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As the name suggests this is a fracture at the base of the 5th metatarsal. Fractures at the base of the 5th metatarsal are quite a common injury.
A “Fracture”, “break”, and “crack” are often used to describe an injury to a bone. Contrary to what most people think, they all mean the same thing. A fracture is a complete or incomplete break in a bone resulting from the application of excessive force.
Displaced avulsion fracture at the base of the 5th metatarsal
There are 3 types of 5th metatarsal base fracture depending on the Zone of injury:
X-ray demonstrating the areas of injury from 5th metatarsal foot fractures
The mechanism of injury differs according to which zone the fracture has occurred in:
Foot x-ray demonstrating the zones of injury from 5th metatarsal fractures
These injuries are also known as a Dancer’s fracture. A twisting injury to the foot and ankle literally pulls (avulsion) of a small piece of bone at the base of the 5th metatarsal. While as the name suggests it occurs in dancers, anyone can get this fracture, from a trivial injury such as stepping off a kerb.
A muscle in the leg called peroneus brevis attaches via its tendon to the base of the 5th metatarsal. When the ankle is forced inwards, the pull on the muscle and its tendon is strong enough to pull a bit of bone off.
This is an acute injury. The mechanism of injury is similar to an avulsion injury. It occurs at the junction of the metaphysis and diaphysis of the metatarsal bone (where the widened part of the bone at its end begins to thin out as it becomes the shaft of the bone). This injury is associated with sports such as football and rugby.
X-ray of the foot demonstrating a Jones fracture
This can be thought of as a chronic Jones fracture. The history is typically of pain for several weeks or months. This is a stress fracture of the 5th metatarsal. It typically occurs in athletes and is often a sports injury. This part of the metatarsal has a poorer blood supply than the bone more proximal and distal to it. It is called a “vascular watershed” zone. For that reason healing occurs slower. Repetitive strain and injury from playing sports for example can weaken the bone and result in a stress fracture. A stress fracture occurs when the rate of injury is greater than the bodies rate of healing.
This fracture can also occur in people who have very high arched feet (pes cavus). People with this foot shape tend to walk on the outer aspect of their foot. This can cause lateral foot overload, resulting in a stress fracture of the 5th metatarsal.
Symptoms vary depending on the site of the fracture.
X-ray of the foot demonstrating the zones of injury in base of 5th metatarsal fractures
Radiographs (x-rays) of the foot help identify the fracture and importantly the zone of injury. This helps distinguish whether it is an avulsion (Zone 1) from a Jones fracture (Zone 2) for example. Radiographs also provide information regarding the fracture:
CT and MRI are not usually required to make the diagnosis in acute setting. They may be considered in the setting of delayed healing or non-union.
CT scan of the 5th metatarsal showing partial union (healing) of the 5th metatarsal bone (white circle)
The prognosis depends on individual patient factors and characteristics of the fracture itself.
The majority of these injuries heal with conservative management without complication. There is a small risk of non union particularly if there is significant displacement.
As with most fractures a Jones fracture will usually heal if the foot it protected from weight bearing for a long enough period of time. Approximately 66-75% of these fractures will heal with conservative management.
However, as discussed earlier the area of the bone that is fractured has a relatively poor blood supply. This means that it may take longer for the bone to heal (delayed union), or that the bone may not heal at all (non union). Due to the high risk of non union many patients decide to have surgical fixation.
The same can be said for these fractures. In addition as these fractures are related to repetitive stress at the level of the fracture site, there is always a concern that the fracture may recur. In patients with a foot and lower limb that lends itself towards lateral overload (High arched feet – Pes cavus for example) there may be a higher risk of developing non-union and repeat fractures.
General risk factors for delayed healing, or non union of fractures include:
CT of the foot demonstrating non union of a 5th metatarsal bone fracture
X-ray of a minor undisplaced 5th metatarsal fracture that can be treated without undergoing an operation
Surgical management is reserved for patients who have failed to respond to non operative treatment or when a decision has been made to pursue surgery due to the high complication rate associated with non operative management, for example non union. There is an argument that operative treatment can also enhance recovery and healing times which may be important for example in patients who wish to return to sports sooner.
Patients should understand that the decision to undergo surgery should not be taken lightly.
A variety of surgical options exist which need to be tailored to the individual and the stage of the disease.
Very rarely is it necessary to operate on these fractures acutely. When there is significant displacement a patient may choose to undergo surgical fixation of the fracture.
In patients managed non-operatively, if recovery has been complicated by painful non union particularly in the presence of significant displacement surgery is indicated.
A – Displaced non union 5th metatarsal fracture B – a 5th metatarsal fracture successfully fixed with plate and screws
Before and after radiographs of a non-union avulsion base of 5th metatarsal fracture fixed with bone graft and screw
Undisplaced and simple 2 part fractures, that are acute, can be treated using an intramedullary screw. This is often performed using an MIS technique.
An illustration of an Arthex 5th metatarsal solid screw
For patients with a comminuted (multi fragmentary), delayed presentation, established non union or displacement of the fracture, a mini open technique will be employed. This is to allow freshening up of the fracture site, insertion of bone graft (often obtained from the calcaneum), and anatomical fixation. A small anatomical plate is often used in such cases. This allows for rigid fixation and early mobilisation.
An illustration of a Arthex 5th metatarsal anatomical plate
An x-ray showing a plate fixation for a 5th metatarsal fracture
Operative management is as for Zone 2: Jones fracture. For recurrent fractures or non healing fractures in patients who have very high arched feet (pes cavus). It may be necessary to alter the biomechanics of the foot. People with this foot shape tend to walk on the outer aspect of their foot. This can cause lateral foot overload, resulting in a stress fracture and non healing of the 5th metatarsal.
In rare situations it may be necessary to undertake reconstructive surgery which would repair not only the fracture (often with bone grafting) but also changing the shape of the foot by cutting and repositioning one or more bones in the foot and/or lower leg. A common bone cutting procedure (osteotomy) would be a lateralising calcaneal osteotomy. This involves cutting the heel bone and shifting it more to the outside. This would stop the foot rolling on to the outside (lateral) border when weight bearing.
The aim of surgery is to alleviate pain and return a patient to full function.
It should be borne in mind that complications can result from a condition with or without surgery.
Potential complications of non operative treatment applicable include:
These non operative complications apply to all three types of fracture, Avulsion 5th metatarsal base fracture, Acute and Chronic Jones fracture.
Complications can occur as with any type of surgery. Please see Complications for more detailed explanation of post surgical complications.
Potential complications of operative treatment to all three types of base of 5th metatarsal fractures include:
Please read the information regarding what to expect post surgery on this website.
Remember that below is a guide to recovery and that everyone heals at different rates and some people do take longer. Use this information to help you understand your condition, possible treatment and recovery. The timeframes given below are a minimum, it is important that you appreciate this when considering surgery as your healing and recovery may take longer.
Please do not remove your bandages until you are seen by your surgeon Mr Malik at the two week post operative clinic appointment.
For 6 to 8 weeks you will non weight bearing using two crutches. The physiotherapist will guide you with this after your operation and before your discharge from hospital.
For the first two weeks following your surgery please keep your foot elevated to the level of your heart for 95% of the time. It is advisable during this period to remain at home.
High elevation of the foot and ankle following surgery
Naturally most people do not have a hospital bed at home. The same effect can be achieved by lying in a bed or lengthways on a sofa, with pillows behind your back and under your foot. You cannot have your leg elevated sitting in a chair. It is strongly advised that during the first two weeks you are house bound.
To minimise risk of infection keep the foot dry and cool. Avoid humid and hot environments. Keep the foot dry and when showering wear a Limbo bag.
To minimise the risk of blood clots please move your foot and ankle at regular intervals. Please ensure you are well hydrated. If you have a risk of blood clots please notify Mr Malik who may organise for you to have blood thinning injections as a precaution.
You will be reviewed at the clinic and your dressings removed. Your wound will be checked.
At this stage if the swelling has subsided sufficiently you will be advised to keep your foot in an elevated horizontal position (50-75% of the time). You will require to wear the special post operative shoe for another 4 weeks. Although this does not mean you can walk on the operated foot. The shoe is only there to protect your foot incase you stumble. Short trips can be made outside, within limits of pain and swelling.
Driving will be permitted for short trips if the left foot has been operated on and you drive an automatic. If the right foot has been operated on it will be at least 8 to 10 weeks before any driving is advisable.
Scar desensitisation should start as soon as the wound has completely healed. You can do this by massaging cream (E45 for example) into the scar and around the wound area.
You will have radiographs taken just before you are seen in clinic. You will go over these with Mr Malik and compare the before and after images. If you have had a bony procedure, it will take a minimum of 6 to 8 weeks to heal.
At this stage if your healing is progressing satisfactorily swelling and bruising should have subsided considerably, although expect some degree of swelling for at least 3 to 4 months.
If there are signs of radiological healing at this appointment, you will be able to start weight bearing gradually in a special walker boot as comfort allows. During the 6 to 8 weeks of immobilisation your foot & ankle will get stiff and your calf and thigh muscles will waste. Hydrotherapy (exercises in the swimming pool) will help to restore ankle range of motion and general fitness. Pool running using a bouyancy belt is an excellent non impact form of exercise and will help regain muscle and bone strength.
Once you have been given permission to put partial weight through the injured foot then an exercise bike can also be used for fitness work. At this stage a referral to a physiotherapist will be made who will guide you through your rehabilitation.
Final clinical examination. Discharge if satisfactory.
Please see guidance above and information here. Ultimately it is the responsibility of the patient to decide if they are safe to drive. A good way of knowing is if you can stamp your right foot heavily on the ground to mimic an emergency brake. If you have any hesitation or pain then it should suggest you are not safe to drive. Remember prolonged driving involves keeping your feet in a dependant position. This will worsen the post operative swelling.
This really depends on you and your job. If you have a job that involves a lot of standing, walking and is manual it may be 12 weeks at the earliest. If you have a sedentary job, for example in an office and you have a reasonable commute you may be able to go back to work at 2 weeks, although this would be exceptional and not the norm.
This really depends on how long it takes the fracture to heal. It will then be important to exercise and regain your fitness. Returning to activity too early, before the bone has fully healed runs the risk of re-injury or development of a new injury.
Excellent pain relief and return to full function. Ability to participate in sports by 6 months. Sometimes up to a year before the foot feels “normal” and fully healed.
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