Show Notes

Episode Produced by Audrey Bree Tse, MD

Background:

Why do we care about Jones fractures?
- Propensity for poor healing due to watershed area of blood supply
Fifth metatarsal fractures account for 68% of metatarsal fractures in adults
Proximal 5th metatarsal fractures are divided into 3 zones (93% zone 1, 4% zone 2, 3% zone 3)
Zone 1 (pseudo-Jones):
- Tuberosity avulsion fracture
- Typically avulsion type injuries due to acute episode of forefoot supination with plantar flexion
- Typical fracture pattern is transverse to slightly oblique
Zone 2 (Jones fracture):
- Fracture at the metaphyseal-diaphyseal junction of the fifth metatarsal
- Typically acute episode of large adduction force applied to forefoot with the ankle plantar flexed
Zone 3:
- Proximal diaphyseal stress fracture
- Typically results from a fatigue or stress mechanism

Clinical Presentation:

History of acute or repetitive trauma to forefoot
Fracture type / pattern closely related to injury location
Foot often swollen, ecchymotic, very tender to fifth metatarsal +/- crepitus, inability to hear weight

Diagnosis:

Clinical exam:
- Evaluate skin integrity
- Check neurovascular status
- Evaluate toes/ feet/ ankles/ tib fib/ knees/ hips, involved tendon function, associated adjacent structures (Achilles, ankle ROM/ function, etc)
3 XR views: lateral, anteroposterior, 45* oblique
Acute stress fractures are typically not detected on the standard 3 views; therefore, repeat XRs 10-14d after onset of sx (may see radiolucent reabsorption gap around fracture)
For more complex mid foot trauma, consider CT to r/o Lisfranc

Treatment:

Consider classification of fracture, patient demographics & activity level when deciding on treatment
Tertiary care centers that have access to Orthopedics/Podiatry services
- Consider consultation for “true” Jones fractures, as some cases may be operatively managed acutely and/or for expedited follow-up to be arranged
If working in community/rural locations: other than patients that present with “open” injuries, concerns for compartment syndrome (almost never), and “high-end”/professional athletes, there are generally no other circumstances that would require expedited transfer to a tertiary care center for immediate further evaluation.
Less favorable outcomes associated with certain patient factors: female gender, DM, obesity

Surgical:

Different modalities of surgery:
- Intramedullary screw
- Bone graft
- Closed reduction and fixation with K-wire
- ORIF (all +/- need for bone graft)
Surgery likely recommended for displacement >10 degrees of plantar angulation or 3-4 mm of translation in any plane
Indications for OR:
- Neck and shaft fractures with >10 degrees plantar angulation or 3mm of displacement in any plane with insufficient closed reduction
- Avulsion fractures (zone one) with >3 mm of displacement or comminuted
- Zone two fractures: displaced zone two fractures require operative management. For acute non displaced Jones fractures, consider early intramedullary screw fixation in athletes (studies have shown return to sport ~ 8 weeks, weight bearing within 1-2 weeks)
- Zone three fractures (diaphyseal stress fractures) in athletes

Nonoperative:

All non displaced fifth metatarsal fractures can be treated non operatively
Non displaced zone 1 fractures: protected weight bearing/ symptomatic care in short leg walking cast, air-boot, posterior splint, or compression wrap/ rigid shoe until discomfort subsides
Zone 2 and 3 fractures are more complex because they often result in prolonged healing time and potential for delayed/ nonunion
Acute zone 2 fractures: nonweightbearing in short leg cast for 6-8 weeks
Acute zone 3 fractures: nonweightbearing in short leg cast for up to 20 weeks
With respect to athletes: repeat fracture after surgical treatment of Jones fracture can occur after healing and screw removal; thus it is recommended that the screw be left in until the end of the athlete’s career

References:

Bowes J, Buckley R. Fifth metatarsal fractures and current treatment. World J Orthop. 2016;7(12):793–800. Published 2016 Dec 18. doi:10.5312/wjo.v7.i12.793

Petrisor BA, Ekrol I, Court-Brown C. The epidemiology of metatarsal fractures. Foot Ankle Int. 2006 Mar; 27(3): 172-4.

Rammelt S, Heineck J, Zwipp H. Metatarsal fractures. Injury. 2004;35 Suppl 2:SB77–SB86.

Tham W, Sng S, Lum YM, Chee YH. A Look Back in Time: Sir Robert Jones, ‘Father of Modern Orthopaedics’. Malays Orthop J. 2014;8(3):37–41. doi:10.5704/MOJ.1411.009

Thomas JL, Davis BC. Three-wire fixation technique for displaced fifth metatarsal base fractures. J Foot Ankle Surg. 2011;50:776–779.

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LISFRANC SHOW NOTES:

Intro:

Can’t miss diagnoses: needs stat ortho
20% miss rate
Can be dislocation, fracture, fracture dislocation, or ligamentous injury
Jacques Lisfranc in Napoleonic Wars: performed transmetatarsal amputation for midfoot gangrene

Anatomy:

Lisfranc ligament: 3 ligaments that run from the base of the second metatarsal to the medial cuneiform bone. Helps attach the forefoot to the midfoot bones
If ligament complex gets disrupted, can end up with chronic deformity and disability

Injury definitions:

Dislocation: widening between base of 1st and 2nd metatarsal, or between cuneiforms
Fracture dislocation: associated fracture, most commonly at the base of the proximal second metatarsal

Physical Exam:

Pain and swelling in midfoot
Pain elicited with passive abduction and pronation of the midfoot while holding heel steady
Plantar ecchymosis
r/o compartment syndrome
Feel for DP pulse!

Diagnosis:

XRs: AP, lateral, oblique, stress views with weight bearing
Watch out for “fleck sign”
Consider CT if pt cannot bear weight, or even if XR negative and high suspicion

Treatment:

Ortho consult!

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THANKS TO DANNY PURCELL, MD and MAY LI, MD

Episode 165.0 – Foot Fractures

Core EM - Emergency Medicine Podcast

Episode 165.0 – Foot Fractures