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Stress Fractures of the Fifth Metatarsal http://dx.doi.org/10.14517/aosm15025 Review Article pISSN 2289-005X·eISSN 2289-0068 Stress fractures of the fifth metatarsal Jae-Young Lee, Jin-Wha Chung Department of Orthopedic Surgery, The Catholic University of Korea, Bucheon St. Mary’s Hospital, Bucheon, Korea A stress fracture can be defined as a spontaneous fracture due to accumulation of stress on a healthy bone. Stress frac- tures of the 5th metatarsal usually locate to the proximal 1.5 cm of the metatarsal shaft, a characteristic based on ana- tomical and biomechanical parameters. Many surgeons agree that the postoperative outcome of 5th metatarsal stress fractures tend to be associated with prolonged healing time, with nonunion, and sometimes with refracture. Acute stress fractures have been treated with immobilization using a non-weight-bearing cast, but the incidence of complications (delayed union or nonunion) after non-surgical treatment makes surgical treatment a more favorable treatment option for competitive athletes, even for young adults. Curettage and bone grafting or intramedullary screw fixation, the stan- dard surgical treatment for the 5th metatarsal stress fractures, has been associated with rapid recovery and early return to physical activities. Malalignment or instability of the foot or ankle must be addressed at the time of surgical treatment. Keywords: Fifth metatarsal; Stress fracture; Metatarsal fracture; Jones fracture INTRODUCTION 5th metatarsal fractures make it a condition of clinical significance and one that requires an accurate diagnosis In stress fractures, a sustained submaximal external force, and an appropriate treatment [3]. In 1902, Jones sug- which is just inadequate to induce an acute fracture, over- gested that a base fracture of the 5th metatarsal may also lays the bone and causes a characteristic hairline fracture occur as a result of an indirect trauma [4]. A classification that can be seen on radiographs [1]. Stress fractures are system to divide these fractures into groups was devised often found on tibial, metatarsal, and tarsal bones on by Torg et al. [5] in 1984, and many studies have investi- which a lot of weight-bearing occurs and in professionals gated the treatment, classification, and prognosis of base such as athletes, dancers, and military soldiers whose job fractures of the 5th metatarsal. requires overuse of the lower limbs as well as in the nor- mal population [2]. However, stress fractures are distinct ANATOMY AND BIOMECHANICS OF THE 5TH from pathologic fractures that are induced by even trivial METATARSAL BONE force on bones that are pathologically weakened as a re- sult of systemic metabolic or inflammatory diseases or of A metatarsal bone consists of a head, a tibia, a shaft, a severe osteoporosis. base, and a tuberosity. The tuberosity protrudes into the The base of the 5th metatarsal of the foot is the region posterolateral base of the plantar foot and provides the in which the stress concentrates biomechanically; thus, dorsolateral insertion site for the peroneous brevis ten- for anatomical characteristics the prevalence of stress don. The insertion of the lateral fibrous tissue of the fractures is higher in the 5th metatarsal compared to plantar fascia in the direction of the plantar contributes those of other sites. For reasons related to blood flow, the to the stability of the base of the 5th metatarsal bone time taken to bone union is slow, and complications such (Fig. 1). In the 2nd and 3rd metatarsal bones, the base as refractures are common. These factors associated with and the cuneiforms form a lattice-shaped joint that build Received December 1, 2015; Revised December 23, 2015; Accepted December 23, 2015 Correspondence to: Jin-Wha Chung, Department of Orthopedic Surgery, The Catholic University of Korea, Bucheon St. Mary’s Arthroscopy and Hospital, 372 Sosa-ro, Wonmi-gu, Bucheon 14647, Korea. Tel: +82-32-340-7034, Fax: +82-32-340-2671, E-mail: [email protected] Orthopedic Sports Medicine Copyright © 2016 Korean Arthroscopy Society and Korean Orthopedic Society for Sports Medicine. All rights reserved. CC This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/ AOSM by-nc/4.0) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Arthrosc Orthop Sports Med 2016;3(1):1-5 1 Jae-Young Lee, Jin-Wha Chung. Stress fractures of the fifth metatarsal Peroneus Peroneus Nutrient brevis tertius artery Metaphyseal arteries Lateral band of plantar fascia "Avascular zone" Fig. 1. An adduction force on the fifth metatarsal bone is counterbal- anced by a stress force that induces a stress fracture. Between the coun- teracting forces of the 5th metatarsal bone, the rigid fascial and tendi- nous anchors act as a fulcrum. Fig. 2. Blood supply to the fifth metatarsal is provided by a single nutri- ent artery to the shaft and by the epiphyseal and the metaphyseal arter- ies to the base and to the tuberosity. a stable anatomical structure. In the 4th and 5th metatar- sal bones, the base does not contribute to the stability of the joints in this way. For this anatomical basis, during the tarsal is one of the factors that prevent successful fracture rehabilitation after treatment of the latter two metatarsal healing. Shereff et al. [8] found that whilst vascular supply fractures, adduction and abduction exercises in the axial to the shaft of the 5th metatarsal is provided through one plane are restricted and around 10o of flexion motion is nutrient artery, that to the base of the 5th metarsal is pro- permitted in the sagittal plane [6]. Of the metatarsals, the vided through more than one metadiaphyseal arteries. distal portion of the 5th metatarsal has the most mobility, Because stress fractures of the proximal 5th metatarsal thus movement is permitted relatively freely. Conversely, occur near the medial cortical hole through which the the base of the 5th metatarsal, as the section that receives nutrient vasculature feeds through, upon fracture this the most support from the ligaments and tendons, acts as site is separated from the source of blood vessels leading a lever during metatarsal movement, and therefore is the to formation of an avascular fracture site; this has been region where stress accumulates excessively. The accu- reported to be one of the important anatomical reasons mulation of stress leads to stress fractures at the proximal for the high rate of nonunion or delayed union in 5th 5th metatarsal, especially because of stress that accumu- metatarsal fractures (Fig. 2) [8]. lates with repeated adduction of the foot. By evaluating the fracture site radiographically, we can deduce by way DIAGNOSIS AND CLASSIFICATION OF of the fracture line that the fracture began at the lateral STRESS FRACTURES OF THE FIFTH plantar foot and extended toward the medial dorsal foot. METATARSALS Biomechanical causes of stress on and, therefore, of stress fractures of the base of the 5th metatarsal during Early stress fractures are distinctively associated with a weight-bearing gait include a larger than normal curva- precursory symptom of intermittent pain, rather than ture of the distal shaft of the 5th metatarsal, inversion of acute pain. This mild, intermittent pain is mistakenly the tibia, and cavus foot-induced excessive abduction taken for soft tissue injuries that gradually increase in in- force on the base of the 5th metatarsal [7]. The risk of tensity. Often, this precursory pain suddenly exacerbates stress fractures can also increase if patients already have with a piercing sensation during exercise or during gait. an inversion deformity of the hindfoot. This is because Patients with 5th metatarsal fractures have a history of a an inverted hindfoot leads to a sustained locking of change in habit such as taking up a new sports or an in- the metatarsals during the stance phase of a gait in the crease in the intensity or in the amount of sports activity background of an already low subtalar joint mobility; the and rarely have a history of trauma. metatarsal locking compromises the flexibility of the foot The fractures at the proximal 5th metatarsal can be di- and increases chances of fractures because the foot can- vided into 3 types according to anatomical position. Zone not effectively absorb the shock against ground force. 1 fractures are avulsion fractures that occur at the most The vasculature distinctive to the base of the 5th meta- proximal metatarsal bone, the tuberosity. They occur as 2 www.e-aosm.org Jae-Young Lee, Jin-Wha Chung. Stress fractures of the fifth metatarsal a result the insertion of the peroneous brevis tendon and prominent. Thus, when stress fractures are suspected plantar facia. Zone 2 fractures occur in the metaphysio- and an early plain radiography is not suggestive of them, diaphyseal junction, and zone 3 fractures occur within imaging should be repeated across a few weeks until they 1.5 cm of the proximal shaft of the 5th metatarsal (Fig. 3). can be seen. Conversely, nuclear medicine test or mag- Fractures of the latter two zones, for reasons related to netic resonance imaging may assist early diagnosis of the anatomical and biomechanical factors, are associated stress fractures. with a high incidence of delayed union, of nonunion, or Torg et al. [5] established a classification system that of refractures. Zone 2 fracture are also known as Jones’ divided the base fractures of the 5th metatarsal into 3 fracture and are usually limited to acute fractures. Be- stages: a type 1, acute injury; a type 2, delayed union; and cause patients’ symptoms and their history of trauma a type 3, nonunion (Fig. 4). Type 1 fractures are acute frac- tend to be ambiguous, it is difficult to differentiate Jones’ tures without expansion of the fracture line or without fractures from stress fractures that arise at the same site intramedullary sclerosis but with trivial hypertrophy of [9].
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