The surgical treatment of symptomatic nonunions of the proximal (metaphyseal) fifth metatarsal in athletes. The intraosseous blood supply of the fifth metatarsal: implications for proximal facture healing.
Analysis of failed surgical management of fractures of the base of the fifth metatarsal distal to the tuberosity: the Jones fracture.
Tuberosity avulsion fractures cause pain and tenderness at the base of the fifth metatarsal and follow forced inversion during plantar flexion of the foot and ankle.
The tuberosity (styloid process) is a bony prominence that protrudes laterally and plantarward from the base of the fifth metatarsal.1 The distal metaphysis tapers to the tubular diaphysis (shaft) of the fifth metatarsal. If not displaced or comminuted, these fractures uniformly heal well with conservative treatment. Acute and stress fractures of the metatarsal shaft, within 1.5 cm of the tuberosity, occur in this area. Management and prognosis of both acute (Jones fracture) and stress fracture of the fifth metatarsal within 1.5 cm of the tuberosity depend on the type of fracture, based on Torg's classification.
The peroneus brevis tendon inserts in a fan-like pattern across the proximal fifth metatarsal.


Physical examination reveals tenderness at the base of the fifth metatarsal, often with ecchymosis and swelling at the site.
In contrast, the static lateral band of the plantar fascia has a focused insertion on the proximal tip of the fifth metatarsal. Patients complain of pain at the base of the fifth metatarsal and may have ecchymosis and edema at the site.
They usually report a prodromal period of aches and pain at the base of the fifth metatarsal while exercising or weight bearing. Although most fractures of the proximal portion of the fifth metatarsal respond well to appropriate management, delayed union, muscle atrophy and chronic pain may be long-term complications.Patients with fractures of the proximal portion of the fifth metatarsal commonly present to family physicians.
The two basic fracture types are tuberosity avulsion fractures and fractures of the metatarsal shaft within 1.5 cm of the tuberosity (Table 1). Treatment options, as well as potential complications of prolonged immobilization, such as reflex sympathetic dystrophy and muscle atrophy, should be fully discussed with the patient at the time of presentation.
Treatment of type II and type III stress fractures parallels that described for acute fractures (Table 3).INDICATIONS FOR ORTHOPEDIC REFERRALCriteria for referral of stress fracture are the same as for acute fractures.
The development of a secondary center of ossification (apophysis) at the proximal end of the fifth metatarsal can be mistaken radiographically as a fracture site (Figure 3).


Elite athletes, active athletes or patients who are reluctant to undergo conservative treatment with possible prolonged immobilization should be considered for surgical intervention.
In girls nine to 11 years of age and boys 11 to 14 years of age, the apophysis becomes visible on plain radiographs as a fleck of calcification adjacent to the fifth metatarsal shaft.1 The apophysis has an oblique orientation, with the radiolucency aligned parallel to the fifth metatarsal diaphysis. In a type II fracture, referral should be considered if the patient is an active athlete, requires an accelerated healing time or prefers surgical treatment.
Note the oblique orientation with the radiolucency aligned in parallel to the fifth metatarsal diaphysis.Apophysitis (Iselin's Disease). Apophysitis of the fifth metatarsal base (Iselin's disease) is a self-limiting disorder of active children that spontaneously resolves with completion of growth.



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