Fracture pattern analysis of fractures to the diaphysis of the fifth metatarsal

BACKGROUND

Fractures to the fifth's metatarsal (MT-V) diaphysis are common. These are inconsistently referred to as diaphyseal-, shaft-, or Dancer's fractures. A comprehensive analysis of the MT-V fracture morphology is missing. The aim was to qualitatively and quantitatively analyze fracture patterns of MT-V diaphyseal fractures.

HYPOTHESIS

Fractures to the shaft of the fifth metatarsal feature specific fracture morphologies.

MATERIALS AND METHODS

Retrospective, radiologic database study. Included were all acute, isolated MT-V shaft fractures (including the proximal [Lawrence and Botte (L&B) III] and distal meta-diaphysis). Demographics and fracture characteristics were assessed. Each proximal fracture line was drawn, scaled, and a qualitative and quantitative fracture line analysis was conducted. The quantitative fracture line analysis aimed at identifying dens clusters with arbitrary shape using the DBSCAN algorithm. Data are presented as mean±standard deviation.

RESULTS

Out of 704 eligible MT-V fractures, 156 met the inclusion criteria. Patient's mean age was 46±19 years and 94% suffered a low energy trauma. Qualitative and quantitative fracture line analysis revealed three distinct fracture patterns. The proximal (30%) and distal (5%) meta-diaphyseal clusters showed a predominant transverse fracture pattern. The vast majority of diaphyseal fractures (56%) were spiral/oblique fractures, progressing from the proximal lateral meta-diaphyseal region in an oblique course at 61±9° to the medial distal diaphyseal cortex. Seven percent of diaphyseal fractures showed a transverse fracture pattern.

DISCUSSION

Based on a qualitative and quantitative analysis of all MT-V shaft fractures, three distinct fracture clusters were identified with homogeneous fracture patterns. MT-V shaft fractures should therefore be classified as proximal meta-diaphyseal (L&B Type III), diaphyseal (oblique or transverse) and distal meta-diaphyseal.

LEVEL OF PROOF

IV; retrospective database study.

Existing fixation modalities for Jones type fifth metatarsal fracture fixation pose high rates of complications and nonunion

Jones type fifth metatarsal fractures pose a challenge to the foot and ankle surgeon, given documented high nonunion rates as well as high complication rates including hardware prominence, nerve injury, and screw breakage for existing treatment modalities including screw and plantar plate fixation. We call for the design of innovative Jones-fracture specific implants which contour to the natural curve of the fifth metatarsal. Future research should aim to expand upon existing literature for Jones fracture fixation and evaluate efficacy of novel implants which are designed to address unacceptably high complication rates for existing treatment modalities.

Short leg cast versus orthotic removable support for the management of pseudo-Jones avulsion fracture: A systematic review and meta-analysis

BACKGROUND

The fifth metatarsal base avulsion fracture (i.e., Pseudo-Jones fracture) is one of the most common foot fractures. The management of pseudo-Jones fractures could be carried out surgically or conservatively. This systematic review and meta-analysis aimed to provide an update about the efficacy of orthotic removable support compared to short-leg casting for individuals with pseudo-Jones fracture.

METHODS

We searched Embase, Medline, and Cochrane Central register of Controlled Trials (CENTRAL) for randomized controlled trials (RCTs) that compared the clinical outcomes of orthotic removable support and short-leg cast for adult individuals with a fifth metatarsal base avulsion fracture. We used 95% as a confidence level and P <0.05 as a threshold. The standardized mean difference (SMD) was used for the continuous outcomes, and the risk ratio (RR) was used for the dichotomous outcomes.

RESULTS

A total of 6 RCTs incorporating 403 individuals out were deemed eligible. There was no significant difference between orthotic removable support and short-leg casting regarding AOFAS score (standardized mean difference (SMD)= 0.31, 95% CI -0.17 to 0.8), pain on VAS score (SMD= -0.08, 95% CI -0.39 to 0.22), VAS-FA score (SMD= 0.22, 95% CI -0.19 to 0.62) EQ-5D VAS score, and non-union rate (RR=0.37, 95% CI 0.05 to 2.74).

CONCLUSION

The current meta-analysis reveals that there is no difference between orthotic removable support and short-leg casting for the conservative management of individuals sustaining pseudo-Jones fracture.

Can low-intensity pulsed ultrasound (LIPUS) accelerate bone healing after intramedullary screw fixation for proximal fifth metatarsal stress fractures? A retrospective study

Background

Intramedullary screw fixation is considered the standard treatment for proximal fifth metatarsal stress fractures. Low-intensity pulsed ultrasound (LIPUS) is a well-known bone-healing enhancement device. However, to the best of our knowledge, no clinical study has focused on the effect of LIPUS for postoperative bone union in proximal fifth metatarsal stress fractures. This study aimed to investigate the effect of LIPUS treatment after intramedullary screw fixation for proximal fifth metatarsal stress fractures.

Methods

Between January 2015 and March 2020, patients who underwent intramedullary screw fixation for proximal fifth metatarsal stress fractures were investigated retrospectively. All patients underwent intramedullary screw fixation using a headless compression screw with autologous bone grafts from the base of the fifth metatarsal. The time to restart running and return to sports, as well as that for radiographic bone union, were compared between groups with or without LIPUS treatment. LIPUS treatment was initiated within 3 weeks of surgery in all cases.

Results

Of the 101 ft analyzed, 57 ft were assigned to the LIPUS treatment group, and 44 ft were assigned to the non-LIPUS treatment group. The mean time to restart running and return to sports was 6.8 and 13.7 weeks in the LIPUS treatment group and was 6.2 and 13.2 weeks in the non-LIPUS treatment group, respectively. There were no significant differences in these parameters between groups. In addition, the mean time to radiographic bone union was not significantly different between the LIPUS treatment group (11.9 weeks) and the non-LIPUS treatment group (12.0 weeks). The rate of postoperative nonunion in the LIPUS treatment group was 0% (0/57), while that in the non-LIPUS treatment group was 4.5% (2/44). However, this difference was not statistically significant.

Conclusions

There were no statistically significant differences regarding the time to start running, return to sports, and radiographic bone union in patients with or without LIPUS treatment after intramedullary screw fixation for proximal fifth metatarsal stress fractures. Therefore, we cannot recommend the routine use of LIPUS to shorten the time to bone union after intramedullary screw fixation for proximal fifth metatarsal stress fractures.

Adequate union rates for the treatment of acute proximal fifth metatarsal fractures

PURPOSE

To compare the bone healing, clinical, and return to daily activity outcomes after either surgical or conservative management of acute zone 1, 2, and 3 fifth metatarsal fractures.

METHODS

A literature search was performed to identify studies published from the earliest record to January 2019 using EMBASE (Ovid), MEDLINE via PubMed, CINAHL, and Web of Science. All articles assessing clinical outcomes of acute proximal fifth metatarsal fractures were included. Bone healing and clinical outcomes were thereafter calculated using a simplified pooling method.

RESULTS

Thirty-two articles comprising of a total of 1,239 fractures were included, of which one was a randomized controlled trial, seven were prospective studies, and 24 were retrospective studies. 627 zone 1 fractures demonstrated union rates of 93.2% following conservative treatment and 95.1% following surgical treatment. Conservatively managed zone 1 fractures were displaced 49.5% of the time, compared to a rate of 92.8% for the surgically treated cases. For Jones' (zone 2) fractures, bone healing outcomes of conservative versus surgical treatment showed union rates of 77.4% versus 96.3%, refracture rates of 2.4% versus 2.1%, and mean time to union of 11.0 weeks versus 9.4 weeks, respectively. Only ten proximal diaphyseal (zone 3) fractures were reported, with a mean return to work of 8.2 weeks.

CONCLUSION

Acute zone 1 fractures are preferably treated conservatively as similar union rates were found after both conservative and surgical management. In contradistinction, acute zone 2 fractures demonstrate higher union rates and faster time to union when treated surgically. The outcomes of acute zone 3 fractures are rarely reported in the literature, so treatment recommendations remain unclear. Further research of proximal fifth metatarsal fractures is warranted to provide more definitive conclusions, but current findings can aid surgeons during the shared clinical decision making process.

LEVEL OF EVIDENCE

IV.

High union rates following surgical treatment of proximal fifth metatarsal stress fractures

PURPOSE

The primary purpose of this study was to determine the union rate and time for surgical- and non-surgical treatment of stress fractures of the proximal fifth metatarsal (MT5). The secondary purpose was to assess the rate of adverse bone healing events (delayed union, non-union, and refractures) as well as the return to sports time and rate.

METHODS

A literature search of the EMBASE (Ovid), MEDLINE (PubMed), CINAHL, Web of Science and Google Scholar databases until March 2020 was conducted. Methodological quality was assessed by two independent reviewers using the methodological index for non-randomized studies (MINORS) criteria. The primary outcomes were the union time and rate. Secondary outcomes included the delayed union rate, non-union rate, refracture rate, and return to sport time and rate. A simplified pooling technique was used to analyse the different outcomes (i.e. union rate, time to union, adverse bone healing rates, return to sport rate, and return to sport time) per treatment modality. Additionally, 95% confidence intervals were calculated for the union rate, adverse bone healing rates, and the return to sport rate.

RESULTS

The literature search resulted in 2753 articles, of which thirteen studies were included. A total of 393 fractures, with a pooled mean follow-up of 52.5 months, were assessed. Overall, the methodological quality of the included articles was low. The pooled bone union rate was 87% (95% CI 83-90%) and 56% (95% CI 41-70%) for surgically and non-surgically treated fractures, respectively. The pooled radiological union time was 13.1 weeks for surgical treatment and 20.9 weeks for non-surgical treatment. Surgical treatment resulted in a delayed union rate of 3% (95% CI 1-5%), non-union rate of 4% (95% CI 2-6%) and refracture rate of 7% (95% CI 4-10%). Non-surgical treatment resulted in a delayed union rate of 0% (95% CI 0-8%), a non-union rate of 33% (95% CI 20-47%) and a refracture rate of 12% (95% CI 5-24%), respectively. The return to sport rate (at any level) was 100% for both treatment modalities. Return to pre-injury level of sport time was 14.5 weeks (117 fractures) for surgical treatment and 9.9 weeks (6 fractures) for non-surgical treatment.

CONCLUSION

Surgical treatment of stress fractures of the proximal fifth metatarsal results in a higher bone union rate and a shorter union time than non-surgical treatment. Additionally, surgical and non-surgical treatment both showed a high return to sport rate (at any level), albeit with limited clinical evidence for non-surgical treatment due to the underreporting of data.

LEVEL OF EVIDENCE

Level IV, systematic review.

Bunionette: Is There a Minimally Invasive Solution?

A bunionette deformity is a painful prominence on the lateral aspect of the fifth metatarsal head. Surgical treatment can be considered if conservative treatment has failed to relieve the symptoms. The percutaneous approach consists of 2 steps: a condylectomy and an osteotomy of the fifth metatarsal. The learning curve is small and the final results are similar to the open techniques. The main advantages are the hardware-free technique and the minimally invasive approach. This percutaneous approach avoids complications related to hardware and soft tissue healing. Because of this low complication rate, the percutaneous technique may become the new gold standard.

The outcome of conservative treatment of fifth metatarsal diaphyseal fractures

INTRODUCTION

The fifth metatarsal diaphyseal fracture is a common fracture. However, clear consensus about the treatment is lacking. Unlike the avulsion fracture or Jones' fracture, literature available on the treatment and long-term outcome of the diaphyseal fracture is scarce.The purpose of this study is to demonstrate a substantial number of conservatively treated patients with persistent pain and to evaluate metatarsal shortening and displacement within this group.

METHODS

In this retrospective study, 106 patients who had experienced a fifth metatarsal diaphyseal fracture were included and evaluated. The minimum follow-up period was three months. FAAM, AOFAS and NRS scores were used as outcome measurements for function and pain. Length and displacement were analysed on plain X-rays.

RESULTS

At least 11% of the patients who received conservative treatment for their fifth metatarsal diaphyseal fracture had persistent pain at least 3 months after initiation of conservative treatment. No relationship has been found between the length of the fifth metatarsal and the FAAM (r( Petrisor et al., 2006) 2 = 0,051), AOFAS (r( Petrisor et al., 2006) 2 = 0,009) and NRS (r( Petrisor et al., 2006) 2 = 0,001). Furthermore, there was no association between patients with a shorter fifth metatarsal and FAAM, AOFAS, NRS, displacement and BMI.

DISCUSSION AND CONCLUSION

The finding of persistent pain in at least 11% of all patients at long-term follow-up confirms our hypothesis on long-term symptoms. However, the results suggest that these persistent symptoms are not related to metatarsal shortening or displacement.

Plantar loading in the youth soccer player during common soccer movements and risk for foot injury

INTRODUCTION

Soccer players are at high risk of stress injuries in the foot. While most research addresses this issue in professional athletes, there is little information concerning young athletes. As soccer is practiced around the world since early infancy, we set out to determine whether young soccer athletes are susceptible to increased foot loading that increase risk factors for foot injuries in a similar manner as reported by the literature to the adult athlete.

METHODS

twenty-six male adolescents (mean age 16 years old) were organized into two groups: soccer players (n = 13) and controls (n = 13). Groups were compared regarding foot sensitivity, ankle range of motion, Q-angle, and plantar pressure determined during running and cutting movements performed at maximal speed and using different shoes.

RESULTS

Foot sensitivity, ankle range of motion and Q-angle did not differ between the groups. During performance of soccer actions, young players showed higher peak pressure in the lateral region of the foot including the fifth metatarsal region. These higher peaks were minimized by manipulation of the footwear.

CONCLUSION

In summary, young soccer athletes show dynamic plantar pressure patterns that are related to foot injury in the adult athlete, and this condition can be minimized by the manipulation of the footwear. Additional attention should be paid to the young athlete in soccer aiming to minimize long-term risk for stress injuries in the foot.

Management of spiral diaphyseal fractures of the fifth metatarsal: A case series and a review of literature

INTRODUCTION

Spiral diaphyseal fractures of the fifth metatarsal can present with significant displacement. It is considered that non-operative management is sufficient in most cases but there is no clear consensus as to what this may be. This study reports the functional outcome of this injury in a small patient cohort and is the first study to report on outcomes of different non-operative measures.

MATERIAL AND METHODS

This is a retrospective study of 33 consecutive patients presenting to a central London teaching hospital who were managed by a variety of treatment modalities depending on surgeon preference which included a boot or a rigid sole shoe. Demographic data was obtained and time to pain free walking and return to normal footwear was recorded. The patients were asked how restrictive the injury was on a Likert scale (1-5). The average final follow up was 12 months.

RESULTS

All fractures were managed conservatively with excellent functional outcomes. Those patients managed in a shoe had a statistically significant shorter average time to return to pain free walking (4.6 vs 8.4 weeks, p=0.027) and average time to return to normal footwear (6 vs 7.3 weeks, p=0.044) in comparison to a boot. Patients managed in a shoe reported the injury was less restrictive in comparison to patients managed in a boot (p=0.0002). The average time to evidence of bony union was 8.3 weeks. There were 3 delayed unions.

CONCLUSION

All patient in this series were treated without surgery regardless of the degree of displacement. Conservative management of this fracture in a rigid sole shoe resulted in better outcomes and was reported to be less restrictive by the patients in comparison to a boot. On this basis, non-surgical management of these injuries is recommended in a shoe, full weight bearing with early range of movement of the ankle.

technique (Fifth metatarsal, Extra-portal, Rigid, Innovative)

Purpose

One of the main problems of Kirschner wire fixation of fifth metatarsal base fractures (in combination with a tension band wiring technique) seems to be hardware intolerance and several studies in athletes also report failure after isolated fixation with a screw only. These reports prompted us to look at new materials and a novel technique through fixation with an intramedullary screw combined with a high-resistance suture via the presented F.E.R.I. (Fifth metatarsal, Extra-portal, Rigid, Innovative) technique.

Methods

This cadaveric study describes F.E.R.I. technique. On a cadaver, through two mini portals, a full reduction and solid internal fixation with an intramedullary screw and suture cerclage with Fiberwire of a fifth metatarsal base fracture is achieved. In this article, the cadaveric study and proposed surgical technique are explained and illustrated step by step.

Results

The presented internal fixation F.E.R.I. technique is indicated in acute proximal fractures, stress fractures or non-union of metatarsal 5 (Zone 2–3 by Lawrence and Botte) and it resulted feasible and stable during manual stress test. The authors intend to study this technique in the clinical setting in the near future.

Conclusions

Fifth metatarsal base fractures gain specific interest when occurring in athletes. In this group of patients, internal fixation is often required to obtain a satisfactory outcome and time to return to play. The aim of the presented cadaveric study is to illustrate an innovative concept of internal fixation, named F.E.R.I.

Direction and location of the nutrient artery to the fifth metatarsal at risk in osteotomy for bunionette

BACKGROUND

The aims of this study were to identify the artery feeding the fifth metatarsal and determine how bunionette osteotomy could injure this vessel.

METHODS

The nutrient artery entering the fifth metatarsal was investigated in 10 adult cadaveric lower limbs by barium injection and enhanced computed tomography.

RESULTS

The nutrient artery entered the medial aspect of the fifth metatarsal around the junction of the middle and proximal thirds obliquely from a distal direction (mean angle 36°) in the coronal plane in all cases; in the axial plane, the point of entry and direction of the artery was medial-plantar (mean angle 49°).

CONCLUSIONS

This report revealed direction and location of the nutrient artery entering the fifth metatarsal.

Initial support with no immobilisation as therapy of choice for fractures of the fifth metatarsal

AIM

To demonstrate the effectiveness of early weight bearing with no immobilisation (functional therapy) applied to fractures of the fifth metatarsal.

MATERIAL AND METHOD

A retrospective case and control observational study was performed among 382 fractures on the fifth metatarsal comparing functional, conservative-orthopaedic and surgical treatments. Fractures were classified according to the settlement on the distal, diaphyseal or proximal part of the bone, the recommended therapy and the treatment performed. Influence of age, profession and characteristics of the injury were considered and results were measured using the parameters incapacity for work and number and intensity of complications.

DISCUSSION

Fractures of the fifth metatarsal are the most common injuries of the foot. Whether conservative or surgical treatment is recommended depends on the sort of fracture, the trend nowadays is to use non-invasive methods.

CONCLUSIONS

Functional treatment for metatarsal fractures provides earlier healing and fewer adverse effects than conventional therapies, and becomes first choice for non-displaced fractures and most displaced fractures of the fifth metatarsal.

Symptomatic treatment or cast immobilisation for avulsion fractures of the base of the fifth metatarsal: a prospective, randomised, single-blinded non-inferiority controlled trial

AIMS

The purpose of this study was to compare symptomatic treatment of a fracture of the base of the fifth metatarsal with immobilisation in a cast. Our null hypothesis was that immobilisation gave better patient reported outcome measures (PROMs). The alternative hypothesis was that symptomatic treatment was not inferior.

PATIENTS AND METHODS

A total of 60 patients were randomised to receive four weeks of treatment, 36 in a double elasticated bandage (symptomatic treatment group) and 24 in a below-knee walking cast (immobilisation group). The primary outcome measure used was the validated Visual Analogue Scale Foot and Ankle (VAS-FA) Score. Data were analysed by a clinician, blinded to the form of treatment, at presentation and at four weeks, three months and six months after injury. Loss to follow-up was 43% at six months. Multiple imputations missing data analysis was performed.

RESULTS

At four weeks and six months, symptomatic treatment proved non-inferior in terms of primary outcome.

TAKE HOME MESSAGE

Immobilisation is no better than symptomatic treatment in the management of a fracture of the base of the fifth metatarsal when judged by PROMs. Significant loss to follow-up with this injury could be expected in longer term. Cite this article: Bone Joint J 2016;98-B:806-11.

Fifth metatarsal fractures and current treatment

Metatarsal fractures are one of the most common injuries of the foot. There has been conflicting literature on management of fifth metatarsal fractures due to inconsistency with respect to classification of these fractures. This article provides a thorough review of fifth metatarsal fractures with examination of relevant literature to describe the management of fifth metatarsal fractures especially the proximal fracture. A description of nonoperative and operative management for fifth metatarsal fractures according to anatomical region is provided.

Plantar pressure asymmetry and risk of stress injuries in the foot of young soccer players

BACKGROUND

Asymmetries in the magnitude of plantar pressure are considered a risk factor for stress fracture of the fifth metatarsal in soccer athletes.

OBJECTIVE

To investigate the presence of plantar pressure asymmetries among young soccer athletes.

DESIGN

Observational.

SETTING

Laboratory.

PARTICIPANTS

Thirty young adolescents divided into a soccer player group (n = 15) or a matched control group (n = 15).

MAIN OUTCOME MEASURES

Mean plantar pressure was determined for seven different regions of the foot. Data were compared between the preferred and non-preferred foot, and between the groups, during barefoot standing on a pressure mat system.

RESULTS

Higher pressure was found in the hallux, 5th metatarsal and medial rearfoot of the non-preferred foot in the young soccer players. These asymmetries were not observed in the control group. Magnitudes of plantar pressure did not differ between the groups.

CONCLUSION

Young soccer players present asymmetries in plantar pressure in the hallux, 5th metatarsal and medial rearfoot, with higher pressure observed in the non-preferred foot.

Guide wire placement for fifth metatarsal intra-medullary screw fixation: A technical tip

Treatment of fifth metatarsal fractures in elite athletes or delayed/non unions often requires operative fixation. However, this can cause technical difficulties and we present an operative tip to avoid complications is presented.

Vitamin D insufficiency and deficiency in patients with fractures of the fifth metatarsal

INTRODUCTION

The fifth metatarsal is a common site for both acute and stress fractures in the foot. They are usually isolated low-energy or stress fractures. Vitamin D deficiency has been associated with fragility fractures in many parts of the body. We believe that low Vitamin D could be a significant aetiological factor in fractures of the fifth metatarsal.

METHODOLOGY

A prospective study of patients with fractures of the fifth metatarsal was conducted. Patients presenting to fracture clinic with these fractures had their vitamin D and calcium levels measured. We also conducted a literature review of studies of vitamin D levels in the Northern Hemisphere between 1990 and 2014.

RESULTS

Forty patients with fifth metatarsal fractures were studied (22 metatarsal base fractures, 6 shaft fractures, and 2 stress fractures). The average patient age was 49 (range 22-83). 12 patients (30%) had a Vitamin D level consistent with deficiency, and a further 14 (35%) had a level consistent with insufficiency. Average Vitamin D levels in winter fractures were significantly lower (52.23nmol/L) than for those sustained in summer (76.73nmol/L).

CONCLUSIONS

Hypovitaminosis D was common in patients with fifth metatarsal fractures. Vitamin D supplementation has been shown in animal studies to improve fracture healing rates, and in humans to decrease the risk of fragility fracture. It should be part of regular practice to check Vitamin D levels in these patients, and supplement where necessary.

Percutaneous bunionette correction: results of a 49-case retrospective study at a mean 34 months' follow-up

INTRODUCTION

Bunionette consists in a lateral prominence of the head of the fifth metatarsal (M5), inducing a callus. Toe malpositioning determines the varus, supraductus or infraductus form.

HYPOTHESIS

A percutaneous method without osteosynthesis was assessed in 38 patients suffering from this pathology.

PATIENTS AND METHODS

A continuous single-operator multicenter series operated on between May 2005 and January 2012 was analyzed with mean follow-up of 34 months. The inclusion criterion was bunionette with or without varus deviation. All patients were operated on percutaneously without tourniquet, on a day-care basis. All were clinically assessed, preoperatively and at latest FU, by visual analog pain scale (VAS), AOFAS and Coughlin scores, and callus status. Standard radiological assessment comprised monitoring of intermetatarsal (M4M5) and metatarsophalangeal (M5P1) angles.

RESULTS

VAS decreased from 8 (range, 6-9) preoperatively to 0.3 (range, 0-1) out of 10 at follow-up. AOFAS score increased from 58 (range, 52-75) to 97 (range, 80-100) out of 100. According to the Coughlin score, 97.5% of patients were satisfied or very satisfied. Deformity correction was systematic, with disappearance of preoperative callus. M4M5 and M5P1 angles decreased respectively from 10° (range, 6-13°) and 16.2° (range, 8-24°) preoperatively to 5.5° (range, 4-8°) and 4.3° (range, 2-9°). There was 1 case of complex regional pain syndrome and 1 delayed consolidation.

DISCUSSION

This procedure appeared reliable for correcting all types of bunionette deformity. Other minimally invasive methods with comparable results use pin fixation. The advantages over conventional techniques are the quality of results, low morbidity and absence of osteosynthesis material. The percutaneous technique should, we believe, be widely adopted in this indication.

LEVEL OF EVIDENCE

IV.

Utility of follow-up radiographs in conservatively managed acute fifth metatarsal fractures

Fifth metatarsal fractures are the most common fracture of the foot, with the majority being managed conservatively. A variety of treatment methods are described in the literature. Follow-up radiographs are taken to identify fracture displacement, and subsequently to assess for bony union throughout treatment. We assessed the utility of serial radiographic assessment in management of these fractures. Clinical notes and radiographs of 79 patients with fifth metatarsal fractures were analysed retrospectively. Serial radiographs were studied to identify displacement and the last X-ray was reviewed for evidence of fracture union. 96% of fractures were managed conservatively. 29% showed radiological healing at last clinic visit, the rest being discharged as were considered clinically healed. Similar fracture types were managed differently. 3 fractures were surgically treated after failed conservative management. 1 fracture showed displacement from initial radiographs, and was successfully managed conservatively. Without clear guidelines, these injuries are managed differently from a radiological perspective. Follow-up radiographs taken before 6-8 weeks do not appear to alter patient management. Based on the current study we present our recommendations for radiographic assessment of acute fifth metatarsal fractures.

Fractures of the proximal fifth metatarsal: percutaneous bicortical fixation

Background

Displaced intraarticular zone I and displaced zone II fractures of the proximal fifth metatarsal bone are frequently complicated by delayed nonunion due to a vascular watershed. Many complications have been reported with the commonly used intramedullary screw fixation for these fractures. The optimal surgical procedure for these fractures has not been determined. All these observations led us to evaluate the effectiveness of percutaneous bicortical screw fixation for treating these fractures.

Methods

Twenty-three fractures were operatively treated by bicortical screw fixation. All the fractures were evaluated both clinically and radiologically for the healing. All the patients were followed at 2 or 3 week intervals till fracture union. The patients were followed for an average of 22.5 months.

Results

Twenty-three fractures healed uneventfully following bicortical fixation, with a mean healing time of 6.3 weeks (range, 4 to 10 weeks). The average American Orthopaedic Foot & Ankle Society (AOFAS) score was 94 (range, 90 to 99). All the patients reported no pain at rest or during athletic activity. We removed the implant in all cases at a mean of 23.2 weeks (range, 18 to 32 weeks). There was no refracture in any of our cases.

Conclusions

The current study shows the effectiveness of bicortical screw fixation for displaced intraarticular zone I fractures and displaced zone II fractures. We recommend it as one of the useful techniques for fixation of displaced zone I and II fractures.