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524399

research-article2014

FASXXX10.1177/1938640014524399Foot and Ankle SpecialistFoot and Ankle Specialist

vol. 7 / no. 2

Foot & Ankle Specialist

〈 Roundtable Discussion 〉 Fifth Metatarsal Fractures This is a 27-year-old marathoner who sustained a twisting injury to the left foot 3 days prior. How would you manage this fifth metatarsal fracture? Figure 1.

Berlet: This fracture will likely heal uneventfully with protection in a boot walker. This is assuming that there is not a spike directed plantarward that the AP image does not reveal. I have on occasion placed percutaneous cannulated screws to facilitate a more anatomic repair and would discuss both options with the patient. Olms: I would use two or three 2.0mm lag screws for fixation. A plate is

optional but rarely needed. The patient would place 20 kg of partial weight bearing in a surgical shoe for 3 to 4 weeks and then gradually increase weight bearing until week 6. At that time full, weight bearing is begun. I would use enoxaparin until the patient is full weight bearing. Saxena: Let me start by a quote from George Sheehan, MD: “Everyone is an athlete, some just don’t know it yet.” I think that if a treatment is safe and shortens the healing and return to activity (RTA), it should be an option regardless whether you are a professional or recreational or high school athlete, an industrial worker, or a grandmother having to care for active grandkids. I would fix this with either screws or K-wires (could be absorbable pins), put a cast on for 2 to 3 weeks, allow no weight bearing for 3 weeks, let the patient ride a stationary bike with the heel on the pedal, take an x-ray to make sure there is no displacement or avascular necrosis developing at the metatarsal heads, switch to a boot for another 2 to 3 weeks (the patient could run in the deep end of the pool at this time if fixation is stable), and if the patient is pain-free let him or her start running on an antigravity treadmill at 60% to 70% body weight between 6 and 8 weeks. Running on a regular treadmill usually would begin around 8 to 12

DOI: 10.1177/1938640014524399. For reprints and permissions queries, please visit SAGE’s Web site at http://www.sagepub.com/journalsPermissions.nav. Copyright © 2014 The Author(s)

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Fracture of the fifth metatarsal is one of the most common injuries presenting to a foot and ankle specialist, yet there is little consensus as to the optimal treatment. Philosophies range from benign neglect to operative intervention. This symposium explores the spectrum of fifth metatarsal fractures. CONTRIBUTORS Gregory C Berlet MD Orthopedic Foot and Ankle Center Fellowship Director Westerville, OH Kai Olms, MD Private practice, Founding President of GFFC (Association for Foot & Ankle Surgery) Bad Schwartau, Germany Helios Agnes Karll Krankenhaus, Bad Schwartau, Germany Affiliate Atlanta, GA Amol Saxena, DPM, FACFAS, FAAPSM Fellowship Director, Palo Alto Division, Dept. of Sports Medicine in Sports Medicine Foot & Ankle Surgery Palo Alto Foundation Medical Group. Palo Alto, CA USA SECTION EDITOR John M. Schuberth, DPM Chief, Foot and Ankle Surgery Department of Orthopedic Surgery Kaiser Foundation Hospital San Francisco, CA

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weeks because of the metatarsal head fractures, and the patient could run outside thereafter as soon as he or she felt stable.

likely to fix the fifth metatarsal as described above with closed reduction and percutaneous cannulated compression screw fixation.

Schuberth: Early in my career I would have operated on this patient without hesitation as I believed in the so-called AO doctrine. I would have kept this patient non–weight bearing (NWB) for 4 to 6 weeks postoperatively for fear of disruption of the fixation (small caliber screws). As time went on, I observed a number of patients who were treated by other providers in a walking boot. The interesting thing is that these patients all seemed to do well. In fact, I cannot ever recall seeing a patient who had weight transfer problems because of medial overload as a consequence of the distal fragment elevation. I think we tend to assume that the distal fragment will elevate an inordinate amount that would compel operative reduction. Yet, after observing many of these patients, I have noticed that the distal fragment doesn’t seem to angulate even though it almost universally translates in a dorsal direction. The mobility of the fourth and fifth rays seems to mitigate any slight deflections in the sagittal plane. The distinction between angulation and translation is really the key in my mind, and since the former is so uncommon, I typically let these patients ambulate in a boot immediately. Although unequivocal radiographic consolidation can take 3 to 4 months, the fracture is usually stable enough to permit full activity to tolerance at approximately 6 weeks.

Olms: No, even if I would fix the fractures of the second, third, and fourth metatarsals.

Would your treatment change at all if you decided to fix the intraarticular injury to the second metatarsal head? If so, how? Berlet: If the patient is under anesthesia for another injury I would be

How would you manage this fracture in a 50-yearold female nurse? Figure 2.

Saxena: Not really, because the patient would be NWB for 3 weeks and I would likely just pin that, again possibly with something bioabsorbable, but in essence it is close to a distal lesser metatarsal osteotomy and I let people use a stationary bike with a boot (heel on the pedal) all the time without issues. Schuberth: Yes, because I would not allow weight bearing with open reduction and internal fixation (ORIF) of the intra-articular injury on the second metatarsal head. I still would not fix the fracture of the fifth metatarsal.

Figure 3.

Would your treatment change if this were a 74-year-old community ambulator? If so, how? Berlet: I would tend to support in a boot walker and expect to heal without surgery. Olms: Yes. I would rather treat conservatively in a surgical shoe or cast with 2 weeks of NWB and then partial weight bearing for 2 weeks with gradual increase of weight bearing until week 6. Full weight bearing is allowed at 6 weeks. Again I would use enoxaparin until the patient is bearing at least 20 kg of weight. Saxena: I would consider nonsurgical treatment if health and home status are not ideal. However, if surgery makes the patient better faster, then I would still recommend surgery for at least for the fifth metatarsal. The patient may need a walker as opposed to crutches. Schuberth: Other than consideration of a postoperative shoe in lieu of a cast, no.

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Berlet: With shortening and significant displacement I would perform ORIF. I would anticipate that soft tissue is interposed between these fracture fragments, making closed reduction and percutaneous screws impossible. My internal fixation would be cannulated screws. On occasion I have defaulted to ORIF with a plate, but the problem is that plates almost always need to be removed later due to prominence. Olms: I would use 2 or 3 lag screws with an optional plate and the same postoperative care as above. Saxena: I would perform ORIF with 2 screws and possible augmentation with cerclage wire. The patient would be NWB for 3 weeks in a boot or cast and then full weight bearing for an additional 2 to 3 weeks in boot.

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Schuberth: Although tempting, I would still manage this nonoperatively in the same manner as the first example. I would tell the patient that radiographic union will take many months, but nonunion is extremely rare and fourth metatarsalgia is almost nonexistent.

The enigmatic “true” Jones fracture has been applied to many injury patterns of the proximal fifth metatarsal. This lends to the confusion, which in turn confounds the ability to achieve consensus. How would you define a true Jones fracture? Figure 4.

Foot & Ankle Specialist

ie, in a patient with a men’s shoe size greater than 11). Interestingly, research has shown no real difference between stress fractures versus acute Jones fractures in this region and they should be treated the same.

What do you believe to be the mechanism of injury in a true Jones fracture? Berlet: I subscribe to the biomechanical theory of repetitive bending loads resulting in a stress fracture. These occur at a higher rate in the cavus and adductus foot, both of which load more on the lateral border of the foot. Olms: Inversion force to plantar flexed foot or direct force to the fifth metatarsal from plantar to dorsal in adduction. Saxena: Inversion with the forefoot loaded (heel off), as in a lateral shift away from the foot involved. Schuberth: I think one only has to make the distinction between the repetitive load from a cavovarus foot type and the acute inversion episode. I would not necessarily change the treatment plan. It is surprising that there is not much agreement or bench studies to universally support a particular mechanism.

Berlet: A true Jones is a fracture at the metaphyseal/diaphyseal junction of the fifth metatarsal. Olms: These fractures have been defined as occurring in zone 2 according to Quill’s classification and occur at the fourth to fifth intermetatarsal articulation at the diaphyseal-metaphyseal junction of the fifth metatarsal. They have a transverse fracture pattern and are sometimes close to the “avascular zone.” Saxena: They occur approximately 1.5 cm distal to fifth metatarsal tuberosity, which is in the region of the shaft-base junction (could be further in longer feet;

How would you manage the above fracture in a competitive recreational tennis player? Please be specific, including fixation construct and postoperative management (if you choose to operate). Berlet: I would recommend percutaneous placement of an intramedullary screw in the fifth metatarsal. If the fracture has a degree of chronicity, I will occasionally add a biologic stimulant at the site of the fracture. I do not open the fracture. There is considerable controversy regarding the choice of fixation, with options being solid stainless, cannulated

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stainless, and cannulated titanium. There is some biomechanical research to support increased strength of solid stainless but no convincing clinical evidence. My choice of fixation is usually a cannulated titanium screw, although I would consider solid screw options in select cases. For technique I would set a screw length adequate for the threads to be distal to the fracture, but the recent trend has been for shorter screws. Olms: Intramedullary screw fixation with a 4.5- or 5.5-mm screw. Usually a 4.0-mm screw is too small. The patient would begin immediate partial weight bearing (20 kg) with full weight bearing after 3 weeks. Saxena: Intramedullary screw typically 4.5 to 5.5 cancellous and usually solid. NWB 2 weeks in a below-knee cast and then weight bearing in a boot for an additional 4 weeks. Usually the patient can get out of the boot pending the x-ray at 6 to 8 weeks with full RTA at 8+ weeks. Schuberth: Although I treat the vast majority of Jones fractures nonoperatively, I believe that the fracture does heal more quickly when operated. The fundamental question is how much more quickly and does it matter to the patient. Yet, I would lean toward operative treatment. Accordingly, I select an intramedullary screw based on the diameter of the canal at the point of suspected screw thread contact and the morphology of the proximal fifth metatarsal. The screw should be slightly wider than the endosteal canal to gain purchase. Some patients have a more curved proximal metaphysic, which would favor the use of a shorter screw. I use a fully threaded noncannulated titanium screw. I believe that the modulus of titanium is more compatible with bone, lessening the need to retrieve the screw after healing. Postoperatively, I keep patients NWB for 6 weeks, but this is probably overkill.

Would your protocol be any different in a 70-yearold obese patient? Berlet: I would discuss the risk of nonunion with nonoperative care. I

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would consider intramedullary screw fixation in the compromised 70-yearold. The likelihood of this patient being able to heal nonoperatively is low. Fixation would be done with a cannulated titanium compression screw.

Figure 5.

Olms: No. Saxena: NWB 6 weeks if possible but at least a walker for that period. Again, I would look for x-ray signs of healing, not just clinical healing, because often with an intramedullary screw the patients do not have pain but can still have lack of consolidation in the plantar aspect and that is where refractures occur. I could consider plating as well. Schuberth: This is a tough situation because the patient’s capacity to remain NWB is suspect. Yet, I am not compelled to operate on the acute fracture. I do my best to convince patients not to walk on the cast, and I see them back early to see how compliant they are. The literature shows a 50% union rate with weight bearing, so I am hopeful that the fracture will consolidate even if they cheat. If it goes to nonunion, I would operate.

This next x-ray is from a 40-yearold female athlete who is 4 months post fracture. She was initially treated with 8 weeks of NWB in a short leg cast. She is anxious to return to her athletic endeavors. Can this fracture heal without surgical intervention? If yes, what would you do? How would you manage this surgically? Berlet: These fractures can heal without surgery although it has been my experience that few athletes are patient enough to work through the long healing process. I believe that the risk of refracture is higher in these patients. I would obtain a computed tomography (CT) scan to assess the amount of healing that has occurred prior to recommending a return to sporting activity.

I prefer to not open these fractures but rather use an intramedullary screw where the reamings are the internal bone graft. If additional graft if desired I would add an injectable demineralized bone matrix material soaked with bone marrow aspirate to inject around the fracture site percutaneously. I would use a cannulated titanium screw with threads just distal to the fracture site and avoid distracting the fracture by placing an excessively long screw. Olms: The fracture may heal; however, it usually refractures after some months depending on the patient’s activity. I would treat it the same, with an intramedullary screw with the same postoperative course. Saxena: Medullary sclerosis is a bad sign and incompatible with healing. This needs to be curetted out, bone grafted (autograft, don’t put dead bone in dead bone!), and usually plated. This is one area in which level II research has shown a benefit of mixing platelet-rich plasma (PRP) with the ORIF of fractures in the Jones region. This can be done using a trephine technique I learned from Rich Bouché, DPM: taking the nonunion out and then inserting an autograft from the heel and plating over it. Schuberth: I don’t think this will heal without an operation. I would do ORIF with autologous graft from heel or distal tibia. The medullary sclerosis needs to be eliminated. I have found that the best way

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to do this is with a longitudinal slot burred across the nonunion site with the graft packed into the slot such that it bridges the interface. A small, low-profile, nonlocking plate is then placed over the slot. The success rate is actually very high and patients can weight bear in about 6 weeks.

This next series of x-rays represent a healthy 45-yearmale with progressive pain over the lateral aspect of the foot. The x-rays were taken at 2-week intervals, while the patient was allowed to ambulate in a postoperative shoe. Six weeks after the last x-ray, there is no appreciable change in the appearance of the film, and the patient is still quite symptomatic. He has a cavo-varus foot type with an otherwise normal neuromuscular examination. What would you have done differently in the initial management of this patient? Berlet: I think this patient has a high risk of nonunion because of his cavus foot. I would have likely offered him surgery on the first consultation. The challenge here is the shape of his fifth metatarsal, in that it has developed an adductus posture through the fracture. When the intramedullary screw is placed, this bone will straighten, which may complete the fracture of the medial cortex. I do not correct the shape of the cavus foot on the primary fifth metatarsal fracture but rather leave periarticular osteotomies for cases of nonunion or refracture. Olms: Intramedullary screw fixation. Saxena: I would have placed a NWB below-knee cast/boot for at least 4 weeks. Schuberth: I would have treated this exactly like an acute Jones fracture by

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Foot & Ankle Specialist

Figure 6.

placing the patient in a short leg, NWB cast for 6 to 8 weeks, recognizing that the refracture rate is high after the commencement of weight bearing and activity.

What would you do now? Please be specific including how you would address the cavovarus foot type (if at all). Berlet: I would place an intramedullary screw in the fifth metatarsal. I do not recommend realignment osteotomies for a first-time fracture of the fifth metatarsal. If the patient gets a nonunion with good surgery and has cavus, then I will add periarticular osteotomies to the treatment algorithm. Olms: I would use intramedullary screw fixation. The intramedullary reaming should be enough for the sclerosis. Another option would be an autogenous bone graft from the lateral heel with an intramedullary guide wire for the screw. I would trephine the nonunion site, leaving the medial cortex intact. Postoperatively, the patient would be NWB for 2 weeks and then partial weight bearing for 4 weeks in a surgical shoe or cast depending on compliance.

For the varus, I would like to see a Saltzman view and do a lateral calcaneal slide or Dwyer. I would need more details before deciding to do a Cole osteotomy. It sounds crazy to do rearfoot reconstruction for a fifth metatarsal fracture; however, it is sometimes necessary. Saxena: I would still just treat the fracture, again using autograft. A short threaded intramedullary screw would be my first choice, but I could also use the plating technique. With some of these fifth metatarsal fractures, we are able to get bone stimulators approved. My personal experience has been that the pulsed electromagnetic field type work better, especially if there is hardware present. I have had to address the adducto-varus in very few cases but it can be an issue. John Grady, DPM, used to say that stress fractures are mother nature’s way of doing surgery, and certainly with this type of fracture, the tension has created it. In a very few select revision cases, I will resect the fracture nonunion and create realignment osteotomy within the fracture to address this. There could be a consideration for doing a gastrocnemius slide, cuboid closing osteotomy, and even a lateral calcaneal slide in this situation, but it would be rarely necessary.

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Schuberth: Fixing the nonunion is straightforward with essentially the same technique for the nonunion of the Jones fracture. However, it is very tempting to realign the foot because of the insidious change in the posture of the foot. I believe that the posture of the foot was developmental due to an occult or subclinical muscle imbalance. Furthermore, choosing the realigning procedures that will prevent refracture is not so straightforward, because the deformity is at or distal to the midtarsal joint. Accordingly, I would probably do a cuboid osteotomy with lateral transfer of the anterior tibialis tendon and a peroneal switch. This sounds aggressive but there is no credible literature that defines the refracture rate after reconstructive surgery. So it does not make sense to ignore the muscle imbalance. Although osteotomies may align the foot for a while, over time the muscle imbalance will prevail and the morbid shape of the foot will return. Nonetheless, I would not do any reconstructive surgery in an older patient when fixing the nonunion, and I would be selective in recommending this strategy to a younger patient at the same time as well.

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This is a very athletic 30-yearold female who sustained an inversion injury to the right foot. How would you manage this fracture? Figure 7.

Berlet: A tuberosity avulsion fracture is managed nonoperatively in a boot unless there is progressive displacement, at which point I will add a cannulated compression screw applied percutaneously. The screw is placed obliquely to capture the medial cortex and does not go intramedullary like traditional Jones screws. These screws are often symptomatic after union and have a higher rate of hardware removal than intramedullary screws. It is important to avoid splitting the tuberosity piece as this small, 4.0 cannulated, screw is placed. Olms: Lag screw fixation with purchase of medial cortex or tension band. Postoperative protocol would be 2 weeks NWB, 2 weeks partial weight bearing, and a gradual increase in weight bearing until full. Again, we would use enoxaparin. Saxena: ORIF with 4.0 cancellous screw since it is intra-articular; weight bearing within a week postoperatively in a below-knee boot, to be worn for 5 to 6 weeks. Again, she can use a stationary bike with the boot and heel

on the pedal. Nonsurgically, I would keep her NWB in a short leg cast 3 weeks and an additional 3 weeks in a boot.

Figure 8.

Schuberth: Almost all of these fractures heal well with a short leg walking cast for 6 weeks. I don’t like removable boots because when the patient takes the boot off even for short periods of weight bearing, the fracture has a tendency to displace with repetitive pull of the peroneus brevis. I probably would not intervene even with slight displacement even though it is intra-articular unless there is a step-off. With frank displacement I would use a single 2.0- or 2.4- or 2.7-mm screw placed across the fracture to capture the medial cortex. I would let the patient walk after the first postoperative visit in a short leg cast.

Would your treatment protocol change in 70-yearold obese person who is household ambulatory and has marked chronic obstructive pulmonary disease (COPD)? Berlet: I am likely to accept more residual displacement in the compromised patient you describe and would manage nonoperatively. Olms: I would treat conservatively in a surgical shoe and enoxaparin. Saxena: I would be less likely to do ORIF, but she may get benefit from a bone stimulator and use of a walker. Plan on taking it much longer to heal. Schuberth: No, other than allowing immediate postoperative weight bearing in a cast.

If this were the fracture pattern, how would you manage both scenarios (active 30-year-old vs 70-year-old obese patient with COPD)? Berlet: The displaced tuberosity is being pulled by the lateral band of the plantar fascia and the peroneus brevis Downloaded from fas.sagepub.com at CARLETON UNIV on June 13, 2015

insertion. In the active 30-year-old I would recommend reduction (closed if possible) and a single small-caliber (4.0) oblique compression screw In the compromised 70-year-old I would manage this in a boot walker and accept the displacement, and if there is residual pain I would advocate an excision of the tuberosity. Olms: Tension band fixation. Postoperative care as above. Saxena: I would treat the same as the last patient (ie, options of surgery, boot, etc) but could consider excising the fragment and using a bone anchor. It would not require bone healing, but for the active patient the time for tenodesis could actually be longer. This shouldn’t make a difference with the COPD patient. Schuberth: I would probably fixate this in the young active patient with a small-caliber solid screw. A tension band may be necessary due to the small size of the fragment, but I would really try to avoid its use because hardware removal is commonly needed. In the older patient, I would advise immediate full weight bearing in a short leg walking cast for 4 to 6 weeks to protect the peroneus brevis insertion. I think without

vol. 7 / no. 2

immobilization, the fragment will displace further, which indicates further loss of the insertion and consequent functional compromise.

What about this fracture in the same set of circumstances? Figure 9.

Foot & Ankle Specialist

more communition, gapping, or displacement), some newer plates are made specifically for this type of fracture. Prongs go into the fifth base near the tendon and work as a tension band with the drill holes distal to the fracture being eccentrically drilled. Schuberth: It looks like the articular surface is comminuted with some implosion, but it is hard to tell. I would get a CT scan and would be inclined to fix this with a tension band if highly comminuted in either of these patient scenarios. If it was not comminuted, I would treat with 6 weeks of immobilization.

One of the most vexing problems in foot and ankle surgery is fifth metatarsal-cuboid arthritis. How would you manage this healthy 45-year-old nonathletic patient? Figure 10.

Berlet: In the active athlete, this is not an acceptable position as the tuberosity will create impingement on the calcaneal cuboid joint. I would try to reduce closed and hold reduced with a percutaneous screw. In the older compromised patient, I would immobilize in a boot walker and accept some malunion. If the patient has unacceptable pain with malunion, I would excision the fragment. Olms: Conservative. Surgery if secondary dislocation should occur. Saxena: For the active patient, NWB 3 weeks with boot and weight bearing for an additional 3 weeks. Could do a PRP injection or bone stimulator. (We charge a minimal amount to cover the syringes for our PRP injections in our setting, nothing close to the exorbitant amounts I hear are used around the country.) Same for the older patient but wouldn’t be able to be NWB. In terms of surgery (although I don’t think it is needed at this point but would be if there were

Berlet: I would maximize what I could achieve with ultrasound-guided fluoroscopic injections. An orthotic can be helpful in this patient population. If surgery is the only option, I would do an interposition arthroplasty using either an allograft skin matrix or peroneus tertius as the interposition material. The results with interposition are good but not great, meaning that significant pain relief is possible but it is not likely to resolve all of the patient’s symptoms. I avoid fusing the lateral column.

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Olms: I would try to determine etiology. RSO for rheumatoid patients. Pain radiation if bone scan is negative/ inactive. Diagnostic injection/infiltration with local and steroid to find out whether fifth metatarsal cuboid joint is the reason for pain. Nonoperatively, I would try some insoles. I would also obtain a CT scan and would avoid fusion if possible. However, it can be successful even though there will be some residual pain. Arthroplasty is preferred with soft tissue interposition. Saxena: I remember fusing these early in my career, and after seeing them break down even with rigid fixation and autograft, I asked Ted Hansen and Rich Bouché what they do. They both do a “Keller” of the fourth metatarsal base and interpositional arthroplasty. Operatively, I resect a small portion of the bases and then interpose either local tissue like peroneus tertius or muscle from extensor digitorum brevis. Alternatively, in my opinion, this would be an indication for a soft tissue collagen-type supplement to interpose. I did a few of the ceramic interposition arthroplasties a while back but their cost is high and I’m not sure this route is any better than the other options I mentioned above. I went to school in Missouri, the “Show Me State,” so I need to see proof that these options are unbiased by financial incentives. I keep patients NWB in a cast or boot for 3 weeks or longer (depends on other procedures such as the rest of Lisfranc’s being fused, etc). Nonsurgically, a lace-up ankle brace and sometimes a shoe with a midfoot rocker built-in would be recommended as well as glucosamine and/or nonsteroidal anti-inflammatory medications and activity modification. Some type of foot orthoses can be tried, but I usually find that stiffening up this area too much underneath (like a rocker-bottom foot) can aggravate it. It is a tough problem and deserves more detailed attention. Schuberth: These patients have a difficult problem and I really try to

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avoid surgery because of the uncertain outcomes. I try to convince the patient to learn to manage the symptoms indefinitely. Rocker bottom type shoes are helpful, as are fluoroscopically assisted injections. Naturally, antiinflammatories can be of benefit as well. If the patient can convince me that she is significantly disabled and I can isolate the pain to the either or

both of the metatarsal cuboid joints, then I will operate. To date, I have not fused this joint in a sensate patient. When I do operate I tell the patient that there is 50% to 60% chance of significant functional improvement. I like the so-called anchovy procedure, which involves interposition of one of the expendable tendons of the foot into the space created by resection

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arthroplasty. Since this procedure is not that common, it is hard to gather enough experience to determine the optimal amount of bone taken from the proximal metatarsal. Placing ceramic or other foreign materials is not logical in my view, although the literature is no less available than it is for soft tissue interposition.

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Fifth metatarsal fractures.

524399 research-article2014 FASXXX10.1177/1938640014524399Foot and Ankle SpecialistFoot and Ankle Specialist vol. 7 / no. 2 Foot & Ankle Specialis...

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