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The Clinical Importance of the Os Peroneum: A Dissection of 156 Limbs Comparing the Incidence Rates in Cadavers versus Chronological Roentgenograms

Posted on February 1, 2011 | Comments Off on The Clinical Importance of the Os Peroneum: A Dissection of 156 Limbs Comparing the Incidence Rates in Cadavers versus Chronological Roentgenograms

by Brion Benninger, MD 1 , Jessica Kloenne 2 

The Foot and Ankle Online Journal 4 (2): 2

Introduction: The purpose of this study was to assess radiograph incidence versus cadaver incidence rates of the os perineum (OP) within the fibularis (peroneus) longus tendon (FLT) and to assess why broad variants have occurred in previous radiograph and cadaver studies. The OP or sesamoid bone in the FLT has a history of controversy regarding the terminology and frequency. Recent histological studies have proven sesamoid terminology. Cadaver studies have revealed high incidence rates (IR), yet virtually all texts and atlases exclude it. Clinicians recognize it in routine foot radiographs. No studies have compared IRs between cadavers and injured patients of the general population.
Methods: A literature search of texts, atlases, journals and websites was conducted identifying incidence of OP within the FLT. Dissection of 82 embalmed cadavers (M 52, F 30) identified the IR of the OP. Oblique foot radiographs from 1,025 individuals were examined.
Results: A literature review revealed OP in 20% of atlases, 7.69% in texts, and previous cadaver study results are 46%, 90%, and 14.9%. This study’s cadaver results reported an IR of 88.46% with an average age of 78.1 (45 – 89yrs). Radiographic results revealed 15.12% incidence with an average age 41.97 (10 – 89yrs). The average IR from 10 to 70 years was 13.32%. From 70 onwards it increased to 32.98%. The p value per decade from radiographic analysis was 0.0005.
Conclusion: This study suggests there is a high IR of an OP in cadavers (88.46%). This may be a result of the average age of cadavers 78.1 and the technique used to locate the OP. Radiographic results were significantly lower and may be explained by an age factor. Radiographs reviewed were from an emergency room where the majority of patients receiving foot radiographs were between the ages of 19 – 45. The clinical importance has been understated regarding the area of the os peroneum, which can be mistaken for styloid and Jones’ fractures.

Key words: Os peroneum, incidence, foot injury, sesamoid bone, Jones fracture, styloid process.

Accepted: January, 2011
Published: February, 2011

ISSN 1941-6806
doi: 10.3827/faoj.2011.0402.0002

The purpose of this study was to examine the important clinical relevance of the ‘os peroneum’ (OP) within the fibularis longus (FLT) by investigating the incidence of the OP between cadaveric specimens and radiological images.

The ‘os peroneum’ within the fibularis (peroneus) longus tendon has a history of controversy regarding its incidence in both individual and combined radiographic and cadaver studies. Radiographic and cadaveric studies have reported incidence rates of the OP within the FLT, however, a limited number of anatomical textbooks and atlases used by healthcare professionals and trainees mention or illustrate the OP.

Research to date reports a wide variation of incidence rates (IR), which are different in radiographic and cadaveric research. Previously Cilli, et al., in 2005 conducted a radiographic study on males only reporting 31.8% IR. A cadaveric study was conducted by Muehleman, et al., in 2009 which reported a 46% IR. Despite the various studies conducted thus far, no previous studies have conducted a comparison of incidence rates between radiographs and cadavers from separate populations. The objective of this research project was to assess radiograph incidence versus cadaver incidence rates of OP within the FLT and to assess why broad variants have occurred in previous radiograph and cadaver studies. (Fig. 1 and Fig. 2)

Figure 1 Os peroneum in the fibularis longus tendon. (Reproduced with kind permission from Lippincott Williams & Wilkins, Grant’s Anatomy, 12th edition.)

Figure 2 Location of os peroneum in the foot. (Reproduced with kind permission from Elsevier, Gray’s Anatomy, 40th edition.)

Methods

A literature search was conducted of anatomical texts and atlases, specialty texts, journals and websites regarding the presence or incidence of the OP within the FLT. Oblique foot radiographs from 1,025 individuals (range 10-89) were examined to identify OP within the FLT. (Fig. 3A and 3B) Dissection of 82 (156 sides) embalmed cadavers (52M, 30F) with a mean of 78.1 years (range 45- 89) was performed to identify the incidence rate of the OP within the FLT. A skin incision was made from the fifth toe to the styloid process distal to proximal along the lateral border of the foot. Then an oblique incision was made to the lateral malleolus to expose the FLT. (Fig. 4A)

Figure 3A and 3B Oblique radiographs of the OP in the FLT. (A and B)  (Thanks to the OHSU Radiology Department for radiograph.)

At the styloid process a horizontal incision was made along the surface of the foot to the opposite side, then exposing the FLT within the tunnel it traverses. The FLT was freed from its attachment point distally and reflected back. Palpation of the FLT was performed to identify the OP. A longitudinal incision was performed 2cm proximal and distal to the OP and then opened to reveal the ‘sesamoid bone’s’ existence or not. (Fig. 4B) A second examiner palpated and analyzed the longitudinal incision and reported their findings. A paired t-test was conducted on the radiographic data.

Figure 4A and 4B OP within the FLT in a cadaver.

Results

The literature search revealed the OP within the FLT was discussed in anatomy texts (7.69%), contemporary atlases (20%) and specific imaging texts (16.6%). This study’s radiographic evaluation of OP within the FLT from 1,025 individuals with a mean age of 41.97 years had an incidence rate of 15.12% overall.

Incidence by ten-year increments revealed 12.16% for 10-19 years, 11.31% for 20-29 years, 13.87% for 30-39 years, 16.17% for 40-49 years, 15.15% for 50-59 years, 10% for 60-69 years, 41.38% for 70-79 years, and 19.44% for 80-89 years. The number of radiographs analyzed per ten-year increment was from approximately 100 individuals. (Graphs 1 and 2) The p value for the radiographic images was 0.0005. In this study, the incidence rate of the cadaver dissections was 88.46% with a mean age of 78.1.

Graph 1 Radiographic incidence of the OP within the FLT per ten-year increment.

Graph 2 Identification of the OP within the FLT in educational texts.

Discussion

The OP is a sesamoid bone that is located within the FLT. [12] The shape of the OP can be round, oval, triangular, irregular and can also be found as bipartite or multipartite. [6,7]

The etiology of the OP is unknown; however, it has been thought that it arises from both mechanical and genetic factors. [7,11] A literature search of contemporary anatomical texts, atlases and specialty radiographic texts revealed incidence rates of 7.69%, 20% and 16.6%, respectively. This lack of recognition of the OP in commonly used texts and atlases contradicts radiographic and cadaver evidence from our study.

Our study’s incidence rate of identifying the OP within the FLT from radiographs (15.12%) was consistent with other radiographic studies. (Table 1). Radiographic studies report incidence rates of 31.8%, 4.7%, 14%, 14% and 9%. [3,4,1,11,13] The reason the incidence of the OP within the FLT in the images of our study was less than cadaveric results may be due to the average age of the individuals from the radiographs (41.97 years).

Table 1 Review of OP within the FLT in radiographic and cadaveric studies.

The radiographs reviewed were from an emergency room where on average the majority of patients receiving foot radiographs are between the ages of 19-61. [9] The incidence rate might have been higher if the average age of the individuals was higher. Another study had a mean age of 51 years. [11] Two other studies only provided the range of their subjects and none were greater than 72 years. [3,4] Two other radiographic studies did not provide any information on the mean age or range. [1,13] To collect comprehensive research on the radiographic incidence of the OP within the FLT, further data is required in the age range of 60 and up.

The IR of the OP within the FLT in the cadavers (88.46%) was consistent with one cadaveric study with an incidence rate of 90%.8 This consistency may be related to similar methods of identification of the OP within the FLT. Recent cadaveric studies have reported incidence rates of 46% and 14.9%. [7,10]

One study assessed radiographic imaging from the 33 cadavers dissected, but did not look at separate populations for radiographic and cadaveric data. [7] Furthermore, that study did not report the incidence rate of the OP within the FLT when solely palpating the FLT on cadavers; their incidence rate was reported after radiographic and histologic investigation. A combined radiographic (500 individuals) and cadaveric (20 cadavers) study showed 12.3% incidence rate; this study did not separate incidence rates for radiographic and cadaveric results. [5]

In our study, the average age of the cadavers (78.1 years) is much older than the average age of the individuals in the radiographs, which may contribute to the high incidence rate of the OP within the FLT in the cadavers. Other studies that researched incidence rate of the OP within the FLT in cadavers had mean ages that were consistent with our study (81.0, 75.2 and 77.7 years). [7,8,10] However, the age range (33-97 years) was only given for one of these studies. [8]

The method of identification may also contribute to the high incidence rate of the OP within the FLT because our study palpated and dissected open the OP, but did not use histology or radiology to confirm presence of OP from cadavers.

A conflict between cadaveric and radiographic results is the fact that cadaver incidence can be based on a partially ossified OP. Therefore a partially ossified OP could be recorded as positive. In contrast, an incomplete ossification may not be obvious or present on typical radiographs. A partially ossified OP can be cartilaginous and at times cartilage cannot be recognized on ordinary (not over or under penetrated images) radiographic images. [12]

A possible factor affecting the radiographic results of our study is that we used only those patients who presented to the emergency room with foot pain. It is not common for people over age 60 to present to the emergency room with sprained ankles or fractured 5th metatarsals. The over 60 age group population present acutely with hip fractures or with gout of the great toe. There may have been different results if we had randomly chosen from the general population for OP in the FLT.

Conclusion

The clinical importance has been understated regarding the area of the os peroneum, which can be mistaken for styloid and Jones’ fractures. The radiograph IR was always over 10% regardless the age group while the cadaveric incidence rate was 88.46%. This suggests that teaching the OP in the FLT is clinically relevant because lower limb injuries are common.

References

1. Burman MS, Lapidus PW. The functional disturbance caused by the inconstant bone and sesamoids of the foot. Arch Surg 1931 22: 936.
2. Carter DR, Orr TE, Fyhrie DP, Schurman DJ. Influences of mechanical stress on prenatal and postnatal skeletal development. Clin Orthop Relat Res 1987 219: 237-250.
3. Cilli F, Akcaoglu M. The incidence of accessory bones of the foot and their clinical significance. Acta Orthop Traumatol Turc 2005 39: 243-246.
4. Coskun N, Yuksel M, Cevener M, Arican RY, Ozdemir H, Bircan O, Sindel T, Ilgi S, Sindel M. Incidence of accessory ossicles and sesamoid bones in the feet: a radiographic study of Turkish subjects. Surg Radiol Anat 2009 31: 19-24.
5. Le Minor JM. Comparative anatomy and significance of the sesamoid bone of the peroneus longus muscle (os peroneum). J Anat 1987 151: 85-99.
6. Mellado JM, Ramos A, Salvadó E, Camins A, Danús M, Saurí A. Accessory ossicles and sesamoid bones of the ankle and foot: imaging findings, clinical significance and differential diagnosis. Eur Radiol 2003 13: L164-L177.
7. Muehleman C, Williams J, Bareither ML. A radiologic and histologic study of the os peroneum: prevalence, morphology, and relationship to degenerative joint disease of the foot and ankle in a cadaveric sample. Clin Anat 2009 22: 747-754.
8. Oydele O, Maseko C, Mkasi N, Mashanyana M. High incidence of the os peroneum in a cadaver sample in Johannesburg, South Africa: possible clinical implication? Clin Anat 2006 19: 605-610.
9. Reason for Visits to Emergency Room – National Hospital Ambulatory Medical Care Survey 1998-2006. U.S. Department of Health and Human Services; Centers for Disease Control and Prevention; National Center for Health Statistics.
10. Rühli FJ, Solomon LB, Henneberg M. High prevalence of tarsal coalitions and tarsal joint variants in recent cadavers sample and its possible significance. Clin Anat 2003 16: 411-415.
11. Sarin VK, Erickson GM, Giori NJ, Bergman AG, Carter DR. Coincident development of sesamoid bones and clues to their evolution. Anat Rec 1999 257: 174-180.
12. Stranding, S. Gray’s Anatomy: The Anatomical Basis of Clinical Practice, 40th ed. Philadelphia: Elsevier 2005, pg 1420.
13. Tsuruta T, Shiokawa Y, Kato A, Matsumoto T, Yamazoe Y, Oike T, Sugiyama T, Saito M. Radiological study of the accessory skeletal elements in the foot and ankle (abstract). J Jap Orthop Assoc 1981 55: 357-370.

Address correspondence to: Oregon Health & Science University
611 SW Campus Drive, Portland, OR 97239.

1 Department of Surgery, Department of Integrative Biosciences, Department of Orthopaedic Surgery & Rehabilitation, Department of Oral Maxillofacial Surgery, Oregon Health & Science University, Portland, OR.
2 Department of Integrative Biosciences, Oregon Health & Science University, Portland, OR.

© The Foot and Ankle Online Journal, 2011

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Intramedullary Fixation of the Jones Fracture: A case report

Posted on June 1, 2009 | Comments Off on Intramedullary Fixation of the Jones Fracture: A case report

by Al Kline, DPM1

The Foot and Ankle Online Journal 2 (6): 2

Intramedullary fixation of the Jones Fracture is described in this case report. Advantages of this procedure include percutaneous fixation of a Jones fracture without the need for traditional open reduction and a more rapid return to weightbearing and activity. The procedure is not technically difficult and provides excellent compression strength. This technique is indicated in stress fracture and/or fractures of a single cortex involving the fifth metatarsal.

Keywords: Intramedullary screw fixation, Jones fracture.

This is an Open Access article distributed under the terms of the Creative Commons Attribution License.  It permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. ©The Foot and Ankle Online Journal (www.faoj.org)

Accepted: May, 2009
Published: June, 2009

ISSN 1941-6806
doi: 10.3827/faoj.2009.0206.0002

Intramedullary fixation of the fifth metatarsal fracture or Jones fracture is not a new concept. This technique was first described by Kavanaugh, et al., in 1978. Initial techniques employed both the curved Leinbach screw and AO malleolar screw. Unfortunately, these stainless steel screws could break leading to incidence of failure. The procedure subsequently fell out of favor due to this complication. However, with the advent of stronger metals, this technique is once again introduced as a viable alternative to open, plate fixation of the Jones fracture. In April, 2007, the Carolina™ Jones-fracture system for foot and ankle surgery was launched by Wright Medical Group, Inc. Surgeons at Duke University and OrthoCarolina devised a system that uses high-strength screws specifically designed to treat the Jones fracture using intramedullary compression.

There are over 80,000 Jones fractures sustained annually in the United States. [1] It is now commonly reported that this fracture is under treated and sustains a high non-union rate. Some have reported up to 50% non-union rate. [2] Other reports have suggested a delayed-union rate as high as 66%. [3] The technique of intramedullary fixation is indicated for stress fracture of the fifth metatarsal with single cortex involvement and without comminution.

The advantage of this procedure is its simplicity and the ability to perform the procedure through a small percutaneous incision. This allows stable fixation of the fracture without a large incision and use of traditional plate fixation.

The intramedullary screw is ideal to promote stabilization of the fifth metatarsal fracture and allow the patient to return to activity sooner. Activity and weight bearing can be resumed as soon as 10 days following surgery.

Case Report

A 56 year-old female presents with pain and swelling to the lateral border of the foot. She reports slipping down a set of steps and sustaining a “burning pain” to the foot. She denies “twisting” or inverting the foot during injury. She continued to have pain and swelling following the injury and presented to our office. Radiographs confirmed a transverse stress fracture of the fifth metatarsal. The patient has a history of hypertension and hypercholesterolemia. She is a non-smoker and active. We scheduled the patient for intramedullary screw fixation. Because the patient was relatively sedentary and not athletic, we opted to fix the fracture with a 4.0 TiMax™ cannulated lag screw.

Surgical Technique

The patient was brought to the operating room and under IV sedation, a small skin block was performed along the base of the fifth metatarsal.

Using the Hologic®- InSight Fluoroscan mini C-arm, the fracture is identified. A small, percutaneous incision is made along the base of the fifth metatarsal. A guide wire can be used over the skin under fluoroscan to get a quick idea of the screw length needed for fixation. (Fig. 1).

Figure 1   The transverse stress fracture of the fifth metatarsal.  A percutaneous incision is made at the base of the fifth metatarsal under fluoroscan.

We used the TiMAX™ 4.0 cannulated lag screw. The lag design allows compression of the fracture site. It is important to place all the threads distal to the fracture site allowing for proximal lag compression when tightening the screw. By placing the run-out of the screw away from the fracture line, this helps to prevent screw fatigue or fracture. A washer is not required. The intramedullary guide wire is then placed across the fracture site and the proper length is determined. (Fig. 2)

Figure 2   The guide pin is placed across the fracture site to determine proper screw length.  Careful counter pressure is maintained at the fifth metatarsal head to prevent further distraction of the fracture site.

It is important to place some counter pressure along the long axis of the fifth metatarsal at the metatarsal head. This will prevent further distraction of the fracture site while drilling.

This is also important if the pilot hole is over-drilled. Soft tissue and tendon attachment is protected with a small drill sleeve and then the proper length screw is inserted. (Fig. 3).

Figure 3   The guide pin is then overdrilled and the screw is placed into the medullary canal.  The screw is tightened with compression of the transverse fracture site.

As the screw is tightened, you may place counter pressure along the long axis of the fifth ray. Using the fluoroscan, a noticeable ‘pinching’ of the fracture site will occur due to the compression force of the screw. The low-profile screw head may also be ‘buried’ into the hard, thick cortical portion of the styloid process ensuring to prevent screw head irritation. Once the screw is in place, it will provide significant stability to the fracture site and allow for earlier weight bearing and activity. (Fig. 4).

Figure 4   The threads of the lag screw are placed distal to the transverse fracture allowing for proper compression of the fracture.  The lag screw provides increased stability of the transverse fracture allowing for an earlier return to weight bearing and activity.

A single skin suture or ‘butterfly’ tape is then placed to close the small incision. The patient is then placed in a posterior splint and kept non-weight bearing for approximately 10-14 days. This can be followed by placing the patient in a CAM walking in a brace or simple post-surgical shoe. The screw may remain in the bone at the discretion of the patient and surgeon.

At 10 weeks post-op, the fracture site is well healed and the patient is walking without assistance or pain. (Figs. 5A and B)

 

Figure 5A and 5B   The fracture site 10 weeks after surgery.  The patient has been walking on the fracture site for 8 weeks after being maintained non-weight bearing in a posterior splint for the initial 2 weeks after surgery.  The fracture site is stable without signs of re-fracture or instability.

Discussion

Intramedullary fixation of the Jones fracture is a simple and quick operative procedure. It allows for fracture stability without the need for a large, open reduction procedure. The procedure also allows for quicker weight bearing and return to activity without the risk of refracture.

The mechanism of injury is commonly described as stressed inversion and plantarflexion. In our case, however, the patient slipped and sustained an acute transverse stress fracture of the proximal diaphysis. In Kavanaugh et al., [3] original article, he also observed simple transverse diaphyseal stress fracture of the fifth metatarsal without a history of stress inversion or plantarflexion. [3]

Using force-platform analysis in eleven of twenty-three cases confirmed vertical and mediolateral forces concentrated over the fifth metatarsal causing stress diaphyseal fracture, not inversion stress.

Adduction of the forefoot is thought to potentiate stress leading to stress fracture. He concludes this to be the original Jones fracture as first described by Jones in 1902. He also observes that the stress fracture is difficult to treat and led to delayed union in eighteen of twenty-two patients treated conservatively (66.7%). Non-unions and delayed unions continue to be reported in cases of casting, even a stress fracture, since this study was first initiated. Refracture is also high in under treatment of this injury. Kavanaugh, et al., reported nine of twenty-two patients who sustained refracture after immobilization casting for an average of 23.3 weeks! [3]

Wukich, et al., recently reported a higher non-union and refracture rate with intramedullary screw fixation for the Jones fracture in a Division I athlete. This appeared to be due to using a smaller screw diameter. They propose using a larger diameter screw, up to 6.5 mm in diameter screw to fixate the Jones fracture in competitive athletes. [5]

The high incidence of non-union, delayed union and refracture justifies the need for earlier surgical intervention. Of course, patient needs and activity will be individualized. Although early weight bearing and activity can be achieved as early as 7 to 10 days after intramedullary stabilization of a Jones fracture, the individual weight and activity of the patient should be considered. In the athlete, this procedure allows for earlier activity and training. We advise a posterior splint, non-weight bearing for 2 weeks, with progression to weight bearing and a surgical shoe or CAM boot for an additional 2 to 4 weeks. The patient may then resume normal activity after 6 weeks.

References

1. Orthopedic Technology Review.: Product News: Jones-Fracture System.
2. Ortiguera CJ, Fischer DA: A review of the current treatment for fracture of the proximal fifth metatarsal first described by Jones. Orthopedic Technology Review 2 (4): 2000.
3. Kavanaugh JH, Brower D, Mann RV: The Jones Fracture Revisited. J Bone Joint Surg Am 60A: 776 – 782, 1978. [PDF]
4. Kline A: A review of the Jones fracture with simple classification for conservative versus surgical treatment. Podiatry Internet Journal, 1 (1): 10, 2006. [Online]
5. Wukich DK, Rhim B, Dial DM: Failed intramedullary screw fixation of a proximal fifth metatarsal fracture (Jones fracture) in a division I athlete: A case report. The Foot and Ankle Online Journal, 2 (6): 1, 2009. [Online]

Address correspondence to: Al Kline, DPM
3130 South Alameda, Corpus Christi, Texas 78404.
Email: al@kline.net

1  Adjunct Clinical Faculty, Barry University School of Podiatric Medicine. Private practice, Chief of Podiatry, Doctors Regional Medical Center. Corpus Christi, Texas, 78411.

© The Foot and Ankle Online Journal, 2009

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Failed Intramedullary Screw Fixation of a Proximal Fifth Metatarsal Fracture (Jones Fracture) in a Division I Athlete: A case report

Posted on June 1, 2009 | Comments Off on Failed Intramedullary Screw Fixation of a Proximal Fifth Metatarsal Fracture (Jones Fracture) in a Division I Athlete: A case report

by Dane K. Wukich, MD1 , Bora Rhim, DPM2, Dekarlos M. Dial, DPM3

The Foot and Ankle Online Journal 2 (6): 1

Intramedullary screw fixation of a Jones fracture is described in a basketball player (division I athlete). Early mobilization is the cornerstone to using intramedullary screw fixation in athletes. This case report describes the use of a smaller diameter screw to fixate a Jones fracture that failed. The authors have found that using a screw diameter similar to the diameter of the medullary canal may help to prevent screw failure.

Keywords: Intramedullary screw fixation, Jones fracture, screw failure.

This is an Open Access article distributed under the terms of the Creative Commons Attribution License.  It permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. ©The Foot and Ankle Online Journal (www.faoj.org)

Accepted: May, 2009
Published: June, 2009

ISSN 1941-6806
doi: 10.3827/faoj.2009.0206.0001

Jones fracture of the fifth metatarsal has been defined as an acute fracture occurring in the proximal portion of the fifth metatarsal base at the metaphyseal and diaphyseal junction in which the fracture can involve the 4th and 5th intermetatarsal joints. [1] Currently, there is no clear consensus on optimal treatment of acute Jones fractures in the athletic or the non-athletic population. There has been much debate in the treatment of proximal 5th metatarsal fractures since described by Sir Robert Jones in 1902. [2] The treatment of Jones fractures continues to remain controversial and challenging. [3]

Optimal screw selection for operative treatment in competitive athletes with 5th metatarsal Jones fracture has not been determined. Cannulated screw fixation has been a popular method of fixation and has gained wide acceptance. Due to increased failure rates in elite athletes from refracture, delayed union, and non union, Wright, et al., recommended using a larger solid screw in competitive athletes to counter the higher amount of torsional stress placed on the fracture site. [4] We present in this case report a Division I competitive basketball player who sustained a proximal 5th metatarsal fracture. His initial treatment involved open reduction and internal fixation (ORIF) with a small diameter intramedullary screw. The patient developed a nonunion and required autogenous bone grafting with larger diameter screw fixation. Selection of screw type and diameter deserves thorough consideration. The authors utilize large diameter solid screws that are compatible with the 5th metatarsal intramedullary canal diameter.

Case Report

A 21-year-old male collegiate basketball player presents with right foot pain. His symptoms began after jumping and landing awkwardly. He developed severe pain on the lateral border of his right foot. The pain is exacerbated with weightbearing and walking. The patient also reports a similar injury involving the right foot that resulted in a 5th metatarsal fracture 9 months prior.

The initial injury was treated operatively with intramedullary screw (4.0 mm cannulated) fixation. He is 6.9ft tall, weighs 113kg and in good health. The patient is not taking medications and denies any drug allergies. After the initial ORIF, he played in the 2004 – 2005 season. He reported intermittent pain of his right foot at the time.

The patient was evaluated after sustaining the second injury. He walked with an antalgic gait and had no deformity or atrophy.

The foot was tender to palpation at the base of the 5th metatarsal. Neurovascular status was intact with normal range of motion of his right foot and ankle.

Plain radiographs of the right foot revealed a nonunion of the proximal 5th metatarsal right foot. There was a 4.0 mm intramedullary cannulated screw within the 5th metatarsal. The screw was bent on both the anteroposterior and oblique radiographs. (Figs. 1A and B)

 

Figures 1A and 1B Anteroposterior and oblique radiographic views of the right foot demonstrating a bent 4.0 mm cannulated intramedullary screw. (A)  The oblique radiograph demonstrates the nonunion of left proximal 5th metatarsal fracture. (B)

The lateral preoperative views also show bending forces within the screw. (Fig. 2)

Figure 2  Pre-operative lateral radiograph right foot demonstrating nonunion of left 5th metatarsal Jones fracture and bending of the screw fixation.

A computed tomography (CT) scan was ordered and revealed a 50% incomplete union of a fifth metatarsal fracture consistent with nonunion. (Figs. 3A and B)

 

Figures 3A and 3B  CT scan of the right foot demonstrating non-union of right proximal 5th metatarsal (arrow).(A) Reformatted CT scan right foot demonstrating plantar lucency involving 50% of the proximal plantar cortex. (B)

The patient was then scheduled for hardware removal, bone grafting and screw exchange with a larger diameter intramedullary fixation screw. Before surgery, the patient was placed in a CAM walker with weight bearing to tolerance. In surgery, the 4.0mm cannulated intramedullary screw was identified and removed. The nonunion site was identified and curettaged. Autogenous bone graft was harvested from the ipsilateral calcaneus. A larger diameter 6.5 mm screw was placed in the intramedullary canal to achieve appropriate stabilization. He was placed in a compressive dressing immediately postoperatively and transferred into a below-the-knee fiberglass cast on the fifth post-operative day. Clinical union was achieved at 6-weeks and the patient was then asymptomatic. He was advanced to protected weight bearing in a CAM walker. (Figs. 4A and B)

 

Figure 4A and 4B  Post-operative anteroposterior radiograph left foot demonstrating radiographic union after revisional surgery with a 6.5 mm solid screw. (A)  Post-operative lateral radiograph demonstrating complete radiographic union using a 6.5mm solid screw along the plantar cortex with good alignment. (B)

At this time, stationary biking exercises were permitted. At 3-month follow-up, complete radiographic consolidation was noted at the fracture site. A CT scan was ordered and demonstrated complete radiographic healing of the fracture at 5 months. (Figs. 5A and B) The patient was permitted to return to competitive sports at 6 month follow-up.

 

Figure 5A and 5B  Post operative CT scan demonstrating stable 6.5 mm solid screw fixation with complete fracture union right 5th proximal metatarsal. (A)  Post operative reformatted sagittal CT scan. Note the stable fixation and complete fracture union. (B)

Discussion

The type of screw fixation in the treatment of Jones fractures is controversial. Many surgeons support intramedullary screw fixation for Jones Fractures. [1,5,6,7,8,9] Kelly, et al., found that a 6.5 mm screw was superior to a 5.0 mm screw with respect to both pullout strength (in medullary canals greater than 5mm) and cantilever bending forces. [6] Excessive repetitive cantilever forces applied to a suboptimal smaller diameter screw may result in bending and ultimately screw failure resulting delayed or nonunion. For this reason, utilizing a large diameter screw in the larger athletic patient population has been advocated. [4,9,10] Vertullo, et al., encouraged utilizing an internal fixation device with the capability to resist torsion as well as bending. [11]

Refractures following initial intramedullary screw fixation of Jones fractures has been documented in athletes. Wright, et al., reported six refractures after complete radiographic and clinical union utilizing cannulated screw fixation of Jones fractures in athletes. [4]

The refractures were attributed to insufficient screw diameter in athletes with a larger body mass and failure to incorporate functional bracing during first season of play. Glasgow, et al., concluded that insufficient screw selection and vigorous return to activity appeared to correlate with failure and strongly discouraged intramedullary fixation with any device other than a 4.5 malleolar screw. [9]

Conversely, Porter, et al., reported on 23 consecutive athletes treated surgically with a 4.5 cannulated stainless steel screw for Jones fractures. [12] The authors reported 100% clinical healing, mean radiographic healing rate of 98.9% and a zero incidence of refracture in this series. Larson et al reported a 40% (6 of 15) failure rate of patients treated with initial intramedullary screw fixation. [10] There were a higher proportion of elite athletes (division I or professional level) among the failure group (83%) compared with those without complications (11%). None of the screws fractured in the failure group, but it was noted intraopratively that three were bent. There were no significant differences in age, sex, and screw diameter, use of bone graft or age of fracture between patients with failures and those without complications. In the current case report, suboptimal screw diameter was implicated as the precursor to refracture and failure.

Operative and non-operative treatment for Jones fractures has been described in the literature; however, in competitive athletic patients, operative treatment appears to be more favorable. [13,14] Due to vascularity, muscle insertions, and motion related to the fifth metatarsal, O’Shea, et al., recommend that most Jones fractures be internally fixated for a more rapid return to function. [15] Early operative treatments of acute Jones fractures results in quicker times to union and return to sports compared with cast treatment. [5,13,15,16] Konkel, et al., recommended nonoperative treatment of fifth metatarsal fractures for patients in whom the time to full activities is not critical. [17]

The fifth metatarsal shaft bowing and intramedullary canal width deserve special attention. If unrecognized, variations in 5th metatarsal diaphyseal anatomy could lead to intraoperative morbidity. Ebraheim, et al., demonstrated that the intramedullary canal is bowed and the dorsoplantar diameter is more than 1mm narrower than the mediolateral diameter. [18]

Pre-operative lateral and oblique radiographs allow assessment of severe lateral bowing of the shaft. [3] We concur with Ebraheim, et al., in that the intramedullary canal assessment allows for precise and accurate screw placement.

When utilizing intramedullary screw fixation for Jones fractures, we interpose the screw over the metatarsal under fluoroscopy. This facilitates accurate intramedullary screw selection and avoids potential intraoperative fracture.

Zelko, et al., reported that athletes in sports such as football or soccer are often able to participate in sports while the fracture is healing and basketball players are most disabled and require surgical treatment. [19] Kavanaugh, et al., noted a predilection for failure of varsity basketball players treated non-operatively. [13] In theory, the repetitive jumping and running of basketball increases cantilever bending at the fracture site compromising union.

Pietropaoli, et el., conducted a biomechanical study demonstrating no biomechanical difference between a 4.5mm malleolar screw and a 4.5mm partially threaded cancellous cannulated screw. [20] The physiologic loading of bone may be greater in the high performance athlete with a larger body mass; making smaller screws vulnerable to bending. In the study by Wright, et al., all patients were athletes and returned to full-speed activity an average of 8.5 weeks post-fixation. [4] Speculation on the cause of re-fracture included early return to activity, insufficient screw diameter, use of cannulated screws, and large patient body mass as possible sources. This case report is consistent with Wright’s study and we believe larger diameter screws are required in patients with a larger body mass.

In conclusion, intramedullary screw fixation provides excellent stabilization in proximal 5th metatarsal fractures. The 5th metatarsal diaphyseal anatomy and patient body mass deserve thorough consideration in selecting a screw that affords adequate endosteal purchase and stability.

References

1. Nunley JA. Jones fracture technique. Techniques in Foot and Ankle Surgery 2: 131 – 137, 2002.
2. Jones R. Fracture of the base of the fifth metatarsal bone by indirect violence. Ann Surg 35: 697 – 700, 1902.
3. Horst F, Gilbert BJ, Glisson RR, James A: Torque resistance after fixation of Jones fractures with intramedullary screws. Foot & Ankle Int 25 (12): 914 – 919, 2004.
4. Wright RW, Fischer DA, Shively RA, Heidt RS Jr, Nuber GW: Refracture of proximal fifth metatarsal (Jones) fracture after intramedullary screw fixation in athletes. Am J Sports Med 28 (5): 732 – 736, 2000.
5. DeLee JC, Evans JP, Julian J: Stress fractures of the fifth metatarsal. Am J Sports Med 11(5): 349 – 353, 1983.
6. Kelly IP, Glisson RR, Fink C, Easley ME, Nunley JA: Intramedullary screw fixation of Jones fractures. Foot Ankle Int 22 (7): 585 – 589, 2001.
7. Nunley JA. Fractures of the base of the fifth metatarsal: The Jones Fracture. Ortho Clin North Am 32: 171 – 180, 2001.
8. Shah SN, Knoblich GO, Lindsey DP, Kreshak J, Yerby SA, Chou LB: Intramedullary screw fixation of proximal fifth metatarsal fractures: a biomechanical study. Foot Ankle Int 22 (7): 581 – 584, 2001.
9. Glasgow, MT, Naranja, RJ, Glasgow SG, Torg JS: Analysis of failed surgical management of fractures of base of the fifth metatarsal distal to the tuberosity: The Jones fracture. Foot Ankle Int 17 (8): 449 – 457, 1996.
10. Larson C, Almekinders L, Taft T, Garrett, W: Intramedullary Screw Fixation of Jones Fractures: Analysis of Failure. Am J Sports Med 30: 55 – 60, 2002.
11. Vertullo C, Glisson R, Nunley J: Torsional Strains in the Proximal Fifth Metatarsal: Implication for Jones and Stress Fracture Management. Foot Ankle Int 25(9): 650 – 656, 2004.
12. Porter D, Duncan M, Meyer S: Fifth metatarsal Jones fracture fixation with a 4.5mm cannulated stainless steel screw in the competitive and recreational athlete: A clinical and radiographic evaluation. Am J Sports Med 33(5): 726 – 733, 2005.
13. Dameron TB Jr: Fractures of the proximal fifth metatarsal: selecting the best treatment option. J Am Acad Orthop Surg 3: 110 – 114, 1995.
14. Kavanaugh JN, Brower TD, Mann RV: The Jones fracture revisited. J Bone Joint Surg 60A: 776 – 782, 1978.
15. O’Shea MK, Spak W, Sant’Anna S, Johnson C: Clinical perspective of the treatment of 5th metatarsal fractures. JAPMA 85 (9) :473 – 480, 1995.
16. Mologne T, Lundeen J, Clapper M, O’Brien T: Early Screw Fixation Versus Casting in Acute Jones Fractures. Am J Sports Med 33 (7): 970 – 975, 2005.
17. Konkel K, Menger A, Retxlaff S. Nonoperative treatment of fifth metatarsal fractures in an orthopaedic surburban private multispecialty practice. Foot Ankle Int 26(9): 704 – 707, 2001.
18. Ebraheim NA, Haman SP, Lu J, Padanilam TG, Yeasting RA. Anatomical and radiological considerations of the 5th metatarsal bone. 21(3): Foot Ankle Int, 212 – 215, 2000.
19. Zelko RR, Torg JS, Rachum A: Proximal diaphyseal fractures of the fifth metatarsal (Jones) fracture after intramedullary screw fixation in athletes. Am J Sports Med 28: 732 – 736, 2000.
20. Pietropaoli MP, Wnorowski DC, Wener FW, et al. Intramedullary screw fixation of Jones fractures: A biomechanical study. Foot Ankle Int 20 (9): 560 – 563, 1999.

Address correspondence to: Dekarlos M. Dial, DPM, Cornerstone Foot and Ankle Specialists, 1814 West Chester Drive, Suite 300, High Point, North Carolina 27262

1  Chief, Foot and Ankle Division, Department of Orthopaedic Surgery; University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
2  3rd year resident, Department of Graduate Medical Education; University of Pittsburgh Medical Center Surgery, Pittsburgh, Pennsylvania.
3  Foot and Ankle Fellow, Department of Orthopaedic Surgery; University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.

© The Foot and Ankle Online Journal, 2009

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Treatment of Fourth Metatarsal Base Fracture Non-Unions in Middle Aged Women with Osteoporosis: A Case Study

Posted on July 1, 2008 | Comments Off on Treatment of Fourth Metatarsal Base Fracture Non-Unions in Middle Aged Women with Osteoporosis: A Case Study

by Lowell Weil, Jr., DPM, MBA, FACFAS1 , Patrick A. McEneaney, DPM2 , Jennifer L. Prezioso, DPM3

The Foot & Ankle Journal 1 (7): 5

Fourth metatarsal base fractures are an uncommon foot injury. These fractures can take extended periods of time to heal that is similar to a Jones fracture. The authors report on four metatarsal fractures, three of which resulted in non-unions in middle-aged women with osteoporosis. When conservative treatment failed, two cases were treated with open reduction and internal fixation while the other was treated with extracorporeal shockwave therapy. All three of these fractures ultimately led to radiographic union.

Key words: Fourth metatarsal base fracture, Jones fracture, osteoporosis, extracorporeal shockwave therapy

This is an Open Access article distributed under the terms of the Creative Commons Attribution License.  It permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. ©The Foot & Ankle Journal (www.faoj.org)

Accepted: June 2008
Published: July 2008

ISSN 1941-6806
doi: 10.3827/faoj.2008.0107.0005

Much has been written about proximal fifth metatarsal fractures, in particular the Jones fracture. These fractures are notorious for having a slow healing potential. [1,2] Because of this, more people are abdicating early fixation of the fracture with an intramedullary screw. Recently, there has been a growing concern regarding the delayed healing of fractures to the fourth metatarsal base.

Fourth metatarsal stress fractures commonly occur in the middle or distal diaphyseal regions. [3] Metatarsal stress fractures of the fourth and fifth metatarsals comprise only 1-3% of all metatarsal stress fractures. [4] Proximal fourth metatarsal fractures are less common. In an epidemiological study of metatarsal fractures, Petrisor, et al., found that out of 412 metatarsal fractures, only 9% of these fractures were of the fourth metatarsal and only 2.7% were at the proximal fourth metaphyseal region. [5]

Several authors have described delayed healing and non-unions of fourth metatarsal fractures and only conservative methods were utilized in each of these cases. [6,7,8,9] The authors report three metatarsal fractures that resulted in non-unions. In these three cases, the first two underwent surgical fixation of the fracture. The final case illustrates the use of extracorporeal shockwave therapy (ESWT) as an adjunct to provide adequate healing across the fracture site.

Case 1

A 47-year-old Caucasian female was evaluated for localized pain over the right fourth metatarsal after dropping a suitcase on her foot one month prior to her initial visit. She had been seen in the emergency room and diagnosed with a fracture. She was treated with a below-the-knee CAM boot and crutches.

Her past medical history included kidney and brain stem cancer. Her medications included the use of Acetaminophen/Vicodin, Spironolactone, Triamterene, and 2 mg of Dexamethasone daily for two years. She related to being unemployed and a non-smoker. She had no history of repetitive stresses to her feet associated with exercise. Clinical evaluation revealed mild edema at the dorsal lateral aspect of the right foot and pain was elicited with palpation along the right fourth metatarsal. Plain film radiographs revealed an incomplete non-displaced lateral break of the cortex to the proximal one third of the fourth metatarsal. The patient was instructed to remain partial weightbearing in a short leg walking boot.

At one month follow up, her pain had improved slightly, but there was no evidence of healing across the previously noted fracture site of the fourth metatarsal. She was kept partial weightbearing with the short leg walking boot. A combined magnetic field bone stimulator (DonJoy®, Vista, California) was also utilized three months post injury.

When the patient returned at four months post injury, the pain had not improved and a radiographic non-union with slightly displacement was observed.

After one more month in a stiff soled shoe and an accommodative insert, no healing across the fracture site was evident on CT scan. Therefore, the decision was made to utilize surgical intervention. The fracture site was cleaned of any debris and the bone ends were drilled to promote bleeding. Trinity™ Multipotential Cellular Bone Matrix (Blackstone Medical Inc., Springfield, MA) was placed in the fracture site and a Stryker four hole locking plate (Stryker, Kalamazoo, MI) was placed in a dorsal fashion over the fourth metatarsal. The patient was placed non-weightbearing in a below-the-knee cast.

After two weeks, the patient had minimal pain and, radiographically, the fracture was in normal anatomical alignment. She was allowed partial weightbearing in a short leg, below-the-knee boot for the next four weeks. During this time, she began physical therapy for range of motion, strengthening, and gait training. She healed uneventfully.

Case 2

A 67-year-old Caucasian female presented ten days following an inversion type ankle sprain. She had localized pain over the right fourth metatarsal. The patient admitted to being diagnosed with a stress fracture of her right foot approximately seven months prior for which she was instructed to ambulate with the use of a surgical shoe. Her past medical history included osteoporosis. Her present medications include Ibandronate, Amitripyline, Raloxifene, and Zolmitriptan. She is a non-smoker who worked part time as a teacher’s aid. Radiographs revealed a fracture to the right fourth metatarsal. She did not return to normal shoe gear until five months following the initial diagnosis.

There was significant edema over the dorsal lateral aspect of the right foot with pain noted along the fourth metatarsal, especially at the base. Plain film radiographs of the right foot revealed a complete non-displaced fracture of the proximal fourth metatarsal with mild gapping.

There was no callus formation across the fracture site. She was advised to be partial weightbearing in a short leg walking boot. After four weeks, her symptoms did not improve. Radiographs of the right foot were taken revealing no evidence of healing across the fracture site of the fourth metatarsal base. A new fracture at the diaphysis of the fifth metatarsal was noted. (Fig. 1)

Figure 1  Plain film radiographs of the right foot display a complete non-displaced fracture of the proximal fourth metatarsal with mild gapping.  A non-displaced fifth metatarsal fracture is also seen.

The patient was instructed to continue partial weightbearing in the below-the-knee walking boot.

After five more weeks, there were still no signs of healing at the fourth metatarsal, and there was an incomplete midshaft fracture at the fifth metatarsal.

Since the fourth metatarsal fracture showed no evidence of healing, the patient elected for open reduction internal fixation of the fourth right metatarsal. A dorsal approach was performed to access the fourth metatarsal base. (Fig. 2)

Figure 2  Intra-operative picture of fracture non-union.

The fracture site was cleaned of any debris, and the bone ends were drilled to promote bleeding. (Fig. 3).

Figure 3  Intra-operative picture of drilling the fractured ends.

Trinity™ Multipotential Cellular Bone Matrix was placed in the fracture site (Fig.4) and a Stryker® four hole locking plate was placed in a dorsal fashion over the fourth metatarsal (Fig. 5)

Figure 4  The fracture defect is packed with Trinity™ Multipotential Cellular Bone Matrix.

Figure 5  A Stryker® Locking plate is used to bridge the fracture site.

She was placed non-weightbearing in a below the knee cast and healed uneventfully in six weeks time. After 2 months, the fracture site revealed good bone consolidation and healing. (Fig. 6)

Figure 6   Radiographs show good bone consolidation and healing of the fourth metatarsal fracture site 2 months after surgery.

Case 3

A 46-year-old Caucasian female presented with a chief complaint of lateral metatarsal pain to both feet. She was an avid runner with a history of stress fractures over the previous four years.

Her most recent stress fracture was at the left fourth metatarsal diagnosed two months prior to her initial presentation. She had been placed partial weightbearing in a boot for one month and was later transitioned into orthotic devices and her running shoes. The right foot had been pain free while there was moderate pain of the left foot.

Her past medical history was remarkable for osteoporosis and acid reflux. The patient’s current medications included Risedronate, Lansoprazole, and Norethindrone/Ethinyl Estradiol. She is a non-smoker. There is localized tenderness over the fourth and fifth metatarsal bases of the right foot and no edema was seen over the area. Biomechanical examination revealed equinovarus and a severe metatarus adductus deformity bilaterally. A bone stimulator was placed on the foot for use thirty minutes a day. She was instructed to refrain from running.

She was seen one month later with report of no improvement in her symptoms. Plain film radiographs revealed evidence of new bone callus formation across the fifth metatarsal fracture sites of the right, and no change of the left fourth metatarsal fracture. She was instructed to be partial weightbearing in a surgical shoe on the left and to continue to limit her activities. Five months post injury, her pain had slightly improved, and she was still quite tender to palpation over the fourth metatarsal. Radiographs of the left foot revealed hypertrophic nonunion of the fourth metatarsal, while the right foot fracture demonstrated signs of osseous bridging. (Fig. 7)

Figure 7   Fourth metatarsal fracture of case # 3 (left foot only) showing painful, hypertrophic non-union. 

She expressed no interested in surgery; therefore she was treated with high energy ESWT followed by a period of partial weightbearing in a walking boot. The patient received ESWT with Intavenous Anesthesia. A Orbasone™ electrohydraulic device was utilized at 22 Kv for 4000 shocks directly over the fracture/nonunion site. At one month follow up, her pain had completely resolved, and there was minimal localized tenderness upon palpation of the fracture site. (Fig. 8)

Figure 8   Fourth metatarsal fracture of case # 3 after a single treatment of ESWT. 

Radiographs revealed some consolidation across the fracture site. The patient was allowed to begin light exercise with avoidance of high impact activity. Three months following ESWT, the patient had no tenderness to palpation of the left fourth metatarsal. Radiographs showed continued consolidation of the fracture site.

Discussion

Hetsroni, et al., theorized that proximal fourth metatarsal fractures may be related to anatomic, functional, and vascular mechanism similar to the Jones fracture. [6] The nutrient artery to the fourth metatarsal enters on the lateral side, while the fifth metatarsal nutrient artery enters on the medial side. [10] Due to their close anatomical relationship, both arteries are subject to similar biomechanical forces that can result in injury. The fourth and fifth metatarsals perform similar actions by allowing for adduction and plantarflexion of the foot. Therefore, abnormal biomechanical forces can traverse both metatarsals.

Theodorou, et al., reported six patients with metatarsal stress fractures associated with an adducted forefoot. [9] These patients did not have the history of repetitive impact activity, but some of the patients had a history of poor bone stock, a neuropathic foot, or multiple stress fractures. It was found that 77% were in a transverse pattern and 86% were located in the proximal one third. The patients were kept non-weightbearing or partial weightbearing with an orthotic device and healed without complication in four to eight weeks. The third case of fourth metatarsal fracture occurred in a severely adducted forefoot while there was a mild metatarsus adductus in the first case. These factors may have also contributed to the occurrence of other fractures.

In a series of five fourth metatarsal fractures in active people, Saxena, et al., found that the healing time of these injuries was eight to sixteen weeks. [8] They also found that patients who did not go through the recommended period of immobilization took up to eight months to return to normal activity. Their recommendation is non-weightbearing with below-the-knee cast immobilization or walking boot.

Shearer and Penner reported two stress fractures of the fourth metatarsal bases that occurred in healthy patients with normal bone stock and without an adducted forefoot, but a mild pes planus. [7] These patients were treated with below-the-knee cast immobilization for eight weeks followed by gradual return to activities and orthoses. [7] After cast removal, they recommended that activities should be gradually resumed and appropriate orthoses considered. The authors concluded that final evaluation of the fracture healing should be based on clinical findings and the CT scan because radiographs may not demonstrate bony union.

In this series, after up to six months of conservative care, there was little evidence of radiographic healing and the patients were still symptomatic. In the first two cases, surgical intervention achieved satisfactory results.

Locking plate technology was used to create stability across the fracture sites. Trinity™ Multipotential Cellular Bone Matrix was placed in the fracture site to provide a rich source of stem cells with osteogenic, osteoinductive and osteoconductive properties to aid in bone healing.

In the third case, high energy ESWT was utilized to facilitate healing of the fracture site. High energy ESWT has been shown to promote fracture healing and have a lower non-union rate versus control groups. [11] Bara and Snyder found ESWT to be an effective treatment for delayed union or non-union of bone with a union rate of 83% after three to six months. [12] In a study by Wang, et al., the results of shockwave treatment were similar to the results of surgical treatment for chronic non-unions. [13]

In this case series, all patients were middle-aged postmenopausal women. The fracture in the first case was caused by direct trauma and most likely resulted in a non-union secondary to long term oral corticosteroid use. Corticosteroids are well known to cause osteoporosis and increase the risk of pathological fracture. [14,15,16] In all three of these cases, decreased bone mineral density may have been a contributing factor. While objective bone density values were not identified in these two patients, the patients were being treated with bisphosphonates for osteoporosis.

All patients were partial weightbearing in a below-the-knee pneumatic walking boot. In all reports, patients were either instructed to be non-weightbearing in a below-the-knee cast/boot [7,8.9] or partial weightbearing in an orthotic device. [9] All fractures resulted in union. It is unclear whether these fractures would have healed if the patients were kept non-weightbearing.

Conclusion

The authors believe fourth metatarsal base fractures, like fifth metatarsal fractures (Jones fracture), have a tendency towards prolonged healing and non-union.

Other factors such as decreased bone mineral density and long term steroid therapy may also contribute to non-union. While most fractures will heal with extended conservative care, surgical intervention is often necessary in patients with painful non-unions. Extracorporeal shockwave therapy can be considered in those patients with delayed unions or in patients with non-unions that are not interested in surgery. The authors feel that early surgical intervention may result in decreased disability and earlier return to normal activity.

References

1. O’Shea, M. et al Clinical Perspective of the Treatment of Fifth Metatarsal Fractures. J Am Podiatr Med Assoc. 85 (9): 473-480, Sep 1995.
2. Holmes, G. et al Treatment of Delayed Unions and Non-unions of the Proximal Fifth Metatarsal with Pulsed Electromagnetic Fields. Foot Ankle Int. 15 (10): 552-556, Oct 1994.
3. Meurman, K. Less common stress fractures in the foot. Br J Radiol. 54(637): 1-7. Jan 1981.
4. Levy, J. Stress fractures of the first metatarsal. AJR Am J Roentgenol. 130(4): 679-81. Apr 1978.
5. Petrisor, B. et al The Epidemiology of Metatarsal Fractures. Foot Ankle Int. 27 (3): 172-174, Mar 2006.
6. Hetsroni, I. et al Base of Fourth Metatarsal Stress Fracture: Tendency for Prolonged Healing. Clin J Sport Med. 15 (3): 186-188, May 2005.
7. Shearer, C. et al Stress Fractures of the Base of the Fourth Metatarsal: 2 Cases and a Review of
the Literature. Am J Sports Med. 35 (3): 479-483, Mar 2007.
8. Saxena, A. et al Proximal Fourth Metatarsal Injuries in Athletes: Similarity to Proximal Fifth Metatarsal Injury. Foot Ankle Int. 22 (7): 603-608, Jul 2001.
9. Theodorou, D. et al Stress Fractures of the Lateral Metatarsal Bones in Metatarsus Adductus Foot
Deformity: A Previously Unrecognized Association. Skeletal Radiol. 28 (12): 679-684, Dec 1999.
10. Shereff, M. et al Vascular Anatomy of the Fifth Metatarsal. Foot Ankle. 11 (6): 350-353, Jun 1991.
11. Wang, C. et al The Effects of Extracorporeal Shockwave on Acute High-Energy Long Bone Fractures of the Lower Extremity. Arch Orthop Trauma Surg. 127 (2): 137-142, Feb 2007.
12. Bara, T. et al Nine Years Experience with the Use of Shock Waves for Treatment of Bone Union Disturbances. Ortop Traumatol Rehabil. 9 (3): 254-258, May-Jun 2007.
13. Wang, C. et al Treatment of Non-unions of Long Bone Fractures with Shock Waves. Clin Orthop Relat Res. 387: 95-101, Jun 2001.
14. Adachi, J. Corticosteroid-Induced Osteoporosis. Am J Med Sci. 313 (1): 41-49 Jan 1997.
15. Eastell, R. et al A UK Consensus Group on Management of Glucocorticoid-Induced Osteoporosis: An Update. J Intern Med. 244 (4): 271-292, Oct 1998.
16. Van Staa, T. et al Use of Oral Corticosteroids and Risk of Fractures. J Bone Miner Res. 20 (8): 1487-1494, Aug 2005.

 
Address correspondence to: Dr. Lowell Weil, Jr. DPM, MBA, FACFAS. Weil Foot & Ankle Institute, Des Plaines, IL. 60016.
Email: lwj@weil4feet.com.

1 Fellowship Director, Weil Foot and Ankle Institute, Des Plaines, IL. 60016
2 PGY-3, Thorek Memorial Hospital/Weil Foot & Ankle Institute. 850 W. Irving Park Road. Chicago, Il. 60613
3 PGY-1, Thorek Memorial Hostpial/Weil Foot & Ankle Institute. 850 W. Irving Park Road. Chicago, IL. 60613.

© The Foot & Ankle Journal, 2008

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