The surgical treatment of symptomatic nonunions of the proximal (metaphyseal) fifth metatarsal in athletes ARTHUR C. RETTIG,* MD, K. DONALD SHELBOURNE, MD, AND JOHN WILCKENS, MD From the Methodist Sports Medicine Center,
Indianapolis,
Indiana
histories and outline our surgical management of these symptomatic nonunions in athletes. Type I fractures (acute fractures at the metaphyseal diaphyseal junction) and type II fractures (fractures at the metaphyseal-diaphyseal junction, with evidence of previous injury) represent significantly different injuries and are not included in s-8
ABSTRACT
case
Eight athletes developed symptomatic nonunions of the base of the proximal fifth metatarsal in the metaphyseal region. All of the athletes were initially treated conservatively without success. We reviewed their case histories and outlined a simple, effective, low morbidity surgical management of these lesions. Two nonunions successfully healed with internal fixation with an intramedullary compression screw. Five additional nonunions were shelled out through a lateral incision of the peroneus brevis without disturbing its insertion. An eighth nonunion fragment was large and articulated the cuboid; it was fixed successfully with an intramedullary compression screw to preserve lateral foot mechanics. There were no complications. All patients returned to full activities 2 to 4 months after surgery.
this review. 2, 3,
CASE REPORTS Case 1 A 25-year-old female athletic trainer sustained an acute inversion injury to her right foot and ankle on July 23, 1988. Radiographs taken at that time revealed an acute fracture of the proximal fifth metatarsal metaphysis. She denied complaints previous to this injury. She was initially treated with a hinged ankle brace. She began running in September 1988, and ran for 4 weeks without pain. She reinjured her ankle on October 11, 1988, and repeat radiographs revealed a refracture. Although she was subsequently immobilized for 4 weeks, she remained symptomatic. Tomograms on November 28, 1988, revealed sclerosis at the fracture margins, suggesting a subacute or slowly healing fracture. She was immobilized for an additional 6 weeks. However, her symptoms persisted and repeat tomograms showed no healing. She then underwent percutaneous 35 mm, 4.0 mm cancellous screw fixation without complication and was placed in a hinged ankle brace, nonweightbearing as tolerated, for 5 weeks. She began running at 4 months with minimal complaints. At 7 months, radiographs revealed a solid union of the fracture. The patient admitted to mild ankle pain when
Proximal fifth metatarsal fractures are relatively common athletic injuries. Mann3 has provided a clear prognostic classification of these fractures. Type III fractures (fractures of the styloid process, metaphyseal fractures, and avulsion fractures) are effectively managed with simple nonoperative treatment, with a predictable quick return to full activity. Athletes with type III fractures can be treated with a cast, wooden shoe, or functional brace and crutches (partial to full weightbearing). Four to six weeks after injury, these patients are typically asymptomatic and return to full activity after successful completion of a functional progression. However, in the last 5 years, we have accumulated a small series of patients who have developed symptomatic nonunions of the proximal fifth metatarsal. We present eight
running on uneven ground. Case 2
*
Address correspondence and reprint requests to: Arthur C. Rettig, MD, Associate Director, Methodist Sports Medicine Center, 1815 N. Capitol Avenue, Indianapolis, IN 46202.
34-year-old male baseball coach presented September 5, 1989, complaining of intermittent right foot pain. He did
A 50
51
previous specific injury, but had been diagfracture nonunion of the base of his right fifth metatarsal. He complained that the area around the fracture would &dquo;flare&dquo; on occasion. Examination revealed erythema, warmth, and swelling over the proximal fifth metatarsal. Radiographs showed an established nonunion of the proximal fifth metatarsal metaphysis. Osteomyelitis was considered, but the patient’s CBC and ESR were within normal limits and a gallium scan revealed low grade uptake that was more consistent with ongoing healing. The patient remained active, and his shoes were fitted with a metatarsal bar that provided some temporary relief. However, his symptoms gradually increased. The large fragment articulated with the cuboid and fourth metatarsal. On October 13, 1989, the patient underwent open reduction and internal fixation with a 55 mm malleolar screw. The nonunion was additionally bone grafted. Cultures from surgery revealed no growth postoperatively. The patient was placed in a below knee cast, nonweightbearing for 4 weeks. With an insert deleveloped at the University of California-Berkeley, the patient began a progressive weightbearing program out of his cast. Radiographs at 8 weeks revealed progressive healing. His conservative treatment continued and he returned to jogging 1 month later. not recall any
nosed with
a
Case 3 A 16-year-old male football player complained of pain in his left foot while sprinting on the track team in May 1988. He admitted to previous injury and pain over his proximal fifth metatarsal, but had completed the prior football, basketball, and half of the track season with minimal symptoms. He denied a specific reinjury. Radiographs taken on May 10, 1988, revealed a nonunion of the base of the fifth metatarsal (Fig. 1). After discussing treatment options, the patient elected to have the nonunion excised so he could return to football that summer. At the time of surgery, June 5, 1988, no motion could be demonstrated at the nonunion site even with the image intensifier. Instead of excision, a 24 mm, 4.0 cancellous screw was placed across the nonunion with compression. The patient was placed in a hinged walking boot, weightbearing as tolerated for 3 weeks. At 3 weeks, he began a program of conservative treatment, which he successfully completed without pain, to return to football in August 1988. Radiographs revealed complete healing at that time (Fig. 2).
Case 4 A
19-year-old male Division I baseball pitcher presented September 14, 1989 complaining of a painful left foot. He recalled no specific injury, but did recall that his foot began hurting while he was playing baseball in August 1989. The patient had been told at that time that he had an avulsion fracture at the base of the fifth metatarsal. Although surgery was recommended, the patient returned to baseball and noted continued pain. Radiographs revealed an old rounded ossicle at the base of the fifth metatarsal. The patient
1. The symptomatic nonunion of the proximal fifth metatarsal (Case 3). A, preoperative AP and oblique view. B, preoperative lateral view.
Figure
surgery after a brief period of modified conservative treatment. On October 13, 1989, the symptomatic lesion was excised through a longitudinal incision in the peroneus brevis. It could be completely shelled out without disturbing the more distal insertion of the peroneus brevis on the proximal fifth metatarsal. Postoperatively, the patient was placed in hinged ankle brace for 3 weeks. At 3 weeks, the patient began a program of conservative treatment without wearing his brace. He returned to baseball noting only incisional tenderness.
ultimately elected
Case 5 A 17-year-old Division I male cross-country runner was evaluated October 23, 1986, after injuring his right foot and
52
to athletics without symptoms. Several weeks prior to the most recent injury, the patient bumped her left foot and noted some mild pain. Radiographs at that time revealed an
established nonunion of the base of the fifth metatarsal. At on December 3, 1987, the patient had tenderness localized to the proximal fifth metatarsal and a radiograph revealed increased separation of the previously described nonunion. The small sclerotic proximal fragment was excised on December 21,1987. For 3 weeks after surgery, she was allowed protected weightbearing in a cast boot. At 3 weeks postoperatively, the patient was weaned from the cast boot and began a functional progression. The patient returned to basketball and unrestricted activities by March
presentation
17, 1988. Case 7 A
21-year-old Division I male college football player presented on September 29, 1988, with a 3-week history of right lateral foot pain, without specific injury. He denied any remote injury. Radiographs revealed evidence of an old avulsion fracture of the base of the right fifth metatarsal. (Fig. 3) Conservative treatment was initially elected. His
Figure healed
2. Postoperative oblique and AP views reveal the proximal fifth metatarsal (Case 3).
ankle. Radiographs taken at that time revealed an old avulsion fracture at the base of the fifth metatarsal. He did not recall a previous injury. He was placed in a below-knee walking cast for 3 weeks. Follow-up radiographs revealed no evidence of healing, although he did not complain of tenderness. He was placed in a hinged cast for an additional 21/2 weeks. After physical therapy and conservative treatment, the patient returned to running. He had no symptoms until September 1989, when he felt a snap in his right foot while running. He was placed in a hinged ankle boot for 3 weeks, but continued to feel tender at the base of the fifth metatarsal. Because of the upcoming track season and his continued pain, the patient elected to have the nonunion excised. The symptomatic proximal fifth metatarsal fragment was excised on October 13, 1989, in a fashion identical to the patient in Case 4. Postoperatively, the patient was placed in a hinged ankle boot for 3 weeks. At 3 weeks he was nontender and began a conservative treatment program. He progressed slowly without complaints. At last followup on January 11, 1990, the patient was running 30 miles a week and playing basketball without symptoms.
Case 6
18-year-old Division I female college basketball player presented on December 3, 1987, with a history of hearing a pop with a sudden onset of pain over the lateral aspect of her left foot while playing basketball. She had previously injured this foot in the eighth grade, and was treated with a period of protective weightbearing. The patient had returned An
right foot remained symptomatic. On November 4, 1988, the patient underwent excision of the symptomatic proximal ununited fragment without complications. At 1 week, the patient was so minimally tender that he was allowed to wear a regular shoe, which he did without complaints. Four weeks after surgery the patient noted no tenderness with activities of daily living and began a
conservative treatment program. Two months postoperato full activity without com-
tively, the patient returned plaints (Fig. 4). Case 8
A 16-year-old male high school track runner noted a pop and sudden onset of pain in his left foot while running the 200-meter dash on May 3, 1989. While he recalled observing a bump on the outside of his foot for sometime previous to this event, he denied any prior injury or symptoms. Examination revealed localized tenderness to the base of the fifth metatarsal. Radiographs revealed an old avulsion fracture of the base of the fifth metatarsal. The patient noted continued pain despite 4 weeks of conservative treatment. On June 9, 1989, the patient underwent excision of the proximal ununited fragment without complication. He was placed in a cast boot with partial-to-full weightbearing as tolerated. Two weeks postoperatively, the patient had no incisional tenderness, and was able to wear normal shoes. Over the next 3 weeks, the patient successfully completed a functional progression and was able to participate in full activities, without restriction, at the start of the football season in August 1989.
DISCUSSION A
symptomatic nonunion of the proximal fifth metatarsal metaphysis is relatively rare. In instances where no
in the
53
Figure excised
4.
Postoperative oblique and AP views reveal the symptomatic fragment (Case 7).
agement. The results of prolonged conservative treatment are
Figure 3. The symptomatic nonunion of the proximal fifth metatarsal (Case 7). A, preoperative AP and oblique views. B, preoperative lateral view. previous history of injury is recalled, these symptomatic lesions may represent an unfused apophysis or symptomatic ossicle (os versalium or os peroneum). Dameron’ has well described these lesions, in addition to the variable anatomy of proximal fifth metatarsal. If, after a brief period of conservative treatment, an unfused apophysis or ossicle continues to be symptomatic, surgical excision is a simple, low morbidity, effective treatment option. Where history of previous injury can be illicited or the radiographs reveal a typical transverse lesion with rounded, sclerotic edges, the symptomatic lesion probably is a nonunion of a fibrous union. On the initial development of symptoms or reinjury, these lesions do not have the same excellent prognosis as the acute fractures. Many of our patients continued to be symptomatic with increased physical activity after a reasonable attempt at conservative man-
unpredictable.
We have identified an effective surgical management protocol for these relatively rare injuries. Symptomatic nonunions can be easily shelled out through a small lateral incision of the peroneus brevis. The attachment of the peroneus brevis is minimally disturbed. We have not needed to reinforce the peroneus brevis attachment to the remaining proximal fifth metatarsal. If at the time of surgery the symptomatic fragment is not movable and cannot be precisely identified to be excised, it can simply be fixed with an intramedullary compression screw with no additional dissection. We have had excellent results with both surgical techniques with no complications. If the proximal fragment is large and involves a significant amount of the articulation with the cuboid (greater than 30%), we feel it is important to restore the anatomy to 3 preserve proper foot mechanics as described by Mann,3 Dameron,l and Pritsch.4 Through the similar previously described surgical approach, these lesions can be easily reduced and fixed with an intramedullary compression screw. Our single representative case healed without complication and returned to full activity without symptoms.
CONCLUSIONS
Symptomatic nonunions of type III fractures of the proximal fifth metatarsal are relatively rare. While treatment of the
54
lesions should be
individualized, in this group of athletes surgical management represented a safe, quick, effective, and predictable treatment option. We recommend surgery in such cases where conservative treatment fails to give satisfactory results.
2.
Kavanaugh JH, Brower TD, Mann RV: The Jones fracture revisited. J Bone Joint Surg 60A: 776-782, 1978 3. Mann RA: Surgery of the foot, in Fractures and Dislocations of the Foot, pp 737-746 4. Pritsch M, Heim M, et al: An unusual fracture of the base of the fifth metatarsal bone. J Trauma 20: 530-531, 1980 5. Richli WR, Rosenthal DI: Avulsion fracture of the fifth metatarsal. AJR 143: 889-891,1984 6. 7.
REFERENCES 1. Dameron TB: Fractures and anatomical variations of the proximal of the fifth metatarsal. J Bone Joint Surg 57A: 788-792, 1975
portion
8.
Torg JS: Fractures of the base of the fifth metatarsal distal to the tuberosity: A review. Contemp Orthop 17: 497-505, 1989 Zelko RR, Torg JS, Rachuw A: Proximal diaphyseal fractures of the fifth metatarsal-treatment of the fractures and their complications in athletes. Am J Sports Med 7: 95-101, 1979 Zogby RG, Baker BE: A review of nonoperative treatment of Jones’ fracture. Am J Sports Med 15: 304-307, 1987
Indianapolis,
Indiana
histories and outline our surgical management of these symptomatic nonunions in athletes. Type I fractures (acute fractures at the metaphyseal diaphyseal junction) and type II fractures (fractures at the metaphyseal-diaphyseal junction, with evidence of previous injury) represent significantly different injuries and are not included in s-8
ABSTRACT
case
Eight athletes developed symptomatic nonunions of the base of the proximal fifth metatarsal in the metaphyseal region. All of the athletes were initially treated conservatively without success. We reviewed their case histories and outlined a simple, effective, low morbidity surgical management of these lesions. Two nonunions successfully healed with internal fixation with an intramedullary compression screw. Five additional nonunions were shelled out through a lateral incision of the peroneus brevis without disturbing its insertion. An eighth nonunion fragment was large and articulated the cuboid; it was fixed successfully with an intramedullary compression screw to preserve lateral foot mechanics. There were no complications. All patients returned to full activities 2 to 4 months after surgery.
this review. 2, 3,
CASE REPORTS Case 1 A 25-year-old female athletic trainer sustained an acute inversion injury to her right foot and ankle on July 23, 1988. Radiographs taken at that time revealed an acute fracture of the proximal fifth metatarsal metaphysis. She denied complaints previous to this injury. She was initially treated with a hinged ankle brace. She began running in September 1988, and ran for 4 weeks without pain. She reinjured her ankle on October 11, 1988, and repeat radiographs revealed a refracture. Although she was subsequently immobilized for 4 weeks, she remained symptomatic. Tomograms on November 28, 1988, revealed sclerosis at the fracture margins, suggesting a subacute or slowly healing fracture. She was immobilized for an additional 6 weeks. However, her symptoms persisted and repeat tomograms showed no healing. She then underwent percutaneous 35 mm, 4.0 mm cancellous screw fixation without complication and was placed in a hinged ankle brace, nonweightbearing as tolerated, for 5 weeks. She began running at 4 months with minimal complaints. At 7 months, radiographs revealed a solid union of the fracture. The patient admitted to mild ankle pain when
Proximal fifth metatarsal fractures are relatively common athletic injuries. Mann3 has provided a clear prognostic classification of these fractures. Type III fractures (fractures of the styloid process, metaphyseal fractures, and avulsion fractures) are effectively managed with simple nonoperative treatment, with a predictable quick return to full activity. Athletes with type III fractures can be treated with a cast, wooden shoe, or functional brace and crutches (partial to full weightbearing). Four to six weeks after injury, these patients are typically asymptomatic and return to full activity after successful completion of a functional progression. However, in the last 5 years, we have accumulated a small series of patients who have developed symptomatic nonunions of the proximal fifth metatarsal. We present eight
running on uneven ground. Case 2
*
Address correspondence and reprint requests to: Arthur C. Rettig, MD, Associate Director, Methodist Sports Medicine Center, 1815 N. Capitol Avenue, Indianapolis, IN 46202.
34-year-old male baseball coach presented September 5, 1989, complaining of intermittent right foot pain. He did
A 50
51
previous specific injury, but had been diagfracture nonunion of the base of his right fifth metatarsal. He complained that the area around the fracture would &dquo;flare&dquo; on occasion. Examination revealed erythema, warmth, and swelling over the proximal fifth metatarsal. Radiographs showed an established nonunion of the proximal fifth metatarsal metaphysis. Osteomyelitis was considered, but the patient’s CBC and ESR were within normal limits and a gallium scan revealed low grade uptake that was more consistent with ongoing healing. The patient remained active, and his shoes were fitted with a metatarsal bar that provided some temporary relief. However, his symptoms gradually increased. The large fragment articulated with the cuboid and fourth metatarsal. On October 13, 1989, the patient underwent open reduction and internal fixation with a 55 mm malleolar screw. The nonunion was additionally bone grafted. Cultures from surgery revealed no growth postoperatively. The patient was placed in a below knee cast, nonweightbearing for 4 weeks. With an insert deleveloped at the University of California-Berkeley, the patient began a progressive weightbearing program out of his cast. Radiographs at 8 weeks revealed progressive healing. His conservative treatment continued and he returned to jogging 1 month later. not recall any
nosed with
a
Case 3 A 16-year-old male football player complained of pain in his left foot while sprinting on the track team in May 1988. He admitted to previous injury and pain over his proximal fifth metatarsal, but had completed the prior football, basketball, and half of the track season with minimal symptoms. He denied a specific reinjury. Radiographs taken on May 10, 1988, revealed a nonunion of the base of the fifth metatarsal (Fig. 1). After discussing treatment options, the patient elected to have the nonunion excised so he could return to football that summer. At the time of surgery, June 5, 1988, no motion could be demonstrated at the nonunion site even with the image intensifier. Instead of excision, a 24 mm, 4.0 cancellous screw was placed across the nonunion with compression. The patient was placed in a hinged walking boot, weightbearing as tolerated for 3 weeks. At 3 weeks, he began a program of conservative treatment, which he successfully completed without pain, to return to football in August 1988. Radiographs revealed complete healing at that time (Fig. 2).
Case 4 A
19-year-old male Division I baseball pitcher presented September 14, 1989 complaining of a painful left foot. He recalled no specific injury, but did recall that his foot began hurting while he was playing baseball in August 1989. The patient had been told at that time that he had an avulsion fracture at the base of the fifth metatarsal. Although surgery was recommended, the patient returned to baseball and noted continued pain. Radiographs revealed an old rounded ossicle at the base of the fifth metatarsal. The patient
1. The symptomatic nonunion of the proximal fifth metatarsal (Case 3). A, preoperative AP and oblique view. B, preoperative lateral view.
Figure
surgery after a brief period of modified conservative treatment. On October 13, 1989, the symptomatic lesion was excised through a longitudinal incision in the peroneus brevis. It could be completely shelled out without disturbing the more distal insertion of the peroneus brevis on the proximal fifth metatarsal. Postoperatively, the patient was placed in hinged ankle brace for 3 weeks. At 3 weeks, the patient began a program of conservative treatment without wearing his brace. He returned to baseball noting only incisional tenderness.
ultimately elected
Case 5 A 17-year-old Division I male cross-country runner was evaluated October 23, 1986, after injuring his right foot and
52
to athletics without symptoms. Several weeks prior to the most recent injury, the patient bumped her left foot and noted some mild pain. Radiographs at that time revealed an
established nonunion of the base of the fifth metatarsal. At on December 3, 1987, the patient had tenderness localized to the proximal fifth metatarsal and a radiograph revealed increased separation of the previously described nonunion. The small sclerotic proximal fragment was excised on December 21,1987. For 3 weeks after surgery, she was allowed protected weightbearing in a cast boot. At 3 weeks postoperatively, the patient was weaned from the cast boot and began a functional progression. The patient returned to basketball and unrestricted activities by March
presentation
17, 1988. Case 7 A
21-year-old Division I male college football player presented on September 29, 1988, with a 3-week history of right lateral foot pain, without specific injury. He denied any remote injury. Radiographs revealed evidence of an old avulsion fracture of the base of the right fifth metatarsal. (Fig. 3) Conservative treatment was initially elected. His
Figure healed
2. Postoperative oblique and AP views reveal the proximal fifth metatarsal (Case 3).
ankle. Radiographs taken at that time revealed an old avulsion fracture at the base of the fifth metatarsal. He did not recall a previous injury. He was placed in a below-knee walking cast for 3 weeks. Follow-up radiographs revealed no evidence of healing, although he did not complain of tenderness. He was placed in a hinged cast for an additional 21/2 weeks. After physical therapy and conservative treatment, the patient returned to running. He had no symptoms until September 1989, when he felt a snap in his right foot while running. He was placed in a hinged ankle boot for 3 weeks, but continued to feel tender at the base of the fifth metatarsal. Because of the upcoming track season and his continued pain, the patient elected to have the nonunion excised. The symptomatic proximal fifth metatarsal fragment was excised on October 13, 1989, in a fashion identical to the patient in Case 4. Postoperatively, the patient was placed in a hinged ankle boot for 3 weeks. At 3 weeks he was nontender and began a conservative treatment program. He progressed slowly without complaints. At last followup on January 11, 1990, the patient was running 30 miles a week and playing basketball without symptoms.
Case 6
18-year-old Division I female college basketball player presented on December 3, 1987, with a history of hearing a pop with a sudden onset of pain over the lateral aspect of her left foot while playing basketball. She had previously injured this foot in the eighth grade, and was treated with a period of protective weightbearing. The patient had returned An
right foot remained symptomatic. On November 4, 1988, the patient underwent excision of the symptomatic proximal ununited fragment without complications. At 1 week, the patient was so minimally tender that he was allowed to wear a regular shoe, which he did without complaints. Four weeks after surgery the patient noted no tenderness with activities of daily living and began a
conservative treatment program. Two months postoperato full activity without com-
tively, the patient returned plaints (Fig. 4). Case 8
A 16-year-old male high school track runner noted a pop and sudden onset of pain in his left foot while running the 200-meter dash on May 3, 1989. While he recalled observing a bump on the outside of his foot for sometime previous to this event, he denied any prior injury or symptoms. Examination revealed localized tenderness to the base of the fifth metatarsal. Radiographs revealed an old avulsion fracture of the base of the fifth metatarsal. The patient noted continued pain despite 4 weeks of conservative treatment. On June 9, 1989, the patient underwent excision of the proximal ununited fragment without complication. He was placed in a cast boot with partial-to-full weightbearing as tolerated. Two weeks postoperatively, the patient had no incisional tenderness, and was able to wear normal shoes. Over the next 3 weeks, the patient successfully completed a functional progression and was able to participate in full activities, without restriction, at the start of the football season in August 1989.
DISCUSSION A
symptomatic nonunion of the proximal fifth metatarsal metaphysis is relatively rare. In instances where no
in the
53
Figure excised
4.
Postoperative oblique and AP views reveal the symptomatic fragment (Case 7).
agement. The results of prolonged conservative treatment are
Figure 3. The symptomatic nonunion of the proximal fifth metatarsal (Case 7). A, preoperative AP and oblique views. B, preoperative lateral view. previous history of injury is recalled, these symptomatic lesions may represent an unfused apophysis or symptomatic ossicle (os versalium or os peroneum). Dameron’ has well described these lesions, in addition to the variable anatomy of proximal fifth metatarsal. If, after a brief period of conservative treatment, an unfused apophysis or ossicle continues to be symptomatic, surgical excision is a simple, low morbidity, effective treatment option. Where history of previous injury can be illicited or the radiographs reveal a typical transverse lesion with rounded, sclerotic edges, the symptomatic lesion probably is a nonunion of a fibrous union. On the initial development of symptoms or reinjury, these lesions do not have the same excellent prognosis as the acute fractures. Many of our patients continued to be symptomatic with increased physical activity after a reasonable attempt at conservative man-
unpredictable.
We have identified an effective surgical management protocol for these relatively rare injuries. Symptomatic nonunions can be easily shelled out through a small lateral incision of the peroneus brevis. The attachment of the peroneus brevis is minimally disturbed. We have not needed to reinforce the peroneus brevis attachment to the remaining proximal fifth metatarsal. If at the time of surgery the symptomatic fragment is not movable and cannot be precisely identified to be excised, it can simply be fixed with an intramedullary compression screw with no additional dissection. We have had excellent results with both surgical techniques with no complications. If the proximal fragment is large and involves a significant amount of the articulation with the cuboid (greater than 30%), we feel it is important to restore the anatomy to 3 preserve proper foot mechanics as described by Mann,3 Dameron,l and Pritsch.4 Through the similar previously described surgical approach, these lesions can be easily reduced and fixed with an intramedullary compression screw. Our single representative case healed without complication and returned to full activity without symptoms.
CONCLUSIONS
Symptomatic nonunions of type III fractures of the proximal fifth metatarsal are relatively rare. While treatment of the
54
lesions should be
individualized, in this group of athletes surgical management represented a safe, quick, effective, and predictable treatment option. We recommend surgery in such cases where conservative treatment fails to give satisfactory results.
2.
Kavanaugh JH, Brower TD, Mann RV: The Jones fracture revisited. J Bone Joint Surg 60A: 776-782, 1978 3. Mann RA: Surgery of the foot, in Fractures and Dislocations of the Foot, pp 737-746 4. Pritsch M, Heim M, et al: An unusual fracture of the base of the fifth metatarsal bone. J Trauma 20: 530-531, 1980 5. Richli WR, Rosenthal DI: Avulsion fracture of the fifth metatarsal. AJR 143: 889-891,1984 6. 7.
REFERENCES 1. Dameron TB: Fractures and anatomical variations of the proximal of the fifth metatarsal. J Bone Joint Surg 57A: 788-792, 1975
portion
8.
Torg JS: Fractures of the base of the fifth metatarsal distal to the tuberosity: A review. Contemp Orthop 17: 497-505, 1989 Zelko RR, Torg JS, Rachuw A: Proximal diaphyseal fractures of the fifth metatarsal-treatment of the fractures and their complications in athletes. Am J Sports Med 7: 95-101, 1979 Zogby RG, Baker BE: A review of nonoperative treatment of Jones’ fracture. Am J Sports Med 15: 304-307, 1987
