Proximal diaphyseal fractures of the fifth metatarsal —treatment of the fractures and their complications in athletes* RUSSELL R.
ZELKO,† M.D.,
JOSEPH S. TORG, M.D., AND ALEXIUS RACHUN, M.D., , New York and Philadelphia Ithaca , Pennsylvania
From the Section of Athletic
, Department of University Health Services Medicine , Cornell the New and of University , , Ithaca York , University Pennsylvania Sports Medicine , Center
, Pennsylvania Philadelphia
ABSTRACT
Twenty-one patients (age range, 15 to 26; 18 patients 15 to 20 years old) had proximal diaphyseal fractures of the fifth metatarsal. Clinical records and radiographs for all patients were available for review. Patient treatment had been individualized and included several methods, including rest, plaster immobilization, and bone grafting. Twenty of the 21 patients were boys or men participating in athletics. Nine of the 21 fractures and 8 of the reinjuries were sustained while playing basketball. Healing required a minimum of 3 months (with bone graft) and some fractures were not radiographically healed at 20 months, although the patients were clinically asymptomatic. The fracture of the proximal shaft of the fifth metatarsal, particularly the 1.5-cm segment distal to the tuberosity, is a troublesome injury in the active athlete. The clinical course does not appear to be influenced by the usual initial conservative treatment modalities, although many of these fractures will heal if the athlete is willing to restrict activities for a prolonged period of time. In this series, bone grafting with a tibial corticocancellous graft after thorough curettage of sclerotic bone obliterating the medullary canal was the most effective treatment modality for delayed union.
A fracture
involving the proximal shaft of the fifth metatarsal distal to the tuberosity (Fig. 1) is a troublesome injury in the athlete. It is different in its behavior from other metatarsal fractures: it is slow to heal, predisposed to reinjury, and often a cause of prolonged disability. It often requires bone grafting for symptomatic delayed or nonunion. Despite these uniquely *
Presented at the interim meeting of the American Orthopaedic for Sports Medicine, Dallas, Texas, February 22 and 23, 1978. t Address correspondence to: Gannett Medical Clinic, 10 Central Avenue, Cornell University, Ithaca, New York 14853.
Society
characteristic clinical features, this specific fracture is rarely mentioned in specialty texts on athletic injuries, fractures, or foot problems. In this paper, we present a series of 21 proximal diaphyseal fractures of the fifth metatarsal. We describe the clinical manifestations and recommend treatment guidelines for this fracture in the athlete. Morrison,l in 1937, stated &dquo;the most important injury is that to the fifth metatarsal near the proximal end.&dquo; He described the mechanism of injury as a sudden sharp inversion with the body being thrown suddenly on the outer side of the foot. The tendon attachments and body weight cause the fracture by cross leverage over the fulcrum of the firmly attached base. Hence, the break is constantly just in front of this base. He warned that sometimes these do not unite and are tender on walking, since they take a large share of the weightbearing on the outside of the foot. Dameron,~in 1975, differentiated between the two distinct clinical fracture entities involving the proximal portion of the fifth metatarsal: ( 1 ) a fracture involving the tuberosity (Fig. 1), and (2) a fracture of the proximal shaft within a distance of 1.5 cm distal to the tuberosity (Fig. 2). He emphasized the difference in behavior of the two types of fractures, noting the frequent complications of proximal shaft fractures in contrast to the lack of significant complications or disability associated with fractures through the tuberosity. Devas,’3 in his monograph on stress fractures, described stress fractures in this same area of the fifth metatarsal and indicated that their course may be prolonged and that they may require bone grafting for lack of union.
CLINICAL MATERIAL AND METHODS
Twenty-one metatarsal
cases
were
of proximal diaphyseal fracture of the fifth analyzed. These cases represented student 95
Fig.
1.
Roentgenogram, oblique view,
which demonstrates location
athletes seen at the Cornell University Health Services and by Dr. Joseph S. Torg of Philadelphia, Pennsylvania. One case was seen at Strong Memorial Hospital, University of Rochester. All except one of these patients were treated by one of the authors between the years 1969 and 1977. The study includes only patients whose clinical records and radiographs were available for review. Approximately 10 additional patients known to have this fracture were excluded from this study because of inadequate information. Ages ranged from 15 to 26 with 18 patients between 15and 20 years old. Twenty of the athletes were males and the one nonathlete was a female (Table 1). The right foot was involved in 11cases and the left foot in 10 cases. The mechanism of injury was described as an inversion twist by 10 patients, spontaneous pain on running associated with a snap (4 patients); an eversion external rotation injury (1 patient) ; and the mechanism was not remembered or not clearly described by 6 other patients. Several patients described experiencing pain at the fracture site for several weeks before any acute injury occurred. Initial radiographic findings included a lucent fracture line with periosteal elevation (14 patients). Eight of these patients also had intramedullary sclerotic margins on their initial films. In only 3 patients was there an acute fracture line without at least some chronic changes. Initial x-ray films were not available for four patients. Initial treatment included a short-leg walking cast in 15 patients for periods varying from 2 to 12 weeks (most of the patients were casted for 6 to 8 weeks). Two had strapping and specially molded orthoses and two patients had only rest from their activities. Two of the patients who presented initially with symptomatic delayed unions had bone grafts. Nonweight-bear96
ing
of fracture through the tuberosity of the fifth metatarsal. treatment was not
evaluated because of lack of
patient
acceptance. RESULTS The clinical course of the patients treated by each of these modalities is described in the following paragraphs. Of the 15 patients treated with walking casts, 2 healed completely-one patient at 7 months and the other at 20 months; 5 patients required bone grafts for symptomatic delayed unions; 7 patients are presently between 6 weeks and 211 months following fracture and are asymptomatic but radiographically not healed; and one patient was lost to follow-up after 8 weeks. Of the two patients who were treated by strapping and specially molded orthoses, one of them healed completely by 7 months and the other developed a symptomatic delayed union which required a bone graft. Of the two patients treated with rest alone, one of them sustained two reinjuries with symptomatic delayed union, which required a bone graft and the other (who was the nonathlete) became asymptomatic after 3 weeks but her fracture was not radiographically healed at 18 months. The two patients who had bone grafts initially because of symptomatic delayed unions had united fractures by 3 months following surgery and returned to their sports without further trouble. During the course of treatment, 10 of the 21 patients sustained reinjuries or refractures. These reinjuries occurred between 8 weeks and I year after the initial injury (Table 1). Six patients had one episode of reinjury and four patients, all basketball players, had two episodes of reinjury. Following an episode of reinjury, there was a recurrence of pain and tenderness at the fracture site and radiographic widening of the
TABLE I
Sport
&dquo;
in which
patient sustained injury and reinjury
Only girl, nonathlete, in series; the other patients were boys or men;
age range 15
to
26 with 18 between 15 and 20 years old. TABLE2
Clinical
course
(series
of 21
patients)
reinjuries before healing. being followed (6 weeks to 21 not healed radiographically).
Fig. 2. Roentgenograms of proximal diaphyseal fracture. A. The anteroposterior view demonstrates the location of the fracture in the fifth metatarsal. B. The oblique view demonstrates most clearly the location of the proximal diaphyseal fracture. C. A lateral view of the same fracture.
&dquo; Patient had
two
Patients
still
are
months after
injury;
fracture line either immediately or within the next several weeks. The clinical course and subsequent treatment of the patients in these two reinjury groups were as follows: of the patients with one reinjury, two had bone grafts (which united within 3 months) and resumed their sport without further trouble while four continued on conservative treatment (the fractures became asymptomatic but are not healed radiographically) ; of the patients with two reinjuries, three had bone grafts (and their fractures united 3 to 4 months following surgery) and one patient continued on conservative treatment (the fracture finally united 20 months after the original injury). A succinct summary of the clinical course of this series of 211 patients appears in Table 2. Eight of the 9 patients who had surgery united their fractures by 3 to 4 months following the graft. Seven returned to their chosen sporting activity without pain or disability. One patient dropped out of sports for personal reasons and I patient had a reinjury 7 months following bone grafting with recurrence of mild symptoms and a new lucent line on radiographs. The graft procedure in 7 patients (treated by J. S. T.) consisted of an autogenous tibial corticocancellous inlay graft from the region of the medial malleolus after thorough curettage and drilling of the sclerotic bone obliterating the intramedullary cavity. One patient had a sliding bone graft from the base of the fifth metatarsal and refractured the metatarsal 7 months following the graft procedure. One patient, treated elsewhere, had merely a curettage of the fracture site and was reported to have healed by 3 months following surgery. Of the patients who had surgery, the longest follow-up has been 4 years following bone graft. Five patients have been followed for 2 years after grafting and the remaining three patients between 4 and 21 months after surgery.
DISCUSSION This imal
study confirms the findings of Dameron~regarding proxdiaphyseal fractures of the fifth metatarsal and adds 211 97
z
additional cases to his report on 20 patients. It confirms his findings that these fractures are slow to heal, often disable athletes, and often require bone grafting. In addition, the spontaneous pain experienced by several of our patients before a distinct traumatic episode and the high incidence of periosteal reaction and other chronic changes on initial radiographs strongly suggest that many of these fractures may be stress fractures. The study further emphasizes the high incidence of reinjury in athletes during the healing period and the tendency of basketball players to sustain multiple reinjuries. it 1 In our patients, basketball players were most disabled by this fracture and were most successfully treated by early bone grafting. Other athletes in sports such as football, soccer, and wrestling are often able to participate with little or no disability while their fractures are healing. We agree with Dameron’ that treatment should be individualized according to the demands upon the patient. In our series (as in his), initial treatment did not appear to influence the result. Rather, in our patients, the type of sport and occurrence of reinjury appeared to be the most important factors in retarding healing and prolonging disability. To clarify our treatment recommendations we have divided our patients into four groups based on their clinical history and initial radiographic findings. Group 1 includes patients with an acute traumatic injury and no prior symptoms. X-ray films show an acute fracture line (Fig. 2) with no chronic changes. For this group we recommend plaster immobilization followed by protective strapping until clinically and radiographically united. Illustrative Case: A 19-year-old college football player twisted his foot while running over sandbags. He had immediate pain, swelling, and tenderness over the proximal right fifth metatarsal. He had no prior symptoms. His initial x-ray films revealed an acute fracture line. He was treated conservatively and his fracture united in 7 months.
right
2 includes patients who sustained an acute injury folmild symptoms. Radiographs show a lucent fracture line with some periosteal elevation (Fig. 3A). For patients in this group we likewise recommend initial conservative treatment with subsequent treatment individualized according to the demands of the patient. These fractures may have a prolonged healing course and require more aggressive treatment in basketball players.
Group lowing
Fig. 3. Roentgenograms of a patient in Group 2 (those patients who sustained an acute injury following mild symptoms). A. The initial x-rayfilm, oblique view, which revealed periosteal elevation adjacent to fracture line. B. Oblique view, following reinjury which occurred 6 months after initial injury; the fracture line has widened. C. Twenty months after original injury, the fracture appears completely healed in an anteroposterior view. 98
Illustrative Case: A 20-year-old basketball player sustained an inversion twisting injury to his right foot. He presented to Student Health Service with pain, mild swelling, and tenderness over the proximal portion of the right fifth metatarsal. His x-ray films showed a lucent fracture line through the lateral cortex with both periosteal and possibly some endosteal callus (Fig. 3A). He denied previous symptoms. He was treated in a short-leg walking cast for 8 weeks. X-ray films, upon removal of the cast, showed some evidence of early union. He was asymptomatic and gradually returned to full activities several weeks later. Six months after his initial injury he again inverted the foot while playing basketball. Radiographs taken I month after his injury revealed widening of the previous lucent fracture line (Fig. 3B). Two months after reinjury the films again showed uniting callus and some obliteration of the fracture line. One month later (9 months following his initial injury), he again twisted the foot. The x-ray films showed a distinct lucent fracture line through the lateral inferior cortex with sclerotic margins. Again he was treated with immobilization followed
Roentgenograms of fracture on fifth metatarsal in a college basketball player. A. Initial injury film. B. Followingfirst reinjury, after initial injury. C. Eight months after initial injury; two reinjuries; film taken just before bone grafting procedure. D. Union of fracture 4 months after bone grafting.
Fig. 4. 4 months
inactivity and he missed the remainder of the Finally, at 20 months after fracture, he was completely asymptomatic and demonstrated complete bony union both clinically and radiographically (Fig. 3C).
intramedullary canal. Radiographs 4 months postgrafting revealed a complete bony union (Fig. 4D), and he has continued his professional career without further difficulty.
3 includes patients who present with a traumatic reinafter one or more previous injuries. Radiographs show a jury lucent fracture line, periosteal reaction, and often intramedullary sclerosis. Treatment in this group should be individualized according to the demands of the patient. Further conservative treatment will probably be prolonged as in the previous patient and early bone grafting is recommended, especially in basketball players or professional athletes.
Group 4 includes patients who present with a history of chronic pain or multiple injury episodes. X-ray films show (Fig. 5A) a lucent fracture line with sclerotic margins, a large periosteal
by
a
period
basketball
of relative
season.
Group
Illustrative Case: A 22-year-old professional basketball player fractured the proximal shaft of his fifth metatarsal while playing college basketball on April 10, 1973 (Fig. 4A). He was treated by plaster immobilization followed by strapping. Mild discomfort persisted. On August 17, 1973, 4 months later, while playing professional basketball he sustained a reinjury (Fig. 4B). Again he was treated by plaster immobilization followed by protective strapping. He sustained a second reinjury on December 6, 1973 (Fig. 4C). On December 13, 1973, he underwent bone grafting with curettage and drilling of the sclerotic
and intramedullary sclerosis. In these patients we recommend early bone grafting as further conservative treatment is doomed to failure.
bulge
Illustrative Case: A 17-year-old football player presented on September 9, 1975, with a long history of pain and tenderness over the proximal left fifth metatarsal. He had not sought prior medical attention. Initial radiographs revealed a lucent line with dense sclerotic margins and periosteal bulge (Fig. 5A). He underwent bone grafting on September 10, 1975. He demonstrated clinical and radiographic union by 2 months after graft (Fig. 5B) and returned to football. Follow-up x-ray films at 28 months showed good bony remodeling (Fig. 5C) and the patient has remained asymptomatic. He sustained a similar fracture of the opposite foot (Fig. 5D) several months ago which is still under treatment. 99
Fig. 5. Roentgenograms of a patient in Group 4 (history of chronic pain or multiple injury episodes). A. Initial film reveals nonunion. B. Two months after bone graft. C. Twenty-eight months after bone graft. D. A similar fracture appeared in the opposite foot. TABLE 3
Summary
The treatment recommendations
are
of recommended treatment based
summarized in Table
3. Based on our experience with 21 patients, we recognize that fracture of the proximal shaft of the fifth metatarsal in the 1.5cm segment distal to the tuberosity is a troublesome injury in 100
on
initial
findings
the active athlete. The clinical course does not appear to be influenced by the usual initial conservative treatment modalities, although many of these fractures will heal if the athlete is willing to restrict activities for a prolonged period of time. Bone grafting with a tibial corticocancellous inlay graft after thor-
ough curettage of any dense sclerotic bone obliterating the medullary canal was the most effective treatment modality for delayed union in this series of patients. ACKNOWLEDGMENT Kenneth DeHaven, M.D., contributed the case of proximal diaphyseal fracture which was seen at Strong Memorial Hospital, University of Rochester, Rochester, New York.
REFERENCES 1. Morrison GM: Fractures of the bones of the feet. Am J
Surg
38:
721-726, 1937 2. Dameron Jr TB: Fractures and anatomical variations of the proximal portion of the fifth metatarsal. J Bone Joint Surg 57A: 788-
792, 1975 3. Devas M: Stress . Fractures London,
Churchill-Livingstone,
1975
101
ZELKO,† M.D.,
JOSEPH S. TORG, M.D., AND ALEXIUS RACHUN, M.D., , New York and Philadelphia Ithaca , Pennsylvania
From the Section of Athletic
, Department of University Health Services Medicine , Cornell the New and of University , , Ithaca York , University Pennsylvania Sports Medicine , Center
, Pennsylvania Philadelphia
ABSTRACT
Twenty-one patients (age range, 15 to 26; 18 patients 15 to 20 years old) had proximal diaphyseal fractures of the fifth metatarsal. Clinical records and radiographs for all patients were available for review. Patient treatment had been individualized and included several methods, including rest, plaster immobilization, and bone grafting. Twenty of the 21 patients were boys or men participating in athletics. Nine of the 21 fractures and 8 of the reinjuries were sustained while playing basketball. Healing required a minimum of 3 months (with bone graft) and some fractures were not radiographically healed at 20 months, although the patients were clinically asymptomatic. The fracture of the proximal shaft of the fifth metatarsal, particularly the 1.5-cm segment distal to the tuberosity, is a troublesome injury in the active athlete. The clinical course does not appear to be influenced by the usual initial conservative treatment modalities, although many of these fractures will heal if the athlete is willing to restrict activities for a prolonged period of time. In this series, bone grafting with a tibial corticocancellous graft after thorough curettage of sclerotic bone obliterating the medullary canal was the most effective treatment modality for delayed union.
A fracture
involving the proximal shaft of the fifth metatarsal distal to the tuberosity (Fig. 1) is a troublesome injury in the athlete. It is different in its behavior from other metatarsal fractures: it is slow to heal, predisposed to reinjury, and often a cause of prolonged disability. It often requires bone grafting for symptomatic delayed or nonunion. Despite these uniquely *
Presented at the interim meeting of the American Orthopaedic for Sports Medicine, Dallas, Texas, February 22 and 23, 1978. t Address correspondence to: Gannett Medical Clinic, 10 Central Avenue, Cornell University, Ithaca, New York 14853.
Society
characteristic clinical features, this specific fracture is rarely mentioned in specialty texts on athletic injuries, fractures, or foot problems. In this paper, we present a series of 21 proximal diaphyseal fractures of the fifth metatarsal. We describe the clinical manifestations and recommend treatment guidelines for this fracture in the athlete. Morrison,l in 1937, stated &dquo;the most important injury is that to the fifth metatarsal near the proximal end.&dquo; He described the mechanism of injury as a sudden sharp inversion with the body being thrown suddenly on the outer side of the foot. The tendon attachments and body weight cause the fracture by cross leverage over the fulcrum of the firmly attached base. Hence, the break is constantly just in front of this base. He warned that sometimes these do not unite and are tender on walking, since they take a large share of the weightbearing on the outside of the foot. Dameron,~in 1975, differentiated between the two distinct clinical fracture entities involving the proximal portion of the fifth metatarsal: ( 1 ) a fracture involving the tuberosity (Fig. 1), and (2) a fracture of the proximal shaft within a distance of 1.5 cm distal to the tuberosity (Fig. 2). He emphasized the difference in behavior of the two types of fractures, noting the frequent complications of proximal shaft fractures in contrast to the lack of significant complications or disability associated with fractures through the tuberosity. Devas,’3 in his monograph on stress fractures, described stress fractures in this same area of the fifth metatarsal and indicated that their course may be prolonged and that they may require bone grafting for lack of union.
CLINICAL MATERIAL AND METHODS
Twenty-one metatarsal
cases
were
of proximal diaphyseal fracture of the fifth analyzed. These cases represented student 95
Fig.
1.
Roentgenogram, oblique view,
which demonstrates location
athletes seen at the Cornell University Health Services and by Dr. Joseph S. Torg of Philadelphia, Pennsylvania. One case was seen at Strong Memorial Hospital, University of Rochester. All except one of these patients were treated by one of the authors between the years 1969 and 1977. The study includes only patients whose clinical records and radiographs were available for review. Approximately 10 additional patients known to have this fracture were excluded from this study because of inadequate information. Ages ranged from 15 to 26 with 18 patients between 15and 20 years old. Twenty of the athletes were males and the one nonathlete was a female (Table 1). The right foot was involved in 11cases and the left foot in 10 cases. The mechanism of injury was described as an inversion twist by 10 patients, spontaneous pain on running associated with a snap (4 patients); an eversion external rotation injury (1 patient) ; and the mechanism was not remembered or not clearly described by 6 other patients. Several patients described experiencing pain at the fracture site for several weeks before any acute injury occurred. Initial radiographic findings included a lucent fracture line with periosteal elevation (14 patients). Eight of these patients also had intramedullary sclerotic margins on their initial films. In only 3 patients was there an acute fracture line without at least some chronic changes. Initial x-ray films were not available for four patients. Initial treatment included a short-leg walking cast in 15 patients for periods varying from 2 to 12 weeks (most of the patients were casted for 6 to 8 weeks). Two had strapping and specially molded orthoses and two patients had only rest from their activities. Two of the patients who presented initially with symptomatic delayed unions had bone grafts. Nonweight-bear96
ing
of fracture through the tuberosity of the fifth metatarsal. treatment was not
evaluated because of lack of
patient
acceptance. RESULTS The clinical course of the patients treated by each of these modalities is described in the following paragraphs. Of the 15 patients treated with walking casts, 2 healed completely-one patient at 7 months and the other at 20 months; 5 patients required bone grafts for symptomatic delayed unions; 7 patients are presently between 6 weeks and 211 months following fracture and are asymptomatic but radiographically not healed; and one patient was lost to follow-up after 8 weeks. Of the two patients who were treated by strapping and specially molded orthoses, one of them healed completely by 7 months and the other developed a symptomatic delayed union which required a bone graft. Of the two patients treated with rest alone, one of them sustained two reinjuries with symptomatic delayed union, which required a bone graft and the other (who was the nonathlete) became asymptomatic after 3 weeks but her fracture was not radiographically healed at 18 months. The two patients who had bone grafts initially because of symptomatic delayed unions had united fractures by 3 months following surgery and returned to their sports without further trouble. During the course of treatment, 10 of the 21 patients sustained reinjuries or refractures. These reinjuries occurred between 8 weeks and I year after the initial injury (Table 1). Six patients had one episode of reinjury and four patients, all basketball players, had two episodes of reinjury. Following an episode of reinjury, there was a recurrence of pain and tenderness at the fracture site and radiographic widening of the
TABLE I
Sport
&dquo;
in which
patient sustained injury and reinjury
Only girl, nonathlete, in series; the other patients were boys or men;
age range 15
to
26 with 18 between 15 and 20 years old. TABLE2
Clinical
course
(series
of 21
patients)
reinjuries before healing. being followed (6 weeks to 21 not healed radiographically).
Fig. 2. Roentgenograms of proximal diaphyseal fracture. A. The anteroposterior view demonstrates the location of the fracture in the fifth metatarsal. B. The oblique view demonstrates most clearly the location of the proximal diaphyseal fracture. C. A lateral view of the same fracture.
&dquo; Patient had
two
Patients
still
are
months after
injury;
fracture line either immediately or within the next several weeks. The clinical course and subsequent treatment of the patients in these two reinjury groups were as follows: of the patients with one reinjury, two had bone grafts (which united within 3 months) and resumed their sport without further trouble while four continued on conservative treatment (the fractures became asymptomatic but are not healed radiographically) ; of the patients with two reinjuries, three had bone grafts (and their fractures united 3 to 4 months following surgery) and one patient continued on conservative treatment (the fracture finally united 20 months after the original injury). A succinct summary of the clinical course of this series of 211 patients appears in Table 2. Eight of the 9 patients who had surgery united their fractures by 3 to 4 months following the graft. Seven returned to their chosen sporting activity without pain or disability. One patient dropped out of sports for personal reasons and I patient had a reinjury 7 months following bone grafting with recurrence of mild symptoms and a new lucent line on radiographs. The graft procedure in 7 patients (treated by J. S. T.) consisted of an autogenous tibial corticocancellous inlay graft from the region of the medial malleolus after thorough curettage and drilling of the sclerotic bone obliterating the intramedullary cavity. One patient had a sliding bone graft from the base of the fifth metatarsal and refractured the metatarsal 7 months following the graft procedure. One patient, treated elsewhere, had merely a curettage of the fracture site and was reported to have healed by 3 months following surgery. Of the patients who had surgery, the longest follow-up has been 4 years following bone graft. Five patients have been followed for 2 years after grafting and the remaining three patients between 4 and 21 months after surgery.
DISCUSSION This imal
study confirms the findings of Dameron~regarding proxdiaphyseal fractures of the fifth metatarsal and adds 211 97
z
additional cases to his report on 20 patients. It confirms his findings that these fractures are slow to heal, often disable athletes, and often require bone grafting. In addition, the spontaneous pain experienced by several of our patients before a distinct traumatic episode and the high incidence of periosteal reaction and other chronic changes on initial radiographs strongly suggest that many of these fractures may be stress fractures. The study further emphasizes the high incidence of reinjury in athletes during the healing period and the tendency of basketball players to sustain multiple reinjuries. it 1 In our patients, basketball players were most disabled by this fracture and were most successfully treated by early bone grafting. Other athletes in sports such as football, soccer, and wrestling are often able to participate with little or no disability while their fractures are healing. We agree with Dameron’ that treatment should be individualized according to the demands upon the patient. In our series (as in his), initial treatment did not appear to influence the result. Rather, in our patients, the type of sport and occurrence of reinjury appeared to be the most important factors in retarding healing and prolonging disability. To clarify our treatment recommendations we have divided our patients into four groups based on their clinical history and initial radiographic findings. Group 1 includes patients with an acute traumatic injury and no prior symptoms. X-ray films show an acute fracture line (Fig. 2) with no chronic changes. For this group we recommend plaster immobilization followed by protective strapping until clinically and radiographically united. Illustrative Case: A 19-year-old college football player twisted his foot while running over sandbags. He had immediate pain, swelling, and tenderness over the proximal right fifth metatarsal. He had no prior symptoms. His initial x-ray films revealed an acute fracture line. He was treated conservatively and his fracture united in 7 months.
right
2 includes patients who sustained an acute injury folmild symptoms. Radiographs show a lucent fracture line with some periosteal elevation (Fig. 3A). For patients in this group we likewise recommend initial conservative treatment with subsequent treatment individualized according to the demands of the patient. These fractures may have a prolonged healing course and require more aggressive treatment in basketball players.
Group lowing
Fig. 3. Roentgenograms of a patient in Group 2 (those patients who sustained an acute injury following mild symptoms). A. The initial x-rayfilm, oblique view, which revealed periosteal elevation adjacent to fracture line. B. Oblique view, following reinjury which occurred 6 months after initial injury; the fracture line has widened. C. Twenty months after original injury, the fracture appears completely healed in an anteroposterior view. 98
Illustrative Case: A 20-year-old basketball player sustained an inversion twisting injury to his right foot. He presented to Student Health Service with pain, mild swelling, and tenderness over the proximal portion of the right fifth metatarsal. His x-ray films showed a lucent fracture line through the lateral cortex with both periosteal and possibly some endosteal callus (Fig. 3A). He denied previous symptoms. He was treated in a short-leg walking cast for 8 weeks. X-ray films, upon removal of the cast, showed some evidence of early union. He was asymptomatic and gradually returned to full activities several weeks later. Six months after his initial injury he again inverted the foot while playing basketball. Radiographs taken I month after his injury revealed widening of the previous lucent fracture line (Fig. 3B). Two months after reinjury the films again showed uniting callus and some obliteration of the fracture line. One month later (9 months following his initial injury), he again twisted the foot. The x-ray films showed a distinct lucent fracture line through the lateral inferior cortex with sclerotic margins. Again he was treated with immobilization followed
Roentgenograms of fracture on fifth metatarsal in a college basketball player. A. Initial injury film. B. Followingfirst reinjury, after initial injury. C. Eight months after initial injury; two reinjuries; film taken just before bone grafting procedure. D. Union of fracture 4 months after bone grafting.
Fig. 4. 4 months
inactivity and he missed the remainder of the Finally, at 20 months after fracture, he was completely asymptomatic and demonstrated complete bony union both clinically and radiographically (Fig. 3C).
intramedullary canal. Radiographs 4 months postgrafting revealed a complete bony union (Fig. 4D), and he has continued his professional career without further difficulty.
3 includes patients who present with a traumatic reinafter one or more previous injuries. Radiographs show a jury lucent fracture line, periosteal reaction, and often intramedullary sclerosis. Treatment in this group should be individualized according to the demands of the patient. Further conservative treatment will probably be prolonged as in the previous patient and early bone grafting is recommended, especially in basketball players or professional athletes.
Group 4 includes patients who present with a history of chronic pain or multiple injury episodes. X-ray films show (Fig. 5A) a lucent fracture line with sclerotic margins, a large periosteal
by
a
period
basketball
of relative
season.
Group
Illustrative Case: A 22-year-old professional basketball player fractured the proximal shaft of his fifth metatarsal while playing college basketball on April 10, 1973 (Fig. 4A). He was treated by plaster immobilization followed by strapping. Mild discomfort persisted. On August 17, 1973, 4 months later, while playing professional basketball he sustained a reinjury (Fig. 4B). Again he was treated by plaster immobilization followed by protective strapping. He sustained a second reinjury on December 6, 1973 (Fig. 4C). On December 13, 1973, he underwent bone grafting with curettage and drilling of the sclerotic
and intramedullary sclerosis. In these patients we recommend early bone grafting as further conservative treatment is doomed to failure.
bulge
Illustrative Case: A 17-year-old football player presented on September 9, 1975, with a long history of pain and tenderness over the proximal left fifth metatarsal. He had not sought prior medical attention. Initial radiographs revealed a lucent line with dense sclerotic margins and periosteal bulge (Fig. 5A). He underwent bone grafting on September 10, 1975. He demonstrated clinical and radiographic union by 2 months after graft (Fig. 5B) and returned to football. Follow-up x-ray films at 28 months showed good bony remodeling (Fig. 5C) and the patient has remained asymptomatic. He sustained a similar fracture of the opposite foot (Fig. 5D) several months ago which is still under treatment. 99
Fig. 5. Roentgenograms of a patient in Group 4 (history of chronic pain or multiple injury episodes). A. Initial film reveals nonunion. B. Two months after bone graft. C. Twenty-eight months after bone graft. D. A similar fracture appeared in the opposite foot. TABLE 3
Summary
The treatment recommendations
are
of recommended treatment based
summarized in Table
3. Based on our experience with 21 patients, we recognize that fracture of the proximal shaft of the fifth metatarsal in the 1.5cm segment distal to the tuberosity is a troublesome injury in 100
on
initial
findings
the active athlete. The clinical course does not appear to be influenced by the usual initial conservative treatment modalities, although many of these fractures will heal if the athlete is willing to restrict activities for a prolonged period of time. Bone grafting with a tibial corticocancellous inlay graft after thor-
ough curettage of any dense sclerotic bone obliterating the medullary canal was the most effective treatment modality for delayed union in this series of patients. ACKNOWLEDGMENT Kenneth DeHaven, M.D., contributed the case of proximal diaphyseal fracture which was seen at Strong Memorial Hospital, University of Rochester, Rochester, New York.
REFERENCES 1. Morrison GM: Fractures of the bones of the feet. Am J
Surg
38:
721-726, 1937 2. Dameron Jr TB: Fractures and anatomical variations of the proximal portion of the fifth metatarsal. J Bone Joint Surg 57A: 788-
792, 1975 3. Devas M: Stress . Fractures London,
Churchill-Livingstone,
1975
101
