ORIGINAL ARTICLE
Likelihood of Surgery in Isolated Pediatric
Fifth Metatarsal Fractures
Susan T. Mahan, MD, MPH,* Jason S. Hoellwarth, MD,w Samantha A. Spencer, MD,*
Dennis E. Kramer, MD,* Daniel J. Hedequist, MD,* and James R. Kasser, MD*
Background: Fractures of the fifth metatarsal bone are common
and surgery is uncommon. The “Jones” fracture is known to be in
a watershed region that often leads to compromised healing,
however, a “true Jones” fracture can be difficult to determine, and
its impact on healing in pediatric patients is not well described.
The purpose of this study was to retrospectively assess patterns of
fifth metatarsal fracture that led to surgical fixation in an attempt
to predict the likelihood for surgery in these injuries.
Methods: A retrospective review was performed on patients aged
18 and under who were treated for an isolated fifth metatarsal
fracture from 2003 through 2010 at our pediatric hospital. Patient demographics, treatment, and complications were noted.
Radiographs were reviewed for location of fracture and fracture
displacement. Patients and fracture characteristics were then
compared.
Results: A total of 238 fractures were included and 15 were
treated surgically. Most surgical indications were failure to heal
in a timely manner or refracture and all patients underwent a
trial of nonoperative treatment. Jones criteria for fracture location were predictive of needing surgery (P < 0.01) but confusing in the clinic setting. Fractures that occurred between 20
and 40 mm (or 25% to 50% of overall metatarsal length) from
the proximal tip went on to surgery in 18.8% (6/32) of the time,
whereas those that occurred between <20 mm had surgery in
4.9% (9/184). This was a statistically significant correlation
(P = 0.0157).
Conclusions: Although fractures of the fifth metatarsal are
common, need for surgery in these fractures is not. However, a
region of this bone is known to have trouble healing, and it can
be difficult to identify these “at-risk” fractures in the clinical
setting. We found simple ruler measurement from the proximal
tip of the fifth metatarsal to the fracture to help determine this
“at-risk” group and found a significant difference in those patients with a fracture of <20 mm compared with those 20 to
40 mm from the tip; this can help guide treatment and counsel
patients.
From the *Department of Orthopaedic Surgery, Boston Children’s
Hospital, Harvard Medical School, Boston, MA; and wDepartment
of Surgery, Metropolitan Hospital Center, New York, NY.
There was no external funding source for this study.
The authors declare no conflicts of interest.
Reprints: Susan T. Mahan, MD, MPH, Department of Orthopaedic
Surgery, Boston Children’s Hospital, Harvard Medical School, 300
Longwood Ave, Boston MA 02115. E-mail: susan.mahan@childrens.harvard.edu.
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Level of Evidence: Level 3.
Key Words: metatarsal fracture, Jones fracture, pediatric foot
fracture
(J Pediatr Orthop 2015;35:296–302)
F
ractures of the fifth metatarsal, in adults and children,
usually unite following 6 weeks of casting.1,2 Fractures
of the proximal metaphyseal-diaphyseal junction or proximal diaphysis—the Jones fracture—are known to be in a
watershed region of bone perfusion, and as such, frequently
have a less favorable course, often requiring prolonged
immobilization or surgery to achieve union.2,3 This is
thought to be due to a watershed region of poorly perfused
bone.3–6 Existing diagnostic criteria are qualitative, often
confusing or inconsistent among authors1–3 and can be
even more confusing.4 Differentiating the “at-risk” fractures from the more routine aids patient counseling.2,7,8
Multiple classification systems have been proposed
for fifth metatarsal fractures due to different clinical outcomes and therefore differing treatment recommendations
based on the subtleties of location of the fracture.2,5,9 It is
difficult in the busy clinical setting to remember and differentiate the important differences of any 1 classification
with regard to the expected clinical outcome and recommended treatment.4 Some commonly used classifications
are only applicable once initial management has failed, and
thus cannot guide initial treatment and counseling. Other
classification includes “zones” which may be confusing
when a fracture line crosses into different zones.5 As such, a
simple method of quantitatively identifying the “at-risk”
fractures seems needed.
Minimal attention has been given to these fractures in
children. Herrera-Soto et al2 presented a classification for
fifth metatarsal fractures in children (see classification in the
Materials and methods section below). They note that some
type II fractures (intra-articular) and most type III fractures
are at risk for difficult healing and recommend a non–
weight-bearing cast for those particular injuries.2
The primary purpose of this study is to retrospectively assess patterns of isolated fifth metatarsal
fractures in the pediatric population, and to predict which
injuries are more likely to undergo surgery. We hope
to find an easier and perhaps quantitative way to determine which fractures are at risk for poor healing. The
J Pediatr Orthop
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J Pediatr Orthop
Volume 35, Number 3, April/May 2015
secondary purpose is to describe isolated fractures of the
fifth metatarsal in a large pediatric population.
METHODS
Institution Review Board approval was obtained
before the initiation of this study. A retrospective review
was undertaken at our large pediatric hospital using the
ICD-9 code for metatarsal fracture (825.25) and a search
for the term “metatarsal” in the department of orthopaedic surgery’s electronic charting database. A total of
931 patients were seen from 2003 to 2010. Inclusion criteria were age 18 years or younger at injury, fracture
isolated to fifth metatarsal, and the bulk of care received
by our medical center. Exclusion criteria were patients
with fractures of >1 metatarsal, multiply injured patients, syndromic or neuromuscular patients, and fractures resulting from tumors or cysts.
These criteria produced our study cohort of 238
fractures. Average age is 12.8 years (SD = 2.84; range, 2
to 18 y) and boys comprise 55.9% (133/238) of the cohort.
Chart review included appropriate demographics and
fracture-related information, including whether initial
management was casting or surgery, whether surgery was
ever required, the indication for surgery, and relevant
comorbidities. Radiographs were available in 238 patients
and were reviewed for location of fracture lines, overall
length of metatarsal, magnitude of displacement, translation, and angulation. Some patients had open physes and
apophyses and in some older patients the apophyses were
completely fused. Classification by Herrera-Soto et al2 were
applied to each fracture as radiographs were available.
Each fracture was evaluated for its distance from the
proximal tip of the fifth metatarsal. Using the digital ruler
the distance from the ossified tip of the proximal fifth
metatarsal to the most proximal extent of the fracture was
measured. The overall length of the metatarsal using digital
ruler was recorded as well (Figs. 1, 2).
The Herrera-Soto et al’s2 classification classifieds
the fifth metatarsal fracture into 5 types. Type I fractures
were apophyseal injuries or fractures at the base of the
fifth metatarsal, also known as a “fleck injury.” Type II
fractures were tubercle fractures with intra-articular extension, and can extend to the metatarsal-cuboid joint.
Type III injuries are at the metadiaphyseal junction, also
often known as the “Jones fracture.” They also included
diaphyseal fractures (type IV) and metatarsal neck fractures (type V) separately. Differentiation between type II
and type III fractures was not clarified.
Data Analysis
Statistical significance was set a priori at P < 0.05
(2-tailed). These variables were recorded as continuous
data: age (y), degree if angulation of fracture, maximal
displacement of fracture, distance of fracture from proximal fifth metatarsal tip, overall length of the fifth metatarsal, and time (wk) from injury to surgery. The distance
of the fracture from the proximal fifth metatarsal tip was
divided by overall length of the metatarsal to obtain the
percentage length of the fracture on the fifth metatarsal.
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Surgery in Isolated Pediatric Fifth Metatarsal Fractures
Data were compared between patients using Student t test
in SAS 9.1.3 (Cary, NC).
Categorical data were recorded based on the HerreraSoto classifications. Data were compared by analysis of
variance in SAS, or if no more than 3 categories by Fisher
exact test in SAS. The continuous data of distance of
fracture from proximal fifth metatarsal tuberosity was
categorized into 9 categories: 0 to 4.99 mm, 5.0 to 9.99 mm,
10 to 14.99 mm, 15 to 19.99 mm, 20 to 24.99 mm, 25 to
29.99 mm, 30 to 34.99 mm, 35 to 39.99 mm, and Z40 mm.
The continuous data of percentage length of the fracture on
the fifth metatarsal was categorized into 9 categories: 0% to
4.9%, 5.0% to 9.9%, 10% to 14.9%, 15% to 19.9%, 20%
to 24.9%, 25% to 29.9%, 30% to 34.9%, 35% to 39.9%,
Z40%. These were then compared based on the rate of
surgery. Further dichotomization of these data was done,
such that fractures of 0 to 24.99 mm from the proximal fifth
metatarsal tuberosity were compared with those Z25 to
40 mm and > 40 mm, as well as those 0% to 24.9% from
those 25% to 39.9% and >40%. Dichotomous data were
also recorded for sex and surgery (yes/no). Comparisons
were made using Fisher exact test in SAS.
RESULTS
Of the 238 fractures, 15 (6.3%) were treated operatively, whereas 223 were treated nonoperatively. Most
surgical indications were failure to heal in a timely manner or refracture (Table 1). No patient had surgery necessitated by an open fracture or compartment syndrome.
Of the 15 patients who underwent surgery, average
age at time of injury was 15.1 years, whereas for those
treated nonsurgically; average age was 12.7 years
(P < 0.01). No one under the age of 11 years underwent
surgery for his or her fifth metatarsal fracture. There was
also male sex predominance in those treated surgically for
this fracture, with 86.7% (13/15) boys, whereas those
treated nonsurgically was more balanced with 53.8%
boys (120/223); this was also significant (P = 0.0146).
Herrera-Soto classification was applied to all fractures (Table 2). There was a statistically significant difference in Herrera-Soto classification for those treated
surgically compared with those nonsurgically (analysis of
variance, P < 0.001), which was maintained even when
just the Herrera-Soto II were compared with HerreraSoto III fractures (Fisher exact test, P = 0.0109).
Upon grouping fracture location based on distance
from proximal fifth metatarsal by 5-mm intervals we
found that as the fragment length became >20 mm, a
substantial increase in surgery was seen (Fig. 3). We then
grouped the patients into 3 groups based on the distance
of the fracture from the proximal tip of the fifth metatarsal: <20 mm zone, 20 to 40 mm zone, and >40 mm
zone. With those divisions, we found that 81.3% (26/32)
fractures within a region of 20 to 40 mm from the tuberosity were able to be treated nonoperatively, compared
with 95.1% (175/184) of fractures proximal to 20 mm
(P = 0.0157). None of the 22 isolated fifth metatarsal
fracture distal to 40 mm had surgery in this series.
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FIGURE 1. Radiographic images showing the right foot of a 13-year-old boy who sustained a proximal fifth metatarsal fracture
that went on to symptomatic nonunion. Oblique views show before surgery (A) and after surgical fixation (B). Note the distance
from the proximal tip of the fifth metatarsal to the fracture site is 7.3 mm. This puts him in the lower risk group for likelihood of
surgery.
The age of patients who sustained fractures in the
<20 mm zone were significantly different from those in
the 20 to 40 mm zone and this was true for those treated
both nonsurgically and surgically. For all patients, those
who had fractures in the <20 mm zone had a mean age of
12.4 years (SD = 2.5) and those who had fractures in the
20 to 40 mm zone had a mean age of 15.1 years (SD =
3.7) (Student t test, P < 0.001). For those treated surgically, patients in with fractures in the <20 mm zone had a
mean age of 13.7 years (SD = 0.93) and those in the 20 to
40 mm zone had a mean age of 17.4 years (SD = 0.64)
(Student t test, P < 0.001).
There were 32 patients with a fracture in the 20 to
40 mm zone. None of the patients aged 15 or under
(n = 6) had surgery for a fracture in the 20 to 40 mm zone
in our series (Table 1). In the 22 patients over the age of
15 with a fracture in the 20 to 40 mm zone, 27.3% (6/22)
had surgery. When patients over the age of 15 only are
included, no patients in the <20 mm zone had surgery (0/
22), 27.3% of the patients in the 20 to 40 mm zone had
surgery (6/22), and no patients in the >40 mm zone had
surgery (0/6) (P = 0.0047).
We also determined if patients with fractures in the 20
to 40 mm zone had different indications for surgery and
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time from initial injury to surgery than those in the
<20 mm region (Table 1). There were 3 patients who had
surgery for refracture, where the initial injury was treated
nonsurgically, 2 in the <20 mm zone and 1 in the 20 to
40 mm zone. For the remaining 12 patients treated surgically, only 1 patient had surgery <3 weeks after injury and
they had a fracture in the 20 to 40 mm zone. As 1 patient
with a fracture in the 20 to 40 mm zone had surgery almost
immediately (1 wk after injury), we revisited our analysis
omitting this patient. When comparing the patients treated
at least 3 weeks after their injury and due to failure to show
satisfactory healing, those with fractures proximal to the
20-mm threshold were treated nonoperatively 95.1% (175/
184) and those in the 20 to 40 mm zone were treated nonoperatively 83.9% (26/31) (P = 0.035).
We also assessed fracture location based on a percentage of the overall metatarsal length. The average
metatarsal length in this group was 71.6 mm (SD = 9.8)
and in patients over age 11 years, the average metatarsal
length was 75.1 mm (SD = 7.2). When the percentage of
metatarsal length was group by 5% increments, results
were similar to the grouping by 5-mm increments. A
slightly cleaner bimodal picture was noted, however,
when groups were put into 3 zones (< 25%, 25% to 50%,
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J Pediatr Orthop
Volume 35, Number 3, April/May 2015
Surgery in Isolated Pediatric Fifth Metatarsal Fractures
FIGURE 2. Radiographic images showing the left foot of a 16-year-old boy who sustained a proximal fifth metatarsal fracture. He
was non–weight-bearing on this leg for 8 weeks before radiographs failed to show satisfactory healing and surgery was recommend. Oblique views show before surgery (A) and after surgical fixation (B). Note the distance from the proximal tip of the
fifth metatarsal to the fracture site is 32.9 mm. This puts him the higher risk group for likelihood of surgery.
>50%) the analysis was very similar from that based on
length of fracture from the proximal tip of the metatarsal.
When angulation (degrees) and displacement (mm)
of the fracture fragment were compared between the
group who had surgery and the group who did not, no
difference was seen.
Fifteen of our patients had surgery for their fifth
metatarsal fracture; 10 different surgeons were involved. In
all cases a 4.0- or 4.5-mm screw was used, usually cannulated. A washer was utilized in some cases. In all but 1 case
the screw was placed from the proximal tip of the fifth
metatarsal in an intramedullary antegrade manner. Complications were seen in 3 patients: 1 had infection of the
screw and excision of the screw and proximal fragment; 1
had screw migration and revision with removal of the
screw, excision of the proximal metatarsal, and reattachment of the peroneus brevis tendon; and 1 other patient had
nonunion and screw migration also with screw removal,
proximal fragment excision and reattachment of the peroneus brevis tendon (Table 1). The complications were all
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in proximal avulsion-type fractures (< 20 mm from proximal tip of the fifth metatarsal). Two additional patients
had elective symptomatic screw removal. All other patients
healed uneventfully.
DISCUSSION
Isolated fractures of the fifth metatarsal must be
managed based on their location. The greatest attention
has been given to fractures of the proximal metaphysealdiaphyseal junction or proximal diaphysis and the tuberosity.1 Although Jones was the first to describe the
fracture (and ultimately gave his name),10 its exact location has been the topic of some debate, with some authors
noting it as the proximal diaphysis2 and others noting it
as the metaphyseal-diaphyseal junction.1,3,4 It is important to differentiate the “Jones” fracture from the
more proximal tuberosity fracture. Some authors have
noted that this differentiation is merely semantics, as both
areas can be troublesome with healing2–4; however,
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Mahan et al
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TABLE 1. Surgical Indications, Timing, and Complications
Patient
Age (y)
Sex
Indications for Surgery
Patients with fracture <20 mm distance from proximal fifth metatarsal
13
Male
Failure to show signs of healing
radiographically and clinically
11
Male
Failure to show signs of healing
radiographically and clinically
13
Male
Symptomatic nonunion
15
Male
Symptomatic nonunion
13
Male
12
Male
14
Female
14
Male
14
Male
Failure to show signs of healing and
further displacement after
conservative measures
Symptomatic nonunion
Symptomatic nonunion
Multiple refractures and failure of
conservative management
Refracture, failure to heal since
most recent fracture
Time from
Injury to
Surgery
Procedure
Complications
25 d, 3.5 wk
ORIF
None
33 d, 4.5 wk
ORIF
None
8 mo
> 3 mo
24 d, 3.5 wk
ORIF
ORIF with tibial
bone graft
ORIF
None
Infection and excision of proximal
fragment 3 mo later
None
> 6 mo
ORIF
12 mo
ORIF
2y
ORIF
Revision and excision or proximal
fragment and reattachment of
peroneous brevis
Nonunion and screw migration,
screw removed, and peroneous
brevis reattached
None
>1 y since initial
injury, 3 mo
since most
recent injury
ORIF
Elective screw removal
ORIF
ORIF
None
None
ORIF
ORIF
ORIF
ORIF
Elective screw removal
None
None
None
Patients with fracture 20-40 mm distance from proximal fifth metatarsal
18
Male
Symptomatic nonunion
5 mo
17
Female
Failure to show signs of healing
5 wk
radiographically and clinically
17
Male
Symptomatic delayed union
8 wk
16
Male
Symptomatic delayed union
8 wk
18
Male
Acute fracture in a soccer player
1 wk
17
Male
Refracture (twice)
1 y since original
injury
ORIF indicate open reduction and internal fixation.
identifying the zone where healing is difficult is still crucial
and often difficult in the clinical setting.4 Fractures of the
proximal tuberosity will usually heal with conservative
management, usually with weight-bearing in a cast or
boot.2,3,9,11–20 However, the proximal metaphyseal-diaphyseal junction and proximal diaphysis remains the area
of difficulty in treatment of fractures to this bone due to a
watershed region of poor perfusion in this location,4,9 and
this is true both in adults and adolescents.2,3 The difficulty
is often differentiating between the fractures that are
likely to heal uneventfully, and the “at-risk” fractures that
may have delayed or difficult healing. Multiple descriptive
classifications have been proposed,2,5,9 but none that is
simple to remember and easy to use at the initial patient
encounter.
We found a simple ruler measurement predictive of
surgery for fifth metatarsal fractures. Patients who had
fractures between 0 and 20 mm of the proximal aspect of
the fifth metatarsal ended up getting surgery 4.9% (9/
184), whereas those 20 to 40 mm had surgery 19% (6/32)
and those >40 mm had no surgery (0/22); this was significant (P < 0.01). This was even more apparent when
TABLE 2. Classification by Herrera-Soto Including Treatment by Classification
Herrera-Soto Classification
I = apophyseal injury
II = tubercle fracture with intra-articular extension
III = Jones fractures
IV = diaphysis
V = head/neck
Total
Total No.
Patients
Patients
(%)
Patients Treated
Nonsurgically
Patients Treated
Surgically
47
132
24
27
8
238
19.7
55.5
10.1
11.3
3.4
100
47
123
18
27
18
223
0
9
6
0
0
15
There was a statistically significant difference in Herrera-Soto classification for those treated surgically compared with nonsurgically (analysis of variance, P < 0.001),
which was maintained even when just the Herrera-Soto II were compared with Herrera-Soto III fractures (Fisher exact test, P = 0.0109).
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J Pediatr Orthop
Volume 35, Number 3, April/May 2015
FIGURE 3. Chart showing percentage of fractures needing
surgery in 5-mm increments measured from the proximal tip
of the fifth metatarsal. The percentage needing surgery is
noted to increase between 20 and 40 mm. There were no
cases where a fracture over 40 mm from the proximal tip of
the fifth metatarsal was determined to need surgery.
only patients over the age of 15 were included. We
also found that fracture location based on an overall
percentage of fracture length was also predictive of surgery, and while this data were visually “cleaner,” it was
not statistically different. We found that distance measuring was simpler, particularly given that surgical treatment of this fracture is in the age of the mostly skeletally
mature child. Certainly by identifying the watershed region of poor healing for fracture management in the
skeletally immature patient the percentage of overall
fracture length can be detected. This simple ruler or
percentage measurement obviates the confusion about
which fractures are “Jones” fractures, and even which
bony landmarks are indicative of poorly healing fractures.4 Other authors have noted this similar watershed
region as being problematic for healing, with an increase
in rates of surgery and delayed healing.3–6 Dameron11
identified the 1.5-cm segment distal to the tuberosity as
the region at greatest risk of poor outcome. Our at-risk
region from 20 to 40 mm is consistent with the size of
Dameron’s observation and appears to correlate with
Smith et al’s21 investigation of the arterial watershed region of the fifth metatarsal.
The difficulty is determining which fractures are in
this zone and warrant increased concern. This simple
ruler measurement can be performed easily and quickly
on any digital imaging system as well as on plain radiographic images to determine if a particular patient’s
fracture falls within this concerning zone. The purpose of
our study is to improve the identification of the zone of
the fifth metatarsal where fractures are at greatest risk for
difficulty healing, and we found this zone to be 20 to
40 mm or 25% to 50% of overall metatarsal length when
measured from the proximal tip of the fifth metatarsal. This
is the zone which may develop delayed healing or nonunion
so that physicians may more confidently and reliably provide informed expectations for management—be it conservatively or operative—at a patient’s initial visit.4,22 It is
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Surgery in Isolated Pediatric Fifth Metatarsal Fractures
also interesting to note that the more proximal fractures,
<20 mm from the proximal tip of the fifth metatarsal,
occur in the younger adolescent, whereas the slightly more
distal fractures, 20 to 40 mm from the proximal tip, occur in
the older adolescent with mature bone.
Our cohort of 238 patients is the largest single-series
review of isolated fifth metatarsal fractures in pediatric
patients, and among the largest overall, which we have
found in the literature. However, we recognize several
limitations. Our primary limitation is using surgery as an
endpoint when it remains somewhat of a subjective choice
by each surgeon and patient, particularly in a retrospective study. However, all of the patients except one
had surgery after a reasonable trial of nonoperative
treatment and went on to surgery after lack of timely
clinical and radiographic healing was evident. One patient
received primary surgery within the first 3 weeks of injury,
which is often done to facilitate return to competitive
athletics; this particular injury may have healed with
nonoperative means. Even when this patient is removed
from the analysis, however, the increased risk in failure of
nonoperative management holds true for fractures of 20
to 40 mm from the proximal tip of the fifth metatarsal. All
other patients underwent surgery for failure to show signs
of healing in a timely manner with ongoing clinical
symptoms. There were patients in this series with painless
nonunions, particularly of the avulsion fracture type. This
number is difficult to quantify because not all patients had
radiographs through bony union, and many asymptomatic patients returned to sports and activities without a
final radiograph; a few who did have a radiograph suggested a possible asymptomatic nonunion. Surgery was
never done for an asymptomatic nonunion. Furthermore,
management varied (eg, cast or boot, weight-bearing or
not) in this large retrospective series with many orthopaedists treating these injuries and it is impossible to
synthesize the treatment. Certainly, some patients may
have continued to experience symptoms after being
cleared for activity but gone elsewhere for subsequent
management. Finally, as a pediatric referral-based hospital we may have seen more fractures that needed surgery than would be typical in the general population.
There has been a relative paucity of data regarding
pediatric metatarsal fractures. Owen et al13 determined the
rate of general metatarsal fractures in children but offered
no guidance for management. Singer et al23 reported on a
consecutive series of 166 metatarsal fractures in 125 children and described their epidemiology and fracture demographics. They found that children who were 5 years old or
less were more likely to sustain their injury inside the house
than older children. They also found that this younger
group was more likely to fracture the first metatarsal and
the older than 5-year group was more likely to fracture the
fifth metatarsal.23 Unfortunately, this did not help differentiate treatment needs. Herrera-Soto et al2 has the most
complete discussion of pediatric fifth metatarsal fractures,
including a classification system, and noted that outcomes are
comparable with adults. They did not provide a picture or
examples of their classification. Although little has been
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available in the literature about pediatric fifth metatarsal
fractures, our experience has been fairly consistent with the
adult literature. However, the difficulty often remains
determining which fractures are the likely-to-heal proximal
fractures, and which are the more-difficult-to-heal “Jones”
fracture. This can lead to a confusing discussion with the
patient, and often unrealistic expectations in the more difficult injury.
In conclusion, we found that most isolated fractures
of the fifth metatarsal in children and adolescents can be
treated nonoperatively. In the absence of an open fracture
or evidence of compartment syndrome, these injuries
should be considered for closed management. However,
we identified a watershed region of 20 to 40 mm from the
proximal tip of the metatarsal that in the older adolescent
(>15 y) may lead to difficult healing and surgical intervention. Although this region corresponds to 25% to
50% of the overall metatarsal length in the younger child,
we found that in the younger adolescent the fractures in
this region healed with nonoperative methods. More
proximal fractures (<20 mm from tip of proximal metatarsal or <25% of overall metatarsal length) were more
likely to heal with nonoperative methods, but when they
went on to symptomatic nonunion, it was in the younger
adolescent age group (age, 11 to 15 y), and surgery was
fraught with complications. Measuring from the tip of the
proximal fifth metatarsal to the fracture line is a simple
way to assess whether an isolated fifth metatarsal fracture
is in the “at-risk” watershed region for increased possibility of needing surgical fixation and this can help guide
treatment and counsel patients.
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Volume 35, Number 3, April/May 2015
2014 Wolters Kluwer Health, Inc. All rights reserved.