What is 5th Metatarsal Fracture?

Fractures of the fifth metatarsal, a bone in the foot, are common injuries that need to be identified and treated correctly to avoid adverse effects on the patient’s health. The upper part of this bone is known to not heal well, which is why it has received a lot of attention since these fractures were first described by Sir Robert Jones, an orthopedic surgeon, in 1902. However, it’s important for health professionals to recognize all types of injuries to the fifth metatarsal. By doing this, they can start the right treatment or refer the patient to a specialist to prevent any complications.

The base of the fifth metatarsal, as classified by Lawrence and Bottle, consists of three areas: zone 1 (the tuberosity), zone 2 (the area where the metaphysis and diaphysis connect), and zone 3 (the diaphyseal area within 1.5 cm of the tuberosity). If the fracture is in zone 1, it’s known as a ‘pseudo-Jones fracture’. If it’s in zone 2, it’s called a ‘Jones fracture’. The patient can also sustain a fracture along the shaft of the bone more than 1.5 cm away from the tuberosity. This could be a long, winding fracture spreading towards the lower metaphysis (referred to as a ‘dancer’s fracture’), or a stress fracture of the metatarsal.

Classifying these fractures is key to deciding on the best course of action. The blood supply to the base of the fifth metatarsal comes from the metaphyseal arteries and diaphyseal nutrient arteries. Zone 2 houses a ‘vascular watershed area’, creating a higher chance of these fractures not mending properly.

What Causes 5th Metatarsal Fracture?

Zone 1 fractures are a type of fracture known as pseud-Jones fractures. These happen when the back of the foot is suddenly twisted while the foot is pointed downwards. This can occur, for example, when an athlete lands awkwardly after a jump. These fractures usually do not affect the joint between the foot and toe – specifically, the joint that connects the fifth bone of the mid-foot and the bones of the toes. These fractures are closer to the connecting points between the fourth and fifth bones of the mid-foot.

Zone 2 fractures are called Jones fractures. They can occur when a strong force pushes the foot inward while the heel is lifted. This kind of injury can happen if an athlete quickly changes direction. These fractures generally affect the joint or connecting points of the fourth and/or fifth bones in the mid-foot and can sometimes fail to heal properly, with rates ranging from 15 to 30%.

Zone 3 fractures are due to repeated minor injuries over time, causing increasing pain during activities over several months. These fractures have a higher risk of not healing properly. A specific example is the dancer’s fracture. This is a long, spiraled fracture of the end part of the foot’s mid-bone. It’s usually caused when a dancer rolls over their foot while in a half-pointe position or while landing a jump.

Risk Factors and Frequency for 5th Metatarsal Fracture

Fractures of the fifth metatarsal, a bone in the foot, are the most common type of metatarsal fractures. They most commonly occur in men in their 30s and women in their 70s. Women are more likely to experience specific types of fractures known as “zone 1 fractures” and “dancer’s fractures”. A zone 1 fracture typically occurs from a twisting injury and is the most common fracture found at the base of the fifth metatarsal.

Signs and Symptoms of 5th Metatarsal Fracture

People who have stress fractures often feel pain on the outside of the front part of their foot. This pain usually gets worse with activities that involve putting weight on the foot. Such foot pain can be a result of an immediate injury or from repeated small injuries happening over a long period of time – weeks to months. When there’s ongoing pain, or the pain gets worse or lasts longer than expected, it’s advisable to check for stress fractures. To decide on the most suitable treatment, it’s essential to get detailed information about a person’s past health issues and their lifestyle habits.

It’s important to check the skin for open wounds, as these might need urgent cleaning to prevent infections. When examined, there may be tenderness, swelling, and bruising at the injury site. Usually, patients will also feel pain when trying to turn their foot outward against resistance. It’s important to assess for any other injuries, such as to the ligaments on the outer side of the ankle or a Lisfranc injury – a type of foot injury that involves the bones and/or ligaments within the midfoot region.

Testing for 5th Metatarsal Fracture

X-rays are often the first step in checking for foot injuries. It’s important to get several different views (front-on, side, and an angle) of the foot to give doctors a clear picture of what’s going on. When speaking about injuries, doctors refer to them as zone 1, 2, or 3. Zone 1 injuries have a break line closer to your ankle than your toes. In Zone 2 injuries, the break line reaches or goes into the space between your fourth and fifth toes. Zone 3 injuries have a break line closer to your toes but, they can sometimes be closer to the ankle as well. Dancer’s fractures, as their name implies, commonly occur in dancers, are twisted and typically start at the bottom and outer edge of the foot, then go upwards and towards the inner side.

In the case of fifth metatarsal base stress fractures (fractures in the upper part of the small toe), they have three types of appearances on x-rays. The Torg Classification System classifies these as Type I, II, or III. Type I is the earliest form of fracture with no dense or hardening of the bone. The fracture lines are sharp with no increase in width and little bone thickening or response from the covering layer of the bone. Type II fractures show signs of the fracture healing with thickening of the bone bone, wider fracture lines and reactions from the covering layer of the bone. Type III fractures represent a non-healing fracture with the bone’s hollow interior completely replaced by hard bone. These show wide fracture lines and new bone growth from the covering layer of the bone.

Additional scans like CT scans and MRIs may be needed if the bone isn’t healing as expected, isn’t joining back together, or if there’s a high chance of a stress fracture that hasn’t shown up on x-ray. These are not routinely done but can provide valuable information when needed.

Treatment Options for 5th Metatarsal Fracture

Treatment choices are based on where the injury occurs, the patient’s personal and medical history, and signs of healing seen in X-rays.

Non-shifted injuries in zone 1 can usually be treated without surgery. Putting weight on your feet is allowed as long as they’re protected in a hard-wearing shoe, a walking boot or a cast. You can start putting more weight on your feet as the pain decreases, usually between 3 to 6 weeks. However, if the fracture involves more than 30% of the joint surface or is offset by more than 2mm, treatment might involve surgery to reposition the fracture and keep it in place with screws, pins, or by removing the fragment.

Zone 2 injuries, also called Jones fractures, which haven’t shifted, may also be treated without surgery by using a non-weight bearing half leg cast for 6-8 weeks. Weight-bearing can increase depending on if the bone is healing as seen on X-rays. Surgery might be needed for athletes, patients who choose surgery, or if the break has shifted. The surgical options include using screws to fix the break, constructing a band to hold the tension, or using low-profile plates and screws. For athletes, surgery might reduce the risk of the break not healing and decrease the time they’re not allowed to participate in physical activities.

Injuries in zone 3 like stress fractures are a bit more complex. Treatment might start off with using a half leg cast without putting any weight. Sometimes, it might take up to 20 weeks for the fracture to heal. Even then, there’s a chance the fracture might not heal. Athletes, or those with Torg Type II or III fractures, might opt for surgery. Options include fixing with screws, grafting devices, or a combination. One type of graft involves removing a section of bone at the fracture area and replacing it with a bone graft. This needs to be done after completely removing the dense bone in the marrow cavity.

Non-shifted fractures in the shaft and neck of the fifth metatarsal, also referred to as dancer’s fractures, are treated similarly to non-shifted injuries in zone 1. As much weight as can be tolerated by pain can be put on the foot. If there is delay in healing, surgery might be needed. If the fracture is displaced by more than 3mm or angulated beyond 10 degrees, it needs to be repositioned and splinted. If the fracture is not properly positioned or shifts again, surgical options with pins, or plate and screws should be considered.

Patients treated with screw fixation or bone graft should avoid putting weight on it and should use plaster splints or a half leg cast for six weeks before slowly returning to their activities.

If you’re experiencing pain in a specific area, it could be due to a variety of reasons. Here are some possible causes:

Bone tumor: an abnormal mass or growth of cells in a bone
Bursitis: inflammation of the small fluid-filled pads that act as cushions at the joints
Calluses: thickened and hardened parts of the skin or soft tissue
Foreign body granuloma: inflammation caused by a foreign object
Ganglia: small sacs (or cysts) filled with fluid that often appear on the joints and tendons
Gout: a type of arthritis that causes painful inflammation in one or more joints
Hemangioma: a noncancerous growth made up of blood vessels
Metatarsalgia: pain and inflammation in the ball of the foot
Morton neuroma: a painful condition that affects the ball of the foot, usually the area between the third and fourth toes
Neuropathic osteoarthropathy: a joint disease that often occurs in people with nerve damage
Osteoarthritis: the most common form of arthritis, affecting millions of people worldwide
Osteomyelitis: an infection in a bone
Plantar fibromatosis: a benign tissue growth on the bottom of the foot
Plantar plate disruption: an injury to the thick supporting ligament on the ball of the foot
Rheumatoid arthritis: a long-term autoimmune disorder causing pain, swelling, and stiffness at the joints
Sesamoiditis: inflammation or fracture of the sesamoid bones, which are embedded inside tendons in your foot
Septic arthritis: inflammation of a joint caused by a bacterial or fungal infection
Stress fracture: a tiny crack in a bone caused by overuse or repetitive activity
Subchondral insufficiency fracture: a type of stress fracture that happens beneath the cartilage of a joint
Tendinosis: a chronic condition involving degeneration of a tendon’s collagen from overuse
Tenosynovitis: inflammation and swelling of the tendon sheath, often in the hand or wrist
Tendon rupture: a tear or break in the tissue that connects muscle to bone
Tenosynovial giant cell tumor: a rare, benign (noncancerous) tumor that develops in the joint
Turf toe: an injury to the base of the big toe

Remember, only a doctor can accurately diagnose your condition. So, if you’re having persistent discomfort, make sure to see a medical professional.

Surgical Treatment of 5th Metatarsal Fracture

Original:

The occurrence rate of appendiceal neoplasms in the United States is 1.2 cases per 100,000; nearly 30% of these patients present with acute abdominal pain. The most common appendiceal malignancies are gastroenteropancreatic neuroendocrine or carcinoid tumors (GEP-NETs), goblet cell carcinoma (GCC), colonic-type adenocarcinoma, and mucinous neoplasm.

Rewritten:

In every 100,000 people in the United States, 1.2 of them are diagnosed with appendiceal neoplasms, a type of tumor in the appendix. About 30% of these people first feel severe belly pain. There are mainly four types of this disease: gastroenteropancreatic neuroendocrine or carcinoid tumors (tumors affecting cells that release hormones in response to signals from the nervous system), goblet cell carcinoma (a type of cancer in the cells that secrete mucus), colonic-type adenocarcinoma (cancer in the cells that line the colon), and mucinous neoplasm (tumors that produce a jelly-like substance).

Original:

Gastroenteropancreatic Neuroendocrine Tumors (GEP-NETs) are the most common histopathological subtype of appendiceal malignancies. They rarely metastasize; primary metastatic sites are the liver and lymph nodes.

Rewritten:

Out of the different types of tumors in the appendix, the gastroenteropancreatic neuroendocrine tumors (GEP-NETs) are the most common ones. Luckily, they rarely spread to other body parts. But when they do, the first places are the liver and lymph nodes.

Original:

Non-Hodgkin lymphoma, including Mucosa-Associated Lymphoid Tissue (MALT) lymphoma, may initially present as acute appendicitis.

Rewritten:

In some cases, a type of cancer known as Non-Hodgkin lymphoma, which includes a subtype called Mucosa-Associated Lymphoid Tissue (MALT) lymphoma, might first appear to be a severe appendicitis.

Original:

Appendiceal mucoceles can manifest with symptoms similar to acute appendicitis. Mucoceles can arise from various benign or malignant processes involving mucosal hyperplasia and intra-appendiceal cystic formations.

Rewritten:

There’s a condition known as appendiceal mucoceles, where the symptoms can feel quite similar to severe appendicitis. These mucoceles, which can be harmless or cancerous, develop due to an overgrowth of mucus-secreting cells and the formation of fluid-filled sacs inside the appendix.

What to expect with 5th Metatarsal Fracture

Most acute, simple fractures of the fifth metatarsal bone heal with normal care within 6 to 8 weeks. However, injuries to zones 2 and 3 of the bone have a higher chance of not healing because of poor blood supply in these areas. Specifically, zone 2 injuries could fail to heal in 15 to 30% of cases. Stress fractures in the shaft of this bone may take a longer time to heal, up to 20 weeks in some cases.

Possible Complications When Diagnosed with 5th Metatarsal Fracture

As previously mentioned, specific types of injuries, particularly those identified as zones 1 and 2, can increase the risk of a bone not healing, or nonunion. Utilizing an intramedullary screw that is less than 4.5 mm in diameter, or a screw that is overly long, may also contribute to this issue by causing the fracture to be distracted or reduced incorrectly.

Those who do not adhere to the advice of avoiding placing weight on the affected area, or those who return to physical activity or sports too soon without confirmed healing evidenced by radiographic imaging, are more likely to experience failure in the fixation and healing process.

Potential Risks:

Increased nonunion risk with zones 1 and 2 injuries
Nonunion risk associated with using undersized or oversized intramedullary screws
Higher fixation failure rates in individuals not abiding by non-weight bearing restrictions
Pre-emptive return to sport or activity before confirming the bone has healed

Recovery from 5th Metatarsal Fracture

High-performing athletes should be aware of the possibility that certain fractures may not fully heal. Doctors need to have a detailed conversation with these patients about both surgical and non-surgical treatment options.

Rehabilitation methods largely depend on the type and severity of the fracture, the selected treatment approach, and the specific guidelines set by the referring orthopedic expert. There isn’t a single rehabilitation plan that works for every type of foot bone (metatarsal) fracture, which makes collaboration with the referring orthopedic team essential to determine the best rehabilitation timeline and components. Moreover, the initial condition and personal goals of the patient also influence the rehabilitation process. For athletes, a more intense approach might be followed, like involving support devices and special treadmills designed to simulate weightlessness, to prevent long gaps in training.

Usually, the rehabilitation comprises three stages: The first stage focuses on improving movement (ambulation) and training with supportive devices, along with movement exercises and pain/swelling control. The second stage continues these exercises while introducing strength training, massage, scar treatment, continued gait training (learning to walk properly again), and workouts to maintain the strength of both lower and upper body. The final stage encompasses full movement of the joints affected, intensified strength training of both the joint and lower body, focus on normalizing walk pattern without support, introduction of stability and awareness exercises, and custom motions related to their respective sport (if the patient is an athlete).

Preventing 5th Metatarsal Fracture

Patients need to understand the necessary steps for recovery, which can vary depending on the type of injury. For instance, in some situations like stress or traumatic fractures of a metatarsal bone, rest may be all that’s needed for healing. It’s also important to stop any activities that could worsen the injury. In other instances, the use of a cast, immobilization, or a rigid shoe may be necessary.

Regardless of whether the treatment is surgical or non-surgical, physical therapy, exercises, and rehabilitation can be part of the recovery plan to help patients get back to their normal activities. It’s essential that patients follow through with the therapy, exercises, and use of any prescribed devices, as their commitment significantly contributes to the success of their recovery.