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Department of Podiatric Medicine, Surgery, and Biomechanics, College of Podiatric Medicine, Western University of Health Sciences, 309 East Second Street, Pomona, CA 91766-1854, USA
Most injuries to the tarsometatarsal (TMT) joint/tarsometatarsal complex (TMC) are acquired through high-velocity trauma such as motor vehicle accidents or a fall from a height.
Low-velocity trauma of Lisfranc injury has been reported to occur to participants of soccer, football, baseball, running, basketball, wind surfing, horseback riding, and ballet.
The athlete typically tries to walk it off and grossly underestimates the gravity of the injury. A Lisfranc injury is severe and has the potential to end an athlete’s career; thus, a timely diagnosis and correct treatment are imperative.
The indirect mechanism of injury involves an axial load applied to a plantar-flexed and slightly rotated foot followed by an abrupt abduction or twisting.
This mechanism of injury happens when a football player falls on the heel of another player’s plantar-flexed foot while the metatarsophalangeal joints are maximally dorsiflexed.
The indirect mechanism also occurs when a windsurfer falls backward and the foot remains in the strap causing it to be forced into a hyper–plantar-flexed position.
To fully understand how an injury can occur at the TMT joint, an understanding of the anatomy involved with the joint is necessary. The TMC is stabilized by both osseous and ligamentous structures, providing primary and indirect stability, respectively.
The osseous structures involved distally are the metatarsals 1 to 5, which articulate proximally with the medial, middle, and lateral cuneiforms and the cuboid. The cuboid articulates with metatarsals 4 and 5. The medial, middle, and lateral cuneiforms articulate with metatarsals 1 to 3, respectively. The middle cuneiform is more proximal than the medial and lateral cuneiforms, creating a mortise and allowing the second metatarsal to articulate with all the 3 cuneiforms, thus creating more osseous stability.
This osseous confirmation allows the base of the second metatarsal to be the keystone in the transverse arch of the foot, enhancing coronal plane stability.
The dorsal and plantar ligaments have 3 components: longitudinal, transverse, and oblique. The longitudinal and oblique fibers connect the tarsals to the base of the metatarsals. The transverse fibers interconnect the bases of the metatarsals. There are dorsal and plantar interosseous ligaments for the metatarsals, cuneiforms, and cuboid. The dorsal ligaments are weaker than the plantar ligaments and this weakness is thought to be a reason for the dorsal dislocation at this joint. The interosseous ligaments are the strongest, yet there is no interosseous ligament between the first and second metatarsals. The first metatarsal is stabilized by the plantar attachment of the peroneus longus and the dorsal attachment of the tibialis anterior. The second metatarsal is stabilized by its osseous surroundings and the Lisfranc ligament. The Lisfranc ligament spans from the lateral aspect of the medial cuneiform, attaching to the base of the medial aspect of the second metatarsal. The Lisfranc ligament measures 1 cm in height and 0.5 cm in width, making it the largest and strongest interosseous ligament.
The least amount of motion is found at the base of the second metatarsal, with only 0.6° of dorsiflexion–plantar flexion arch. The first TMT joint has a dorsiflexion–plantar flexion arch of 3.5°. The most mobile joint of the TMC is the most lateral fourth and fifth TMT joints, with an average of 10° dorsiflexion and plantar flexion.
Anatomy not directly involved with the TMC but still of great concern are the perforating branches of the dorsalis pedis artery and the deep peroneal nerve that courses between the bases of the first and second metatarsals.
Injuries to this nerve and artery can happen in concord with Lisfranc fractures and dislocations. Complications with these neurovascular structures serve as the main necessity for immediate reduction and diagnosis of a Lisfranc injury. The anterior tibial tendon has been proven to prevent proper reduction of a lateral dislocation in a Lisfranc injury.
These classes are based on the congruency of the TMT joints and the direction of displacement of the metatarsals. Type A involves a complete TMT joint incongruity, with all metatarsals displaced in the same direction or plane. Type B involves a partial TMT joint incongruity, with 1 or more displaced metatarsals. Type B1 is a medial displacement of the metatarsals, whereas type B2 is a lateral displacement of the metatarsals. Type C1 involves a divergent pattern of the TMC, with the first metatarsal displaced medially and the lateral 4 metatarsals displaced with partial incongruity. Type C2 involves a divergent pattern of the TMC, with total incongruity.
created a classification system that addresses the low-velocity injuries. This classification system is based on clinical findings, bilateral weight-bearing radiographs, and bone scans. The Lisfranc injury is classified into 3 stages: stage 1, stage 2, and stage 3. A stage 1 Lisfranc injury is a ligament sprain with no diastasis at the base of the second metatarsal and medial cuneiform. The Lisfranc complex is stable. Bone scintigrams are used to show increased uptake at the site of the injury because radiographs, computed tomographic (CT) scans, and magnetic resonance images would likely provide negative results.
The stage 2 Lisfranc injury has a ruptured Lisfranc ligament, a diastasis between 2 and 5 mm at the base of the second metatarsal and medial cuneiform, and no decrease in arch height. The stage 3 Lisfranc injury has a ruptured Lisfranc ligament, diastasis between 2 and 5 mm at the base of the second metatarsal and medial cuneiform, and loss of longitudinal arch height.
Diagnosis of a high-velocity injury such as an automobile accident, crushing injury, or a fall from a height is fairly straightforward. This injury presents with significant edema to the foot accompanied by severe pain and midfoot instability (Fig. 1A).
The injured foot may seem wider or flatter on bilateral comparison to the uninjured foot. A delayed, yet still diagnostic, presentation of a Lisfranc injury is plantar ecchymosis, either in high- or low-velocity injury (see Fig. 1B).
Fig. 1(A) Significant swelling and ecchymosis shown dorsally from midfoot spain. (B) Plantar medial ecchymosis commonly observed in Lisfranc injury.
Significant pain on passive dorsiflexion of the toes in a tensely swollen foot indicates compartment syndrome, and pressures should be measured. A pressure of greater than 40 mm Hg indicates emergent compartment release.
Diagnosis of a low-velocity injury is more difficult. Athletes may underestimate the severity of the injury, especially if they are still weight bearing.
The following bony landmarks should be palpated for tenderness: navicular, medial and middle cuneiforms, bases of metatarsals 1 to 5, and the first intermetatarsal space. Passive pronation and supination of the forefoot can assess the stability of the Lisfranc row, and if this maneuver produces pain, it indicates Lisfranc injury.
If the patient is manifesting more subtle symptoms of a Lisfranc injury, provocation may be achieved by holding the hindfoot fixed in one hand and passively abducting and pronating the forefoot with the other hand.
The initial radiographic evaluation should consist of anteroposterior (beam 15° off vertical), lateral, and 30° oblique views of the foot. The radiograph should be weight bearing to prevent any false-negative results and to clearly see any diastasis from ligamentous injury.
If the injury is mild, it may be necessary to do a bilateral comparison to identify any subtle differences. In an uninjured foot, the anteroposterior radiograph shows the medial side of the second metatarsal base line up with the medial side of the middle cuneiform and the first intermetatarsal space line up with the intertarsal space.
In the lateral view of an uninjured foot, the dorsal surface of the first and second metatarsal bases align with their respective cuneiforms. In the 30° oblique view of an uninjured foot, the medial border of the fourth metatarsal is aligned with that of the cuboid.
The most consistent finding in a Lisfranc injury is when the medial base of the second metatarsal does not line up with the medial aspect of the middle cuneiform.
On a radiograph, a fleck of bone caused by an avulsion fracture from the Lisfranc ligament can be seen between the first and second metatarsal bases.
If Lisfranc injury is suspected and radiographic results are negative, some investigators suggest CT, magnetic resonance imaging (MRI), and/or bone scan. MRI is most helpful when a sprain or tear of the Lisfranc ligament is suspected. Bone scan has proved to be the most useful technique when all others produce negative results.
Fig. 2(A) AP non-weight bearing foot radiograph, there is diastasis observed between 1st and 2nd metatarsals. (B) Oblique foot radiograph shows 2nd, 3rd, 4th metatarsal base fractures.
However, if the diastasis is too subtle, abduction stress radiography cannot detect much separation because the x-ray is too oblique to capture the joint of interest.
Treatment
Nonsurgical treatment
Nonoperative treatment can be used on Nunley and Vertullo
The patient needs to realize that a foot sprain does not heal like an ankle sprain. If the patient understands this concept, compliance is much more likely. Radiographic results of weight bearing must be negative for both displacement and fracture at the TMC.
Although not highly recommended, immediate weight bearing with custom orthotics is appropriate in some cases. Cast immobilization with limited, or no, weight bearing for 6 weeks is the standard nonoperative treatment. A follow-up appointment after 2 weeks for radiographic evaluation of possible diastasis at the base of the second metatarsal and the medial cuneiform is recommended.
If the patient is still point tender after 2 weeks, cast immobilization must be continued for a minimum of 4 more weeks. If the patient is not point tender, weight bearing can be resumed without cast immobilization with or without custom orthotics.
After the patient has completed a minimum of 6 weeks of cast immobilization, weight bearing can be resumed in a walking cast for a minimum of 6 more weeks with range of motion exercises.
stage 2 or stage 3 Lisfranc injury has had highly varied outcomes with an increased incidence for poor results. The most common complication after a Lisfranc injury is posttraumatic arthritis.
This complication, and other complications arising from TMT joint injury, is reduced when anatomic joint reduction is achieved quickly after an initial injury.
Open reduction with internal fixation (ORIF) and arthrodesis are the 2 most common operative treatments. Regardless of the operative procedure chosen, it is imperative to allow at least 48 hours, from the time of initial injury, for decrease in edema. ORIF can use partially or fully threaded 3.5- to 4.5-mm cannulated or solid screws.
There does not seem to be a preferred screw. Screw fixation provides greater biomechanical stability than pinning except in TMT joints 4 and 5 where more motion is required during gait. When the patient has a Myerson type B1 Lisfranc injury, a screw is placed from the medial cuneiform to the base of the second metatarsal. Another screw is placed from the medial to the intermediate cuneiform (Fig. 4).
If the patient has a Myerson type B2 Lisfranc injury, a percutaneous screw can be placed from the medial cuneiform to the base of the second metatarsal.
The disadvantages of using screws are potential hardware breakage, articular damage to the affected joint, and postsurgical hardware removal. A few solutions to these disadvantages are use of absorbable hardware and dorsal plate and tightrope fixation. Thordarson and Hurvitz
used polylactide screws in 14 patients with Lisfranc injury none of whom required screw removal and had no reports of local tissue reaction to the screws. The dorsal plate eliminated articular damage to the affected joint. A biomechanical study on dorsal plate versus screws showed minimal difference in stability and the dorsal plate allowed for earlier postoperative range of motion.
Fig. 4(A–C) Post-operative AP, oblique, lateral radiographs showing open reduction internal fixation of TMT using solid screws and percutaneous K-wire.
Typically, arthrodesis is used as a salvage procedure after a failed ORIF, after a delayed and/or missed diagnosis, or for a comminuted fracture in the TMC.
Many recommend arthrodesis of the Lisfranc joint to be the first choice, with a primary ligamentous injury caused by poor healing at the ligament-osseous structure interface.
recommends hardware to be removed between 12 and 16 weeks after surgery in athletes weighing less than 200 pounds. In athletes weighing more than 200 pounds, hardware is to be removed after 24 weeks.
There is a lot of controversy as to which surgical procedure should be performed to maximize patient outcomes. The largest study to date, performed retrospectively by Myerson and colleagues
reported on 41 Lisfranc injuries in 1988. In both of these studies, ORIF was performed with outcomes reported as good to excellent in about 50% of the patients.
did a retrospective review of 48 patients with a Lisfranc injury initially corrected by ORIF. They reported that 25% of the patients developed polytraumatic arthritis and 50% underwent arthrodesis. For the 48 patients, the average American Orthopaedic Foot & Ankle Society (AOFAS) midfoot score was 77. In 2001, Richter and colleagues
retrospectively reviewed 49 Lisfranc fracture-dislocations with an average AOFAS midfoot score of 71; the best results were from patients who underwent ORIF. There is no reported literature on the percentage of athletes who return to their respective sports after ORIF of the Lisfranc joint.
Treatment of primarily ligamentous Lisfranc joint injuries: primary arthrodesis compared with open reduction and internal fixation. A prospective, randomized study.
proposed that most TMT joint dislocations treated with temporary fixation eventually develop degenerative joint disease at the TMT joint. The investigators reviewed 41 patients with Lisfranc injury who underwent ORIF. Patients who underwent ORIF had an average AOFAS midfoot score of 68.6, whereas patients who underwent primary arthrodesis had an average AOFAS midfoot score of 88.
After 6 months, patients who underwent primary arthrodesis were at 62% compared with preinjury status, whereas patients who underwent ORIF were at 44% compared with preinjury status. After 1 year, patients who underwent primary arthrodesis were at 86% compared with preinjury status, whereas patients who underwent ORIF were at 61% compared with preinjury status. After 2 years, patients who underwent primary arthrodesis were at 92% compared with preinjury status, whereas patients who underwent ORIF were at 65% compared with preinjury status.
Treatment of primarily ligamentous Lisfranc joint injuries: primary arthrodesis compared with open reduction and internal fixation. A prospective, randomized study.
reported a reoperation rate of 75% in patients with an initial Lisfranc injury correction by ORIF. The patients with fusion at the Lisfranc joint had a reoperation rate of 20%. It was found that people who underwent ORIF had difficulty doing single-leg heel raises, whereas patients with fusion had no problem performing single-leg heel raises.
the indications for primary fusions of Lisfranc fractures and dislocations are (1) major ligamentous disruptions with multidirectional instability/dislocation of the Lisfranc joints, (2) comminuted intra-articular fractures at the base of the first or second metatarsal, and (3) crush injuries of the midfoot with intra-articular fracture dislocation. The contraindications for primary fusions of Lisfranc injuries are (1) Lisfranc injuries in children with open physes, (2) unidirectional Lisfranc instability, and (3) unstable extra-articular metatarsal base fractures with questionable ligamentous disruption. Anderson and colleagues
showed similar results in a prospective randomized study and showed reoperative rates of 79% in the ORIF group and 17% in the fusion group. Nunley and Vertullo
reported on 5 professional athletes who underwent TMT joint fusion. Of the 5 athletes, 2 played football in the National Football League and both returned to their sport after treatment.
Despite this report, there is no prospective study published on the percentage of athletes returning to their respective sports after an arthrodesis of the Lisfranc joints.
Summary
Lisfranc fractures account for 0.2% of all fractures, with an incidence of about 1 in 55,000 people yearly. The Lisfranc injury is often misdiagnosed or completely missed because of its subtle symptoms and its usual involvement with polytrauma. Because a Lisfranc injury can often compromise important anatomic structures in its vicinity, long-term effects of a missed diagnosis can end an athlete’s career. The typical mechanism of injury is hyper–plantar flexion of the Lisfranc joint. Examination findings of the Lisfranc injury are pain and tenderness at the metatarsal bases and medial/middle cuneiform, pain with rotational stress of forefoot, and ecchymosis on the plantar aspect of the midfoot. If a Lisfranc injury is suspected, compartment syndrome should not be overlooked. The Lisfranc injury is confirmed with weight-bearing radiographs. If the weight-bearing radiographs show negative results while the patient has positive symptoms, MRI can be used for diagnosis. Nunley and Vertullo classification of the Lisfranc injury involves the amount of diastasis present. Stage 1 injury has diastasis greater than 2 mm and is considered a sprain of the Lisfranc ligament. Conservative treatment involves applying a non–weight-bearing cast for 4 to 6 weeks, with a 2-week follow-up to check for further diastasis with weight-bearing radiographs. Stages 2 to 3 involve a diastasis greater than 2 mm and require surgical reduction of the Lisfranc joint. The Lisfranc injury can be treated by multiple surgical methods, but there is not enough research to determine which method has the best outcome. Reduction of the Lisfranc joint is imperative and must be achieved rapidly after the injury to avoid serious complications.
an English surgeon, sustained a foot injury while dancing around a tent pole at a military party. Radiographic examination of his foot later revealed a fracture about three-fourths of an inch from the base of the fifth metatarsal. In the same year, Jones
published a report on his fracture as well as 6 other similar cases of fifth metatarsal fracture caused by an indirect injury. As a result, this type of fracture has been referred to as Jones fracture or dancer’s fracture.
There are 3 types of fracture that can occur at the base of the fifth metatarsal.
The first fracture is an acute fracture involving the fifth metatarsal tuberosity, which is either an avulsion or comminuted type fracture. The second fracture is the true Jones fracture. The definition of Jones fracture is a transverse fracture located at the diaphyseal and metaphyseal junction, which involves the fourth and fifth intermetatarsal facets on the medial side. The third fracture occurs in the proximal diaphysis of the fifth metatarsal.
The third type is a stress fracture, also known as proximal diaphyseal stress fracture.
Anatomy
A thorough understanding of the regional anatomy of the fifth metatarsal is essential in distinguishing the various fractures in this region of the foot. The fifth metatarsal bone is composed of the base, styloid process or tuberosity, diaphysis, neck, and head. The base of the fifth metatarsal mainly articulates with the cuboid bone and medially with the fourth metatarsal. The soft tissue structure includes the dorsal and plantar cuboideometatarsal ligaments, an intermetatarsal ligament, and the joint capsule. These structures provide stability to the lateral tarsometatarsal joint complex. The peroneus brevis tendon inserts to the dorsolateral aspect of the fifth metatarsal tuberosity, and the peroneus tertius inserts to the dorsal shaft of the fifth metatarsal. Another structure that inserts to the tip of the tuberosity is a lateral band of the plantar aponeurosis that links the tuberosity to the lateral margin of the medial calcaneal tubercle. The flexor digiti minimi brevis muscle originates from the plantar surface of the base of the fifth metatarsal, and the dorsal and plantar interosseous muscles originate from the diaphysis of the fifth metatarsal.
Historically, when the Jones fractures were treated conservatively, numerous delayed unions or nonunions have been reported due to the watershed area at the junction between the diaphysis and tuberosity.
was the first to report 21 proximal fifth metatarsal fractures with a series of delayed unions. He suspected vascular insufficiency as a potential cause for the high incidence of delayed unions in his patients. Shereff and colleagues
reported the intraosseous and extraosseous vascular anatomy of the fifth metatarsal from cadaver models. The dorsal metatarsal artery, the plantar metatarsal artery, and the branch of the lateral plantar artery or the fibular plantar marginal artery have been found to make up the extraosseous circulation of the fifth metatarsal. The blood supply of the fifth metatarsal is similar to that of the long bones. The intraosseous circulation to the fifth metatarsal consists of 3 systems of vessels: the metaphyseal arteries, the periosteal arteries, and the nutrient artery. The periosteal arteries run parallel to the metatarsal shaft and lie within the periosteum. The metaphyseal arteries are derived from the surrounding soft tissues and are found in the head and neck region of the fifth metatarsal as well as the base of the fifth metatarsal. At the junction of the middle and proximal third of the diaphysis, the nutrient artery enters and bifurcates into a short proximal branch and a longer distal branch. The study by Smith and colleagues
reported evidence of different arterial sources for the tuberosity and the proximal diaphysis, thus creating a relative avascular zone between these 2 distributions. The zone of relative avascularity corresponds to the site of Jones fracture, which correlates to the region of poor fracture healing.
Mechanism of Injury
About 70% to 90% of Jones fractures occur in active age groups, from ages 15 to 22 years. According to many reports, those at the greatest risk of suffering Jones fracture are younger athletes with a high level of activity in a running and/or jumping sport.
For example, missteping on the lateral border of the foot, pivoting, or shifting/cutting in sports such as soccer, basketball, or football, with the heel off the ground.
Owing to the ligamentous attachments at the fifth metatarsal, with enough bending motion created from the fifth metatarsal head, the bone fractures before it dislocates.
As a result, a short oblique or transverse fracture at the junction of the metaphysis and diaphysis results, entering the fourth-fifth intermetatarsal joint.
Classification
There are several classification systems that describe the proximal fifth metatarsal fracture. Stewart
devised a classification system based on the location of the fracture, the potential for avascular necrosis, and/or the joint involvement of the fifth metatarsal. He defined Jones fracture as an extra-articular fracture between the metatarsal base and diaphysis. Jones fracture was then categorized as type I fracture under Stewart classification.
The rest of the Stewart classification system includes Type II, intra-articular fracture of the metatarsal base; type III, avulsion fracture of the base; type IV, comminuted fracture with intra-articular extension; and type V, partial avulsion of the metatarsal base with or without a fracture.
Zone 1 is the most proximal avulsion fracture that extends intra-articularly through the metatarsocuboid articulation (Fig. 5A). Zone 2 is a Jones fracture at the metaphyseal-diaphyseal junction (see Fig. 5B). Even though Stewart defined Jones fracture as an extra-articular fracture, the fracture is now considered to begin laterally at the distal portion of the fifth metatarsal tuberosity and extend transversely or obliquely into the area of the medial cortex where the fifth metatarsal articulates with the fourth metatarsal.
Zone 3, a stress fracture that occurs at the proximal 1.5 cm of the diaphysis (see Fig. 5C). Owing to the close proximity, on a radiograph, the distinction between Jones and proximal diaphyseal fractures is often difficult to make. Chuckpaiwong and colleagues
determined that differentiation between Jones and proximal diaphyseal stress fractures is not necessary because regardless of the treatment type, the clinical outcomes were not different between the 2 fracture locations.
Fig. 5Three subanatomic fracture zones of proximal fifth metatarsal fractures. (A) Zone 1: Avulsion fracture. (B) Zone 2: Jones fracture. (C) Zone 3: Diaphyseal stress fracture.
published a classification system to distinguish the healing potential of proximal diaphyseal fifth metatarsal fractures. This classification system is widely used and has become the standard treatment strategy for the Jones and proximal diaphyseal fractures. Torg classification consists of 3 types of fractures based on radiographic findings. Acute type I fracture is defined radiographically by sharp fracture margins, minimal or no periosteal reaction, and minimal cortical hypertrophy. Type I fractures are clinically acute. Type II fractures are characterized radiographically by some periosteal reaction, widened fracture margins, and some intramedullary sclerosis. This injury is characterized by a history of previous injury or fracture. Type II fracture is considered a delayed union. Type III fractures are nonunion fractures that are characterized by a clinical history of repetitive trauma or recurrent symptoms and are characterized radiographically by sclerosis obliterating the medullary canal and blunt fracture edges.
Diagnosis and Imaging
Obtaining a proper history from the patient along with a complete leg-ankle-foot examination is required to make a proper diagnosis. It is vital to rule out other associated injuries, including lateral column Lisfranc sprain and peroneus brevis tendon tear or strain, and to perform stress inversion test for displacement or stability of the foot, subtalar joint, and ankle joint.
There are a few predisposing factors that have been reported to indicate a higher likelihood of Jones fracture. These predisposing factors can be addressed during surgery to prevent chances of delayed union or nonunion or possible recurrence of the Jones fracture. Often, it is imperative that the examiner observes for these predisposing factors when examining a patient
Hindfoot varus can be assessed clinically by observing posteriorly at the Achilles-calcaneal axis, calcaneal axial radiograph, or looking for the peekaboo heel sign.
Normally, the axis is in a slight valgus position instead of a varus position. In hindfoot varus, one should be able to visualize the medial heel pad when the patient is standing with the feet aligned straight ahead.
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The examination of peroneal tendon weakness by comparing with the posterior tibial tendon strength. This weakness is often present, especially with a history of ankle sprain and is a common predisposing factor in lateral foot overload.
For initial evaluation, 3 views of weight-bearing foot radiograph is recommended. Bilateral standing radiographs are rarely required to make the diagnosis. Other ancillary studies such as CT scan, MRI, and bone scan are helpful in diagnosing the injury and suspected associated injury and in the later stages of treatment and management when dealing with possible delayed union or nonunion.
Treatment
Nonsurgical treatment
A nondisplaced Jones fracture and Torg type I (acute) fractures can be treated in a non–weight-bearing ambulation in a short leg cast for 6 to 8 weeks followed by a weight-bearing cast or walking boot for an additional 6 weeks.
However, the exceptions to this treatment option include the high-performance athlete or an informed patient who refuses surgical treatment. When there is no tenderness at the fifth metatarsal and imaging evidence of healing is present, the athlete can resume to play or return to leg-based activities, such as soccer, basketball, or running.
In the literature, there is some question about the success of closed treatment with immobilization in Jones fracture. Even in Jones fracture, immobilization improves the likelihood of union.
reported a series of 46 patients with fractures of the fifth metatarsal base, which were treated nonoperatively and operatively. In this study, 15 patients with acute Jones fractures were cast and immobilized with protected weight bearing. At an average of 6.5 weeks, 93% of the patients healed and 1 patient developed a symptomatic nonunion that required operative management. Only 4 of the 10 patients who followed a partial weight-bearing protocol progressed to union. Therefore, Torg and colleagues
stressed the importance of non–weight bearing in a short leg cast with immobilization.
The biggest disadvantage of the non–weight-bearing cast is that the time to union is often prolonged. Especially, in athletes with prolonged immobilization, the onset of cast disease is of concern. Zogby and Baker
reported a 72% union rate in a series of 25 acute Jones fractures, whereas 28% had clinical and radiographic evidence of nonunion at 25 weeks since the initial injury. From those 25 patients, 7 were then treated with intramedullary screw fixation and a 100% union rate was achieved at an average of 12.1 weeks.
reported a nearly 50% reduction in both the time to clinical union and the time to return to sports when Jones fractures were randomized to 8 weeks of non–weight-bearing cast or early intramedullary screw fixation. However, discussion continues regarding treatments for athletes versus nonathletes. Konkel and colleagues
recommend nonoperative treatment of fifth metatarsal fracture for patients in whom the time to return to full activities is not critical. As a result, a more aggressive approach of intramedullary fixation has evolved for the athletic population to avoid prolonged healing.
Presently, bone stimulation can be used as an adjunct primary therapy to accelerate fracture healing. Various bone stimulators are available that work by electromagnetic fields, high-frequency low-magnitude mechanical stimuli, or ultrasound.
In Jones fracture, because of the nature of the injury and the documented prolonged time it takes to union, bone stimulators can be readily used. Bone stimulators are painless, can be placed outside the cast, and can be applied on a daily basis in the patient’s home. With this treatment, if union occurs, there can be an earlier return to play and avoidance of surgery without the risks of developing postoperative complications.
Surgical treatment
The goal of the operative treatment is to minimize the risk of delayed union, nonunion, and refracture. Most importantly, the goal is to decrease the time to return to athletic activity and allow athletes or even recreational athletes to return to their sports activities more quickly.
The indication for operative treatment includes acute displaced fractures, Torg type II and III diaphyseal stress fractures, and failed nonoperative management.
There are several surgical treatment options available: a percutaneous approach with intramedullary screw, intercalated corticocancellous bone graft, ORIF with minifragment plate and screws, tension band construct, or closed reduction, and Kirschner wire fixation.
Especially, in treating nonunions, bone grafts can be added for biologic supplementation.
With reports of increased union rates and rapid recovery, intramedullary screw fixation of the proximal fifth metatarsal has become first-line treatment option in acute fractures. The intramedullary screws provide compression across the fracture, and the technique allows the placement of the screw in a percutaneous fashion without having to open the fracture site or strip the periosteum, which increases the rate of healing. There are numerous articles reporting increased union rates with using the intramedullary screw approach in athletes. DeLee and colleagues
Fifth metatarsal Jones fracture fixation with a 4.5-mm annulated stainless steel screw in the competitive and recreational athlete. A clinical and radiographic evaluation.
reported a 100% union rate with high satisfaction rates with 2 refractures by using a cannulated 4.5-mm stainless steel screw. Kavanaugh and colleagues
reported on 13 proximal fifth metatarsal fractures treated with a 4.5-mm malleolar screw and demonstrated a 100% union rate with no refractures. Even though all 3 studies have small study groups, average mean time for healing clinically and radiographically was 6.2 weeks and 7.4 weeks, respectively.
The most common complication reported in intramedullary fixation is the recurrence of Jones fracture with screw failure. In this case, the screw size ranges from 4.0 to 5.0 mm after 2.5 to 4.5 months of return to sports activity (Fig. 6).
also reported a case of 4 refractures and 2 symptomatic nonunions, using 4.0- to 6.5-mm screws. It was recommended that athletes returning to full activity before complete radiographic union was predictive of failure. To counter the higher amount of torsional stress placed on the fracture site, Wright and colleagues
recommended using a larger solid screw in competitive athletes (Fig. 7). During surgery, it has been recommended that the dissection to the fifth metatarsal tuberosity be achieved via blunt dissection to minimize damage to the sural nerve. It is also recommended to always use a fluoroscope when placing the guide wires and screw and to use the largest possible screw to maximize pullout strength.
Fifth metatarsal Jones fracture fixation with a 4.5-mm annulated stainless steel screw in the competitive and recreational athlete. A clinical and radiographic evaluation.
Fig. 6(A) A division I basketball player who underwent intermedullary screw fixation for acute Jones fracture using a 4.0 mm cannulated screw. Patient developed nonunion 8 months after returning to his sport. (B, C) With the development of nonunion, oblique and lateral views showed bent intermedullary screw.
Fig. 7(A) Post-operative radiograph demonstrating revision surgery to the nonunion site with 6.5 mm solid screw with bone graft. (B) Post-operative lateral radiograph showing good alignment of the screw.
The lag screw length is important to consider; the intramedullary screw should be inserted perpendicular to the fracture. Normally, a screw diameter of less than 4 mm is not recommended except in certain instances. Athletes with large body mass require a larger screw (5.5 or 6.5 mm) and a protected early return to activity. These screws, when inserted properly within the medullary canal, provide for bending and tension stability. Studies reveal these screws to be less resistant to torsional stress. In case of comminution, small plates can be used, but the plates can destroy extraosseous blood supply. This consequence is important because the injury damages the intraosseous blood supply.
Postoperative care includes placement of the foot in a cast or a boot, and weight bearing should not occur (at the earliest) until 3 weeks after injury. Even then, there must be partial weight bearing if full weight bearing is painful. Patients should be allowed to return to their respective sports when there is no tenderness with imaging evidence of complete union. If plain radiographs are difficult to interpret for complete radiographic union, CT scan of the foot can be used to assess the level of bony healing (Fig. 8).
Fig. 8(A) Prior to allowing the athlete to return to playing basketball, CT scan was ordered. CT scan confirmed complete fusion at the nonunion site. (B) Sagittal view of CT scan demonstrating complete union.
Once union is observed, physical therapy is essential for a proper course of rehabilitation, involving regaining of strength through eccentric and concentric open chain exercises or muscle-specific work.
Closed chain nonimpact activities such as cycling, working out in an elliptical trainer or similar equipments, or deep-water running can be helpful. A graduated return to impact loading and sport-specific agility work is required. The reported pain level from the patient should dictate the activity level and progression during rehabilitation. Especially, in patients with varus of the hindfoot, custom orthotics with significant arch support and the lateral hindfoot wedge extending to the lateral forefoot may decrease the incidence of refractures. Raikin and colleagues
reported 20 patients with 0% refracture rate when the hindfoot varus was corrected with an orthotic.
Summary
Numerous treatment options have been reported for the fifth metatarsal base fractures. For the general population, use of a short leg cast with immobilization seems to be a viable and accepted option; however, for the active population, particularly in competitive athletes who require a faster return to play, surgical treatment is recommended. Owing to numerous reports of early healing and return to play, the treatment options for Jones fracture has changed from nonoperative approach to a more aggressive and operative framework in athletes. Surgically, intramedullary screw fixation has been the technique of choice. Intramedullary fixation is a relatively straightforward procedure that offers a predictable union rate and a minimal period of immobilization, with return to weight bearing in 3 weeks. Immediate intramedullary fixation for Jones fracture is recommended for acute Jones fracture or Torg types II and III fractures. If surgery is chosen, careful dissection with the use of a fluoroscope is must and a cannulated screw with the largest diameter should be used, which increases pull out strength to prevent recurrence or screw failure. Most importantly, complete union should be observed using radiographs or CT scans, before releasing the patient to physical activity.
Treatment of primarily ligamentous Lisfranc joint injuries: primary arthrodesis compared with open reduction and internal fixation. A prospective, randomized study.
Fifth metatarsal Jones fracture fixation with a 4.5-mm annulated stainless steel screw in the competitive and recreational athlete. A clinical and radiographic evaluation.
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