MT.

METHODS

This study was a longitudinal retrospective database study with prospective follow-up. Included were all patients with an acute, isolated fracture to the 5th MT base (types I and II). All patients were treated functionally: weightbearing as tolerated without immobilization. Fracture types and fracture characteristics (displacement <2 mm/>2 mm, articular involvement, number of fragments) were assessed retrospectively. Patient-reported outcome measures (PROMs) including the visual analog scale for foot and ankle (VAS FA) and the quality-of-life score (QoL) SF-12 were collected prospectively at 2- and 5-year follow-up. Out of 95 patients, 43 patients (45%) were included with a median follow-up of 5.7 (1.5) years.

RESULTS

For both the VAS FA and SF-12, excellent scores were observed. For 30 patients (77%), longitudinal 2- and 5-year follow-up was available. No significant longitudinal changes could be observed for the VAS FA and SF-12. For both time points, neither fracture type nor characteristics significantly influenced any outcome parameter assessed.

CONCLUSION

Functional treatment by full weightbearing and free range of motion led to excellent 5-year results for both type I and II fractures. Neither fracture location nor characteristics had a significant influence on the 5-year PROMs.

LEVEL OF EVIDENCE

Level III, comparative study.

Treatment of Zone 1 Fractures of the Proximal Fifth Metatarsal With CAM-Walker Boot vs Hard-Soled Shoes

BACKGROUND

Zone 1 fractures of the proximal fifth metatarsal are usually treated nonsurgically using some type of immobilization. The aim of this study was to compare clinical and functional outcomes, time to return to prior activity levels, and rate of bone healing when using a hard-soled shoe (HSS) vs a controlled ankle motion (CAM)-walker boot (CWB).

METHODS

Seventy-two consecutive patients with zone 1 fractures of the fifth metatarsal base were treated conservatively with either an HSS or CWB by 2 different providers. We included 57 women and 15 men, average age of 41.3 (range, 16-88) years. Radiographic findings, visual analog scale (VAS) for pain, and American Orthopaedic Ankle & Foot Society (AOFAS) midfoot score were assessed. Patients were followed at 4, 8, 10, 12, and 24 weeks or until asymptomatic and able to return to prior level of activities. Statistical analysis was performed using Mann-Whitney U, Fisher exact, and chi-square tests. P values <.05 were considered significant.

RESULTS

Age and gender distributions were similar in both groups (P = .23 and P = .57). Patients had similar VAS and AOFAS scores after 8 (P = .34 and P = .83) and 12 (P = .87 and P = .79) weeks. Average time for bone healing was significantly faster using the CWB (7.2 weeks) when compared to the HSS (8.6 weeks) (P < .001). The average time to return to prior level of activities was similar in both groups (8.3 weeks for CWB and 9.7 weeks for HSS) (P = .11). Fracture displacement was equal in both groups, with a mean of 1.9 mm of displacement in patients using the HSS, and a mean of 1.6 mm in those using the CWB (P = .26).

CONCLUSION

Zone 1 fractures of the proximal fifth metatarsal can be treated conservatively with either a hard-soled shoe or a CAM-walker boot. Even though patients treated in the CAM-walker boot demonstrated earlier signs of complete healing, similar clinical and functional results were achieved with both treatments.

LEVEL OF EVIDENCE

Level III, retrospective comparative series.

Return to Weightbearing and High-Impact Activities Following Jones Fracture Intramedullary Screw Fixation

BACKGROUND

Although the benefit of primary intramedullary (IM) screw fixation of fifth metatarsal Jones fractures in athletes is clear, limited data support its use in conventional patient populations. This study evaluated radiographic and functional outcomes following primary IM screw fixation in a series of Jones fractures to determine if similar excellent outcomes were achievable.

METHODS

We reviewed the data of 32 consecutive patients who underwent Jones fracture primary IM screw fixation by a single surgeon. Demographic risk factors of interest (age, gender, tobacco use, pertinent medical comorbidities, military service status, and prior nonoperative management) were collected prospectively. Primary outcomes included times to return to full weightbearing, radiographic union, and resumption of high-impact or restriction-free activities. Complications including reoperations were recorded. Categorical data are reported as frequencies, and statistical means with P values are reported for continuous variables. Mean age for the 32 patients was 33.4 years.

RESULTS

All 32 fractures healed uneventfully, and at mean follow-up time of 24.2 months, overall patient-reported satisfaction was 100%. Overall mean postoperative outcomes are as follows: 3.7 weeks return to full weightbearing, 10.8 weeks to radiographic union, and 13.0 weeks to resumption of restriction-free activities. Among the risk factors assessed, only preoperative peripheral vascular disease (PVD) and/or diabetes mellitus (DM) and active duty military service resulted in significantly increased and decreased time to resumption of restriction-free activities, respectively, but did not impact overall weightbearing or union times. Patient age, gender, and tobacco use had no effects on radiographic or functional outcomes.

CONCLUSION

Primary IM screw fixation was a safe, reliable option for all appropriate operative candidates with Jones fractures and may result in similar early weightbearing, osseous healing, and expeditious return to full activities consistently reported in high-level athletes.

LEVEL OF EVIDENCE

Level IV, case series.

Delayed Healing in Metatarsal Fractures: Role of Low-Intensity Pulsed Ultrasound Treatment

The most common fracture in primary care is metatarsal fracture, but it is controversial whether to treat this fracture conservatively or surgically. We performed a cohort study to contrast metatarsal fractures that heal normally with fractures that show delayed healing. We analyzed 5% Medicare Standard Analytic Files, selecting all metatarsal fractures in 2011 to 2013, excluding patients with multiple fractures. Delayed healing was defined as treatment >14 days postfracture with either low-intensity pulsed ultrasound or surgery. Treatment for delayed healing was identified using the Current Procedural Terminology and International Classification of Diseases, Revision 9, Clinical Modification codes. Among 9482 metatarsal fractures, 256 (2.7%) showed delayed healing. Patients with delayed healing were younger (p < .0001); more likely to receive specialist referral (p < .001); more likely to have obesity (p = .005), psychosis (p = .003), chronic lung disease (p = .012), or iron deficiency anemia (p = .016); and more likely to receive surgery before ultrasound (p < .0001). Patients more likely to be treated with surgery than ultrasound included younger patients (p < .0001), obese patients (p = .02), and patients who first see a specialist (p < .05).

Early return to playing professional football following fixation of 5th metatarsal stress fractures may lead to delayed union but does not increase the risk of long-term non-union

PURPOSE

5th metatarsal stress fractures are frequently encountered in professional football. There is concern that early return to play following intra-medullary screw fixation may lead to an increased risk of delayed union. The purpose of the study was to assess whether an early return to play after surgical fixation of 5th metatarsal fractures in professional football players is a risk factor for delayed union and the effect of this on the ultimate clinical outcome.

METHODS

Retrospective review of prospectively collected data of a series of 37 professional football players following intramedullary screw fixation of 5th metatarsal stress fractures. End points included time of return to play and to radiological union of the fracture.

RESULTS

At a minimum follow-up of 24 months the mean return to play was 10.5 weeks and mean time to complete radiological union was 12.7 weeks. Return to play at 8 weeks or less resulted in a higher risk of delayed radiological union (24% at 3 months), but this neither prevented the athlete from continuing to play football nor did it affect the ultimate risk of non-union (3% overall). A re-fracture occurred in 1 patient (3%) at 10 months who previously had complete radiographic union at 9 weeks.

CONCLUSION

Intramedullary screw fixation of 5th metatarsal stress fractures leads to a predictable time of return to play and a low rate of non-union. If players return to play at 8 weeks or less a persistent line may be expected in up to a quarter of patients. However, if asymptomatic this radiological finding does not mean that athletes must avoid playing football as ultimately a good outcome is expected with low rates of non-union and refracture.

LEVEL OF EVIDENCE

Case series, Level IV.

Trauma assessment clinic: Virtually a safe and smarter way of managing trauma care in Ireland

INTRODUCTION

The Trauma Assessment Clinic [TAC], also referred to as Virtual Fracture Clinic, offers a novel care pathway for patients and is being increasingly utilised across the Irish and UK health care systems. The provision of safe, patient centred, efficient and cost-effective treatment via a multidisciplinary team [MDT] approach is the primary focus of TAC. The Trauma and Orthopaedic unit at Tullamore Hospital was the first centre to introduce a TAC in Ireland and this overview outlines the experiences of this pilot.

METHODS AND PATIENTS

Patients arriving to the Emergency Department with injuries that were TAC appropriate were treated as per a recognised protocol. They were given information regarding their injury and a removable splint or cast and told to expect a follow up phone call from the orthopaedic team. Within 24 h the patient's clinical notes and x-rays were assessed by the TAC MDT and patients were called immediately to be advised as to their planned treatment.

RESULTS

To date the TAC pilot in Tullamore Hospital has reviewed 2704 patients. 35% of patients were discharged at the TAC review stage, 27% were referred to an appropriate clinic (e.g. Shoulder injuries referred to an upper limb specialist) or a general trauma follow-up clinic, and 38% were referred onto physiotherapy services local and community based for follow-up. A survey of patients reviewed in the TAC revealed that 97% of respondents agreed or strongly agreed that they were satisfied with their recovery. The cost of each TAC consultation was €28 versus €129 for a traditional fracture clinic appointment.

CONCLUSION

Our experience of the TAC is that it provides a very safe, patient focused and cost-effective means of delivering trauma care. It provides a more streamlined and improved patient journey in select patients with certain fracture patterns, allowing for patient empowerment without compromising clinical care and marries current available technology with up to date best clinical practice.

[Metatarsal and toe fractures]

Metatarsal and toe fractures are the most frequent injuries of the foot skeleton. Nondislocated fractures can be conservatively treated with good success. Long-term relief and immobilization including the ankle joint are unnecessary. Metatarsal fractures close to the base are nearly always associated with Lisfranc luxation and treatment must also take the instability of the tarsometatarsal joints into consideratíon. Basal fractures of the 5th metatarsal bone require a differentiated consideration. The correct classification is necessary in order to initiate an adequate treatment. In general, intra-articular layer formation, inclination >10° and shortening between 3 mm and 5 mm, taking the position of the head of the metatarsal bone into consideration, are recommended as indications for surgery. Operative treatment of toe fractures is only rarely necessary.

Walking Gait Before and After Chiropractic Care Following Fifth Metatarsal Fractures: A Single Case Kinetic and Kinematic Study

Objectives

The purpose of this report is to describe the kinetic and kinematic analysis of walking gait following healed left proximal fifth metatarsal fractures.

Clinical Features

A 62-year-old female presented at a chiropractic clinic with concerns that recent metatarsal fractures had not fully resolved and reported abnormal gait due to pain and several weeks use of a "walking boot." The patient's walking gait was evaluated with a force-sensor treadmill and an inertial measurement unit motion capture system. Recordings were made before, at midpoint, and post-chiropractic care (11 visits total). Data were analyzed for spatio-temporal gait parameters, vertical ground reaction forces, and ranges of motion of the hip, knee, and ankle.

Intervention and Outcome

Pre-care, the patient's self-rated disability in walking was 50 out of 80 on a Lower Extremity Functional Scale, which improved to 80 out of 80, post-care. Her self-selected preferred walking speed increased, as did step length, cadence, and single support time. Increased symmetry was seen in timing of peak ground reaction forces, stance phase percentages of loading and pre-swing, and ranges of motion for hip and knee flexion and extension.

Conclusions

The patient recovered completely, and the post-injury kinematic and kinetic data allowed for quantification of gait patterns and changes in the clinical environment.

[Fractures of the base of the V metatarsal bone-current concepts revised]

Fractures of the base of the fifth metatarsal bone are one of the most frequent fractures to the foot and ankle. Despite the high frequency and although a number of studies are now available, treatment frequently does not follow the available evidence. Among the reasons is the inconsistent terminology used and that the studies available are neglected. The aim of this review is to present the current classifications, the available treatment studies and to derive evidence-based treatment recommendations. The term "Jones fracture" has been used inconsistently for different fracture entities and should, therefore, not be used anymore. Fractures are mostly classified according to Lawrence and Botte into three zones. However, the available studies demonstrate that type I and type II fractures according to Lawrence and Botte do not differ with respect to the prognosis. Both fractures can be successfully healed by functional treatment with weightbearing as tolerated. Consequently, a differentiation between these two zones does not seem to be meaningful. Therefore, they should be summarized as epi-metaphyseal fractures. Even dislocated, intra-articular, and multifragmentary fractures in this region can be functionally treated with good results. Fractures in the meta-diaphyseal region (Lawrence and Botte type III, distal to the IV and V intermetatarsal articulation) demonstrate a high rate of symptomatic non-unions after conservative treatment. Therefore, these fractures should be primarily treated operatively by closed reduction and intramedullary screw fixation.

[Effectiveness of mini locking plate combined with Kirschner wire in treatment of comminuted Jones fracture]

Objective

To summarize the effectiveness of mini locking plate combined with Kirschner wire in treatment of comminuted Jones fracture.

Methods

Between January 2011 and October 2016, 25 cases with comminuted Jones fracture were treated with mini locking plate combined with Kirschner wire. There were 9 males and 16 females with an average age of 31.4 years (range, 16-66 years). The fractures located on the left side in 11 cases and on the right side in 14 cases. The causes of injury included spraining in 21 cases, falling down in 3 cases, and bruise in 1 case. The bone fragment of all cases was more than 3 pieces. The fracture line was mostly Y-shape or T-shape. Twelve of them were combined with other fractures. The time from injury to operation was 1-9 days (mean, 5 days). The mini locking plate and Kirschner wire were removed at 9-12 months postoperatively. At 12 months postoperatively, the pain was evaluated by the visual analogue scale (VAS) score, and the function by the American Orthopaedic Foot & Ankle Society (AOFAS) score.

Results

All incisions healed by first intention. All cases were followed up 12-36 months with an average of 21.7 months. Fracture union was observed in all patients without complications such as nonunion, delayed union, and malunion. The fracture union time was 8-12 weeks (mean, 9.4 weeks). At 12 months postoperatively, the VAS score was 1.15±0.87; the AOFAS score was 89.45±6.24, and the results were excellent in 14 cases, good in 9 cases, fair in 1 case, and poor in 1 case, with an excellent and good rate of 92%.

Conclusion

The procedure of mini locking plate combined with Kirschner wire for comminuted Jones fracture has such advantages as convenient operation, more rigid fixation, high rate of fracture healing, and good functional recovery in foot.

Initial support with no immobilisation as therapy of choice for fractures of the fifth metatarsal

AIM

To demonstrate the effectiveness of early weight bearing with no immobilisation (functional therapy) applied to fractures of the fifth metatarsal.

MATERIAL AND METHOD

A retrospective case and control observational study was performed among 382 fractures on the fifth metatarsal comparing functional, conservative-orthopaedic and surgical treatments. Fractures were classified according to the settlement on the distal, diaphyseal or proximal part of the bone, the recommended therapy and the treatment performed. Influence of age, profession and characteristics of the injury were considered and results were measured using the parameters incapacity for work and number and intensity of complications.

DISCUSSION

Fractures of the fifth metatarsal are the most common injuries of the foot. Whether conservative or surgical treatment is recommended depends on the sort of fracture, the trend nowadays is to use non-invasive methods.

CONCLUSIONS

Functional treatment for metatarsal fractures provides earlier healing and fewer adverse effects than conventional therapies, and becomes first choice for non-displaced fractures and most displaced fractures of the fifth metatarsal.

Peroneus brevis tendon in proximal 5th metatarsal fractures: Anatomical considerations for safe hook plate placement

INTRODUCTION

The peroneus brevis tendon (PBT) inserts into the proximal aspect of the 5th metatarsal. Metatarsal bone fractures are encountered to be the most common fractures in the foot with predominantly fractures at the base of the fifth metatarsal bone. Mechanism of injury and treatment of the proximal 5th metatarsal fractures vary due to the complex anatomy and diverse biomechanical properties. The purpose of this study was to analyze the footprint of the PBT with regards to the proximal 5th metatarsal fractures and to define a "safe zone" for hook plate placement.

MATERIALS AND METHODS

Forty-one (41) fixed human lower leg specimens were dissected to expose the PBT insertion. The following footprint characteristics were evaluated: area of insertion (AOI) (mm²), length (mm), width (mm), shape and insertional variations. The position of the main PBT footprint was localized according to the Lawrence and Botte classification for the proximal 5th metatarsal fractures (Zone I-III). A "safe zone" was defined for the fracture-specific hook plate placement.

RESULTS

In 25 (61%) feet the PBT footprint was situated in Zone I and in 16 feet (39%) in Zone I&II. The mean AOI, length and width measured 54.5 mm² (SD 16.5), 16.0 mm (SD 5.1) and 4.7 mm (SD 1.4), respectively. Analysis of the footprint shapes revealed four different shape types: kidney (29.3%), diamond (22.0%), crescent (31.7%) and oval (17.0%). A "safe zone" for hook plate placement without or minimal interference of the PBT at its insertion could be defined at the lateral aspect of the 5th metatarsal.

CONCLUSION

The majority of the PBT footprints were found in Zone I. Hook plate placement demonstrated to be safe when placed strictly laterally at the proximal aspect of the 5th metatarsal. Precise knowledge of the peroneus brevis anatomy may help to better understand the biomechanical aspects of the proximal 5th metatarsal fractures.

Early radiographic and clinical outcomes of minimally displaced proximal fifth metatarsal fractures: cast vs functional bandage

Background

The purpose of this non-randomized retrospective study was to investigate outcomes of minimally displaced, proximal 5MTB fractures, treated by a below-knee walking cast or a functional elasticated bandage with a support of a flat hard-soled shoe.

Methods

A consecutive patient series was divided into two groups: the cast group (CG) and the functional group (FG). The subjects were radiologically and clinically evaluated according to Mehlhorn and Lawrence-Botte classification, and AOFAS Midfoot score, respectively.

Results

154 patients were followed up for a median of 15 months (range 12-24). There was no significant difference (p > 0.05) among the outcomes of each fracture pattern regarding the treatment choice. However, an earlier return to sports was noted in the FG, while Type-3 fractures achieved the worst results.

Conclusion

Type-1 and 2 minimally displaced 5MTB proximal fractures can be successfully treated conservatively without weight-bearing restriction and without benefit of a cast with respect to a functional elasticated bandage.

Level of clinical evidence

level III retrospective comparative study.

Functional treatment for fractures to the base of the 5th metatarsal - influence of fracture location and fracture characteristics

Background

Fractures to the base of the fifth metatarsal are common, but their treatment remains controversial. Especially for Lawrence and Botte (L&B) type II fractures, there is conflicting evidence and consequently no consensus. Further, many authors consider displacement, articular involvement, and number of fragments an indication for surgery, although evidence is missing. The aim of this study was to evaluate the outcome of functional treatment for all L&B type I and II fractures. Of special interest were the influence of (1) the fracture location (L&B type I vs. II) and (2) the fracture characteristics (displacement, intra-articular involvement, communition) on the subjective outcome.

Methods

Retrospective registry study with a prospective follow-up. Patients with an acute, isolated, epi-metaphyseal fracture to the fifth metatarsal bone (L&B type I and II) treated by full weightbearing with a minimum follow-up of 6 months were included. Fracture location (L&B type I and II) and characteristics (displacement <2 mm or >2 mm, intra-articular involvement, and number of fragments) were assessed. Outcome parameters were return to work, return to sports, VAS-FA, and SF-12. The influence of the fracture (1) location and (2) -characteristics on these parameters was tested.

Results

Thirty-nine patients (40 ± 15 years, 56% female) were enrolled with a mean follow-up of 22 ± 10 months. L&B type I fractures occurred in 59%, type II in 41%. Thirty-one percent of all fractures were dislocated, 74% intra-articular, and 41% multi-fragmentary. Patients returned to work after 17 ± 12 days, to sports after 53 ± 22 days. The VAS-FA score at the final follow-up was 96 ± 4, SF-12 PCS score 57 ± 5 and MCS score 51 ± 8. No complications were reported, no patient required surgery. None of the assessed outcome parameters differed significantly between (1) the different fracture locations (L&B type I vs. II) or (2) the different fracture characteristics (displacement, intra-articular involvement, and number of fragments).

Conclusions

(1) Both, L&B I and II fractures featured excellent results with immediate full weightbearing. Consequently, L&B type I and II fractures should be summarized as epi-metaphyseal fractures. (2) Fracture displacement, articular involvement, and number of fragments did not influence the outcome. Therefore, functional treatment should be recommended for all epi-metaphyseal fractures.

The outcome of proximal fifth metatarsal fractures: redefining treatment strategies

BACKGROUND

To optimize the treatment strategy and reduce treatment costs of proximal fifth metatarsal fractures, clinical and patient-reported outcome, and its determinants were addressed.

METHODS

A retrospective adult cohort study including 152 proximal fifth metatarsal fractures: 121 nonoperatively and 31 operatively treated. In the operative group, 21 were zone 1 and 10 zone 2 fractures. Median follow-up was 37.5 (IQR 20.8-52.3) months with a minimal follow-up of 6 months. Twenty-three demographic, fracture, and treatment characteristics were assessed as well as the healthcare costs. Outcome was assessed using the patient files, anterior-posterior and oblique X-rays, foot function index (FFI), visual analog score (VAS), and SF-36 questionnaires.

RESULTS

The median FFI, physical SF-36, and VAS scores did not significantly differ between nonoperatively and operatively treated patients. The FFI and physical SF-36 were predominantly affected by a history of mobility impairment and pre-existent cardiovascular diseases, whereas mental SF-36 correlated significantly with higher ASA-score. Overall complication rate was 5.9% (4.1 vs. 12.9%; p = 0.065, nonoperative vs. operative, respectively). Nonunion was recorded in only one (nonoperatively) treated patient. The total healthcare costs for operative treatment were 4.2 times higher compared to nonoperative treatment (€1960 vs. €463 per patient, respectively).

CONCLUSION

Overall, the clinical and patient-reported outcome was good. The foot function and quality of life were mainly affected by comorbidity, rather than fracture and treatment-related variables. Although nonoperatively treated patients indicated decreased mental quality of life, our study indicates that proximal fifth metatarsal fractures can safely be treated nonoperatively without the risk of nonunion, with fewer complications and lower healthcare costs.

LEVEL OF EVIDENCE

3.

Stress fractures of the foot and ankle, part 2: site-specific etiology, imaging, and treatment, and differential diagnosis

Stress fractures of the foot and ankle are a commonly encountered problem among athletes and individuals participating in a wide range of activities. This illustrated review, the second of two parts, discusses site-specific etiological factors, imaging appearances, treatment options, and differential considerations of stress fractures of the foot and ankle. The imaging and clinical management of stress fractures of the foot and ankle are highly dependent on the specific location of the fracture, mechanical forces acting upon the injured site, vascular supply of the injured bone, and the proportion of trabecular to cortical bone at the site of injury. The most common stress fractures of the foot and ankle are low risk and include the posteromedial tibia, the calcaneus, and the second and third metatarsals. The distal fibula is a less common location, and stress fractures of the cuboid and cuneiforms are very rare, but are also considered low risk. In contrast, high-risk stress fractures are more prone to delayed union or nonunion and include the anterior tibial cortex, medial malleolus, navicular, base of the second metatarsal, proximal fifth metatarsal, hallux sesamoids, and the talus. Of these high-risk types, stress fractures of the anterior tibial cortex, the navicular, and the proximal tibial cortex may be predisposed to poor healing because of the watershed blood supply in these locations. The radiographic differential diagnosis of stress fracture includes osteoid osteoma, malignancy, and chronic osteomyelitis.

Surgical Treatment of Zone 1 Fifth Metatarsal Base Fractures Using the Locking Compression Plate Distal Ulna Hook Plate

BACKGROUND

The distal ulna hook plate was recently introduced for the treatment of fifth metatarsal base fractures, but no special articles have reported the surgical results of the plate fixation of displaced or comminuted fifth metatarsal base fractures in zone 1, which are the most common forefoot fractures.

METHODS

Twenty-one patients with Lawrence classification zone 1 fifth metatarsal base fractures with extra-articular displacement greater than 2 mm (n = 13) and intra-articular displacement fractures (n = 8) were included in the study. Patients were treated with the distal ulna hook plate. Patients were evaluated clinically and radiographically, and the functional outcomes were graded using the American Orthopaedic Foot and Ankle Society midfoot scoring system. Time to union and return to pre-injury levels of activity were calculated.

RESULTS

Mean American Orthopaedic Foot and Ankle Society midfoot scores were 42.25 points (range, 27-55 points) preoperatively and 93.16 points (range, 87-100 points) 1 year postoperatively. Mean time to complete union was 61.9 days (range, 52-85 days). Nineteen patients reported returning to previous activities of daily living at a mean of 79.8 days (range, 59-91 days). Two patients showed radiographic signs of mild degenerative changes and noted mild pain, and one patient experienced hardware irritation.

CONCLUSIONS

The distal ulna hook plate might be considered an effective surgical method for zone 1 displaced fifth metatarsal base fractures or multifragmentary, osteoporotic fifth metatarsal base fractures.

Virtual fracture clinic management of fifth metatarsal, including Jones', fractures is safe and cost-effective

Virtual clinics have been shown to be safe and cost-effective in many specialties, yet barriers exist to their implementation in orthopaedics. The aims of this study were to look at whether the management of 5th metatarsal fractures using a virtual fracture clinic model is safe, cost effective and avoids adverse outcomes whilst being acceptable to patients using the service. All patients with a fifth metatarsal fracture between September 2013 and September 2015 had a standardised management plan initiated (blackboot, full weightbearing) in the emergency department (ED). 663 patients met inclusion criteria, 251 (37.5%) Type 1, 111 (17%) Type 2 (Jones'), 281 (42%) Type 3 or distal, 20 (3%) were misdiagnosed, and 4 (0.5%) patient's images were unavailable. 499 (75%) patients were discharged immediately, 47 (7%) had further imaging, 114 (17%) had either ESP or consultant clinic review, and 3 (<1%) transferred their care privately. The average number of clinic visits per patient was 0.17. At a conservative estimate of 1.3 visits per patient in a traditional pathway this saved 779 clinic visits with a cost saving of £60,000 on clinic visits alone. There were 8 (7%) asymptomatic non-unions in Type 2 (Jones') fractures. One patient required surgical intervention. Fifth metatarsal fractures have excellent outcomes with conservative management yet traditionally have required clinic visits to confirm the diagnosis and explain the management and prognosis. Our study supports the use of a virtual fracture clinic model that is standardised, initiated in ED, that is both safe and cost-effective.