Surgical vs. Nonsurgical Management of Jones Fractures:

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Surgical vs. Non-surgical Management of Jones
Fractures

• A Case study comparison of treatment options

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Anatomy of the 5th
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5th Metatarsal Fractures

• Sir Walter Jones 1902
• First study N6 (including self)
• MOI indirect violence
• Proximal 5th metatarsal diaphysis
• True Jones fracture acute injury (w/o
  prodromal symptoms) involving the 4th-5th
  intermetatarsal facet

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Factors in Assessment

• MOI Sig. adduction force applied to forefoot w/
  ankle PF.
• True Jones vs. Diaphyseal Stress

• Differential Diagnosis
• Tuberosity avulsion fractures
• Diaphyseal Stress Fxs
• Apophysitis (Iselins Disease)
• Accessory Ossicles
• Pathogenic Fractures (metastases, lymphomas,
  plasmacytomas, bone cysts, lipomas, and
  osteoblastomas)

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5th Metatarsal Tuberosity Fracture
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Radiographic Jones
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5th Metatarsal FractureClassification Guidelines

• Tuberosity avulsion
• Jones (Torg Type I)
• Diaphyseal stress
• Torg Type 1 acute
• Torg Type 2
• delayed union
• Torg Type 3
• non-union
• -Quill GE Orthopedic Clinics of N. Amer. 262
  Apr. 1995.

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Literature Review Classification Guidelines

• Torgs Classification System 46 fxs from
  1973-82. Roentgenographic criteria to define (3)
  types of fx
• Type I Acute fracture w/ narrow fx line and no
  intramedullary sclerosis
• Type II Delayed union w/ widening fx line and
  evidence of intramedullary sclerosis
• Type III Non-union and complete obliteration of
  the medullary canal by sclerotic bone
• Torg JS et al., J Bone Joint Surg Am. 1984
  Feb66(2)209-14

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Literature Review Early reports

• difficulty achieving union of prox. 5th.
• Carp L. Ann Surg. 192786308-320.
• 20 of 21 male athletes (15-26 y.o.a.) Surgical
  intervention and treatment consisting of rest,
  plaster immobilization, and bone grafting
• Zelko RR, Torg, JS, Rachun A. Am J Sports Med.
  1979 Mar-Apr 7(2)95-101.

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Literature Review Sugerical Intervention

• Surgical management for acute Jones fx in both
  athletes and non-athletes. 22 patients
  intramedullary screw fixation. Immediate
  intramedullary screw fixation of acute Jones and
  Type I stress fxs 100 union rate w/ avg time
  to union of 6.2 wks.
• Portland G, Kelikian A, Kodros S. Foot Ankle Int.
  2003 Nov24(11)829-33.

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Literature Review-Surgical Intervention (Contd)

• Early screw fixation
• Clinical union 7.6 wks earlier than casting
• RTP 7.7 wks earlier than casting
• 18 of 19 (95) satisfactory results with screw
  fixation
• 8 of 18 (44) casted presented w/ nonunion,
  delayed union or refracture
• Mologne TS et al. Am J Spts Med. 33970-975 (2005)

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Literature Review NFL Perspective

• NFL Combine 4758 elite college ath. (86 Jones
  Fractures in 83 athletes)
• 53 treated surgically w/7(3) non-union.
• 20 (8 of 40) treated non-operatively non-union
• NFL Physicians 77 surgical vs. 23 non-surgical
• Low K, Noblin JD, Browne JE, Barnthouse CD, Scott
  AR. J Surg Orthop Adv. 2004 Fall13(3)156-60.

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Literature Review Surgical Failure

• 6 Athletes full release avg. of 8.5 wks
• Re-fracture from 1 day - 4.5 mo. after return.
• Recommendations
• Large Body Mass Large Screw
• Functional bracing, shoe modification/orthosis
• Changing to larger screw may speed up return
• Alt. imaging to document/assess adequate healing
• Wright RW et al. Am J Sports Med. 2000
  Sep-Oct28(5)732-6.

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Literature Review Surgical Failure

• 15 patients, 6 failures
• (4 refractures, 2 nonunions)
• Full participation _at_ 6.8 wks (9 wks asymp)
• Higher proportion of failure w/ elite atheltes
  (83) vs. those w/o complications (11)
• Larson CM et al. Am J Sports Med. 2002
  Jan-Feb30(1)55-60

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Literature Review Successful Non-operative
Treatment

• Case reports of (3) athletes w/ stress fractures
  of prox. shaft of 5th Met. treated
  non-operatively w/ early returns to play.
  Treatment of this injury should be
  individualized...
• Acker JH, Drez D Jr. Foot Ankle. 1986
  Dec7(3)152-5.
• Non-weightbearing cast immobilization for 6-8 wks
  w/ successful union 72-93
• Rosenberg GA, Sferra JJ. J Am Acad Orthop Surg.
  2000 Sep-Oct8 (5)332-8.

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Case Report 1

• Male 18 yoa
• Defensive Tackle
• 65, 300 lbs
• Initial Onset 9/22/00
• Prodromal pn x2 ½ wks
• Initial Dx Incomplete Jones Fracture

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Case Report 1

• Surgery 1 ORIF 9/29/00 (4.5 cm partially
  threaded cancellous screw)
• NWB x 1wk
• PWB in walker x 2wk
• US Bone stim
• 11/14/00 Released to progress back to full
  participationlimit as tolerated

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Case Report 1

• 2/13/01 c/o incr. pn x 2wks (incr. plyo during
  off-season wk-outs.)
• d/c running and f/u weekly
• X-rays show incr. lucency
• 3/13/01 Surgery 2 ORIF, screw removed and
  replaced w/ 6mm screw and tibial bone graft
  (deformation and bending of screw noted)

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Case Report 1

• Ath NWB x1 month
• 4/24/01 Begin walk short distances w/o boot
• 5/08/01 Begin running progression
  (Hydrotherapy/Zunni Unloader to land
  running)
• Two incidents c/o increased pn 6/18/01, 10/17/04

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Injury Onset
Fracture Line
Narrow/ Non-displaced
Widened/ Displaced
Prodromal
YES
NO
Conservative
O.R.I.F.
Intramedullary Sclerosis
YES
NO
Pes Cavus
Pes Cavus vs. Planus??
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Case Report 2

• Male, 19 yoa
• Defensive Tackle
• 62, 285 lbs
• Initial Onset 07/14/05
• No PMH
• MOI Cut on L foot during agility drill

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Case Report 2

• Dx Non-displaced 5th MT fracture
• Absence of prodromal pain
• Initial Plan NWB w/MaxTrax Walker
• Modalities Exogen bone stim and Anodyne daily
• NWB x 5wks

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Case Report 2

• NWB x5wks
• Began progressional walk/jog in Hydroworx _at_ wk 4
  ½
• Fit custom orthotics w/ 5th MT unloader
• (discussed optional orthotics)
• Return to px 9/6/05

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Injury Onset
Fracture Line
Narrow/ Non-displaced
Widened/ Displaced
Prodromal
YES
NO
Conservative
O.R.I.F.
Intramedullary Sclerosis
YES
NO
Pes Cavus
Pes Cavus vs. Planus??
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Injury Onset
Fracture Line
Widened/ Displaced
Narrow/ Non-displaced
Prodromal
YES
NO
Conservative
O.R.I.F.
Intramedullary Sclerosis
YES
NO
Pes Cavus
Pes Cavus
Pes Cavus vs. Planus??
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In Conclusion

• Anatomy of injury can be confusing and may alter
  treatment plan
• To screw or not to screw
• Conservative/Non-surgical injury management can
  produce favorable results
• Ultimately, whats in the athletes best interest
• How do you help to determine injury management?

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THANK YOU