Early Postoperative Refracture of the Fifth Metatarsal (Jones Fracture)
Abstract & Commentary
Synopsis: The fifth metatarsal is at risk for delayed union and stress fractures. Wright and colleagues note a risk of refracture despite operative intervention.
Source: Wright RW, et al. Refracture of proximal fifth metatarsal (Jones) fracture after intramedullary screw fixation in athletes. Am J Sports Med 2000;28(5):732-736.
Wright and colleagues from several medical centers describe their experience with a serious postoperative complication of intramedullary fixation of the Jones fracture of the proximal fifth metatarsal. Wright et al report refracture in six athletes who were initially diagnosed with an acute fracture of the proximal fifth metatarsal without evidence of prodromal symptoms, medullary canal sclerosis, or cortical thickening (as would be seen with a stress fracture commonly seen in this anatomic site). In three of the patients released to activities at seven, eight, and 11 weeks postoperatively, an acute refracture occurred the day after release! Four of the six patents with a refracture had fixation with a cannulated screw that was 4.5 mm or smaller. Interestingly, no fracture of the internal fixation occurred.
Wright et al noted clinical and radiographic healing prior to release to activities, and the return to functional activity was relatively rapid with light jogging by four weeks postop; two weeks after that, full running was allowed. Several recommendations were made concerning this injury: 1) use a larger screw, depending upon the size of the medullary canal; 2) functional bracing in the immediate season after fixation; 3) question standard assessment of healing, and consider CT, MR, or sonography to fully evaluate fracture healing.
Comment By Robert C. Schenck, Jr., MD
The treatment of the proximal fifth metatarsal fracture is not without controversy. Certainly, the philosophy of management of the acute fracture (no prodromal symptoms, no evidence of sclerosis on plain radiographs) has changed from a nonweightbearing, nonoperative approach, to an operative approach with intramedullary fixation due to the increased demands placed on the athlete to return to competition. Nonetheless, this report of acute refracture after operative treatment is concerning and makes the orthopaedic surgeon reassess the choice of internal fixation, assessment of healing, and timing of return to sport.
Wright et al have critically assessed the failure mechanisms involved in the six patients and suggested the use of an orthotic to provide support for early return to sport. I believe two additional factors need to be considered: 1) fracture personality; and 2) fracture healing. The personality of the Jones fracture is different from most acute fractures. The Jones fracture is slow to heal based on its limited vascularity and continued stresses once healed. Clearly, the healing time for this fracture is different, and time lines based on other fractures won’t translate to this injury pattern. The return to sport is best determined by presence of healing clinically (physical and plain radiographic examination) in conjunction with time. Other imaging modalities may be of use in evaluating healing, but the presence of an implant will make use of CT or MRI difficult. The use of a larger intramedullary fixation device will provide a stronger internal splint with additional support during the slow healing period and return to activities. Although more difficult to place, I prefer a noncannulated, 6.5 mm AO screw. Careful intraoperative imaging is critical with any intramedullary device to ensure proper placement. Although not reported in this series of six patients, smaller cannulated screws have been associated with breakage. The larger cannulated screws are routinely 7.0 or 7.3 mm in diameter and can be too large for the canal.
The management of Jones fractures requires a different approach, and the exact time to return to sport and clinical healing is still being determined. Rapid return to sport in all likelihood requires larger internal fixation devices.
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content