569768 research-articleXXXX
FASXXX10.1177/1938640015569768Foot & Ankle SpecialistFoot & Ankle Specialist
vol. XX / no. X
Foot & Ankle Specialist
〈 Clinical Research 〉 The Epidemiology of Fifth Metatarsal Fracture Abstract: Background. A paucity of data exists studying the epidemiology of fifth metatarsal fractures. While a number of studies exist focusing on specific fracture patterns and patient populations, a large comprehensive epidemiologic study on the general public does not. Objective. We reviewed 1275 fifth metatarsal fractures treated at a multicenter orthopaedic practice attempting to classify mechanism of injury and patient demographics as they pertain to specific fracture patterns. Methods. Patient demographics were recorded and fractures categorized by location and mechanism of injury. Demographics and mechanism of injury were assessed to determine their predictive value for the type of fracture. Statistical analysis was used to predict whether demographics and mechanism of injury were statistically significant for types of fractures and whether gender and age were positive predictive values for fifth metatarsal fractures. Results. Twisting injuries were a statistically significant predictor of zone 1 injuries. A significant correlation between gender and fracture location was seen with women sustaining 75% of zone 1 injuries and 84% of dancer’s fractures. A positive predictive value existed for age and gender with respect to the incidence of
Justin M. Kane, MD, Kristin Sandrowski, MD, Heather Saffel, BS, MS, Anthony Albanese, BS, BA, Med, Steven M. Raikin, MD, and David I. Pedowitz, MD, MS
fractures. Males accounted for more fractures among younger patients and females accounting for the majority of fractures among older patients. Conclusion. Mechanism of injury is a predictor for fracture location. Gender and age have a role in fracture incidence. In younger patient populations, males account for the majority of fifth metatarsal fractures. In older patient populations, females account for the majority of fifth metatarsal fractures. Level of Evidence: Prognostic study, Level II: Retrospective Study Keywords: metatarsal; trauma; fracture; epidemiology
“
in the United States. The studies that do exist pertain to either specific populations (eg, military personnel, athletes, and European populations),2,6-8 or with respect to a specific type of fracture (eg, the base of the fifth metatarsal, shaft fractures, or dancer’s fractures).3,5,8-12 Fifth metatarsal fractures can be classified by location as metatarsal base fractures (zone 1, zone 2, zone 3), shaft fractures, dancer’s fractures, and stress fractures. Lawrence and Botte13 introduced the idea of the proximal fifth metatarsal fracture classification system. Zone 1 fractures occur when the
. . . there is a general consensus that
fifth metatarsal fractures occur more
M
often than any other metatarsal fracture.”
etatarsal fractures are frequently encountered by the orthopaedic surgeon. In the current literature, there is a general consensus that fifth metatarsal fractures occur more often than any other metatarsal fracture.1-5 While studies exist looking specifically at fifth metatarsal fractures, there is a paucity of studies looking at all fractures of the fifth metatarsal. Specifically, no studies to date are applicable to the general population
cancellous tuberosity of the most proximal aspect of the fifth metatarsal is avulsed from the metatarsal base by the lateral band of the plantar fascia. Zone 2 fractures begin laterally in the cancellous tuberosity and extend obliquely proximal to the articulation between the fourth and fifth metatarsal. Zone 3 fractures most often occur as stress fractures and occur in the tuberosity just distal to the
DOI: 10.1177/1938640015569768. From the Thomas Jefferson University Hospital, Philadelphia, Pennsylvania (JMK, KS); Joan C. Edwards Marshall School of Medicine, Huntington, West Virginia (HS); Jefferson Medical College, Philadelphia, Pennsylvania (AA); and Rothman Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania (SMR, DIP). Address correspondence to: David I. Pedowitz, MD, MS, Rothman Institute at Thomas Jefferson University Hospital, 925 Chestnut Street, 5th Floor, Philadelphia, PA 19107; e-mail: [email protected]. For reprints and permissions queries, please visit SAGE’s Web site at http://www.sagepub.com/journalsPermissions.nav. Copyright © 2015 The Author(s)
Downloaded from fas.sagepub.com at UNIV OF CONNECTICUT on June 23, 2015
1
2
Mon XXXX
Foot & Ankle Specialist
articulation between the fourth and fifth metatarsal.13 Shaft fractures occur in the diaphysis of the fifth metatarsal in either a transverse or short oblique pattern. Dancer’s fractures are long spiral fractures involving the diaphysis of the metatarsal with extension into the distal metaphyseal area. Stress fractures were classified when radiographic evidence of periosteal reactivity and callous formation was seen without evidence of complete cortical disruption. In this study, the authors looked at all fifth metatarsal fractures seen from 2005 until 2010 as a cohort of all metatarsal fractures treated by a single multicentered orthopaedic practice in an urban/suburban setting. By assessing patient demographics, fracture location, and mechanism of injury, we aimed to better elucidate the epidemiology of fifth metatarsal fractures more applicable to the general public. An extensive review of the literature was completed and to date, no largescale studies exist looking at fifth metatarsal fractures in the general public.
Figure 1. Stratification of fifth metatarsal fractures with fractures denoted by a white arrow. (A) Avulsion fracture of the base of the fifth metatarsal (zone 1; pseudo-Jones). (B) Jones (zone 2) fracture. (C) Zone 3 fracture of the base of the fifth metatarsal. (D) Dancer’s fracture. (E) Transverse fifth metatarsal shaft fracture. (F) Stress fracture of the fifth metatarsal shaft.
Materials and Methods Patient Selection After obtaining institutional review board approval, a retrospective study was conducted on patients sustaining fifth metatarsal fractures. Using the electronic medical record, a search was conducted for all patients evaluated and treated at our institution for metatarsal fractures by the International Classification of Diseases–9th edition (ICD-9) diagnosis for closed fracture of metatarsal bone(s) (825.25). Records from June 1, 2005 until December 30, 2010 were reviewed. This included office visits, operative reports, and radiographic studies. Initial review yielded a total of 2990 medical records. After excluding patients with incomplete medical records (ie, lack of radiographic studies, missing electronic medical records), and those who sustained injuries other than metatarsal fractures, 2281 patient records were available for final review. Review of the 2281 patients records and
radiographic studied was undertaken and a total of 1275 isolated fifth metatarsal fractures (55.9%) were treated. Only patients with radiographic evidence of an isolated fifth metatarsal fracture were included for evaluation. Patient radiographs were then further reviewed to classify the fracture by location as a base fracture (zone 1, zone 2, zone 3), shaft fracture, dancer’s fracture, or stress fracture (Figures 1 and 2).
Downloaded from fas.sagepub.com at UNIV OF CONNECTICUT on June 23, 2015
Using patient charts, demographics from the office evaluation were collected. Patients were evaluated for age, gender, body mass index, diabetes, tobacco use, and mechanism of injury (twist, fall, crush, no injury).
Stratification of Fractures Fractures were stratified by both location and mechanism of injury.
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Figure 2. Three-dimensional rendering of a fifth metatarsal in both anteroposterior and lateral planes with base fractures designated by roman numerals. The oblique hashed line represents a dancer’s fracture. The solid line represents a transverse distal shaft fracture.
gender in consecutive decades of life demonstrated a peak in the third decade of life among males and a peak in the seventh decade of life among females (Figure 3). Fisher’s exact test determined the difference between age and gender to be statistically significant (P < .05).
Discussion
Location was assessed from imaging obtained at the initial patient encounter. Fractures were stratified as a metatarsal base fracture (zone 1, zone 2, zone 3), shaft fracture, dancer’s fracture, or stress fracture (Figures 1 and 2). Mechanism of injury was ascertained from the initial patient encounter. Mechanism of injury was stratified into twisting, fall, crush, indirect trauma, or unknown if the patient was unable to recall a specific mechanism of injury contributing to their fracture.
Statistical Analysis A logistic regression analysis was utilized to assess risk factors and mechanism of injury to as independent variables in an effort to predict statistical significance for fracture location. Fisher’s exact test was used to assess whether a positive predictive value existed between age and gender in fracture distribution. A P value
FASXXX10.1177/1938640015569768Foot & Ankle SpecialistFoot & Ankle Specialist
vol. XX / no. X
Foot & Ankle Specialist
〈 Clinical Research 〉 The Epidemiology of Fifth Metatarsal Fracture Abstract: Background. A paucity of data exists studying the epidemiology of fifth metatarsal fractures. While a number of studies exist focusing on specific fracture patterns and patient populations, a large comprehensive epidemiologic study on the general public does not. Objective. We reviewed 1275 fifth metatarsal fractures treated at a multicenter orthopaedic practice attempting to classify mechanism of injury and patient demographics as they pertain to specific fracture patterns. Methods. Patient demographics were recorded and fractures categorized by location and mechanism of injury. Demographics and mechanism of injury were assessed to determine their predictive value for the type of fracture. Statistical analysis was used to predict whether demographics and mechanism of injury were statistically significant for types of fractures and whether gender and age were positive predictive values for fifth metatarsal fractures. Results. Twisting injuries were a statistically significant predictor of zone 1 injuries. A significant correlation between gender and fracture location was seen with women sustaining 75% of zone 1 injuries and 84% of dancer’s fractures. A positive predictive value existed for age and gender with respect to the incidence of
Justin M. Kane, MD, Kristin Sandrowski, MD, Heather Saffel, BS, MS, Anthony Albanese, BS, BA, Med, Steven M. Raikin, MD, and David I. Pedowitz, MD, MS
fractures. Males accounted for more fractures among younger patients and females accounting for the majority of fractures among older patients. Conclusion. Mechanism of injury is a predictor for fracture location. Gender and age have a role in fracture incidence. In younger patient populations, males account for the majority of fifth metatarsal fractures. In older patient populations, females account for the majority of fifth metatarsal fractures. Level of Evidence: Prognostic study, Level II: Retrospective Study Keywords: metatarsal; trauma; fracture; epidemiology
“
in the United States. The studies that do exist pertain to either specific populations (eg, military personnel, athletes, and European populations),2,6-8 or with respect to a specific type of fracture (eg, the base of the fifth metatarsal, shaft fractures, or dancer’s fractures).3,5,8-12 Fifth metatarsal fractures can be classified by location as metatarsal base fractures (zone 1, zone 2, zone 3), shaft fractures, dancer’s fractures, and stress fractures. Lawrence and Botte13 introduced the idea of the proximal fifth metatarsal fracture classification system. Zone 1 fractures occur when the
. . . there is a general consensus that
fifth metatarsal fractures occur more
M
often than any other metatarsal fracture.”
etatarsal fractures are frequently encountered by the orthopaedic surgeon. In the current literature, there is a general consensus that fifth metatarsal fractures occur more often than any other metatarsal fracture.1-5 While studies exist looking specifically at fifth metatarsal fractures, there is a paucity of studies looking at all fractures of the fifth metatarsal. Specifically, no studies to date are applicable to the general population
cancellous tuberosity of the most proximal aspect of the fifth metatarsal is avulsed from the metatarsal base by the lateral band of the plantar fascia. Zone 2 fractures begin laterally in the cancellous tuberosity and extend obliquely proximal to the articulation between the fourth and fifth metatarsal. Zone 3 fractures most often occur as stress fractures and occur in the tuberosity just distal to the
DOI: 10.1177/1938640015569768. From the Thomas Jefferson University Hospital, Philadelphia, Pennsylvania (JMK, KS); Joan C. Edwards Marshall School of Medicine, Huntington, West Virginia (HS); Jefferson Medical College, Philadelphia, Pennsylvania (AA); and Rothman Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania (SMR, DIP). Address correspondence to: David I. Pedowitz, MD, MS, Rothman Institute at Thomas Jefferson University Hospital, 925 Chestnut Street, 5th Floor, Philadelphia, PA 19107; e-mail: [email protected]. For reprints and permissions queries, please visit SAGE’s Web site at http://www.sagepub.com/journalsPermissions.nav. Copyright © 2015 The Author(s)
Downloaded from fas.sagepub.com at UNIV OF CONNECTICUT on June 23, 2015
1
2
Mon XXXX
Foot & Ankle Specialist
articulation between the fourth and fifth metatarsal.13 Shaft fractures occur in the diaphysis of the fifth metatarsal in either a transverse or short oblique pattern. Dancer’s fractures are long spiral fractures involving the diaphysis of the metatarsal with extension into the distal metaphyseal area. Stress fractures were classified when radiographic evidence of periosteal reactivity and callous formation was seen without evidence of complete cortical disruption. In this study, the authors looked at all fifth metatarsal fractures seen from 2005 until 2010 as a cohort of all metatarsal fractures treated by a single multicentered orthopaedic practice in an urban/suburban setting. By assessing patient demographics, fracture location, and mechanism of injury, we aimed to better elucidate the epidemiology of fifth metatarsal fractures more applicable to the general public. An extensive review of the literature was completed and to date, no largescale studies exist looking at fifth metatarsal fractures in the general public.
Figure 1. Stratification of fifth metatarsal fractures with fractures denoted by a white arrow. (A) Avulsion fracture of the base of the fifth metatarsal (zone 1; pseudo-Jones). (B) Jones (zone 2) fracture. (C) Zone 3 fracture of the base of the fifth metatarsal. (D) Dancer’s fracture. (E) Transverse fifth metatarsal shaft fracture. (F) Stress fracture of the fifth metatarsal shaft.
Materials and Methods Patient Selection After obtaining institutional review board approval, a retrospective study was conducted on patients sustaining fifth metatarsal fractures. Using the electronic medical record, a search was conducted for all patients evaluated and treated at our institution for metatarsal fractures by the International Classification of Diseases–9th edition (ICD-9) diagnosis for closed fracture of metatarsal bone(s) (825.25). Records from June 1, 2005 until December 30, 2010 were reviewed. This included office visits, operative reports, and radiographic studies. Initial review yielded a total of 2990 medical records. After excluding patients with incomplete medical records (ie, lack of radiographic studies, missing electronic medical records), and those who sustained injuries other than metatarsal fractures, 2281 patient records were available for final review. Review of the 2281 patients records and
radiographic studied was undertaken and a total of 1275 isolated fifth metatarsal fractures (55.9%) were treated. Only patients with radiographic evidence of an isolated fifth metatarsal fracture were included for evaluation. Patient radiographs were then further reviewed to classify the fracture by location as a base fracture (zone 1, zone 2, zone 3), shaft fracture, dancer’s fracture, or stress fracture (Figures 1 and 2).
Downloaded from fas.sagepub.com at UNIV OF CONNECTICUT on June 23, 2015
Using patient charts, demographics from the office evaluation were collected. Patients were evaluated for age, gender, body mass index, diabetes, tobacco use, and mechanism of injury (twist, fall, crush, no injury).
Stratification of Fractures Fractures were stratified by both location and mechanism of injury.
vol. XX / no. X
Foot & Ankle Specialist
Figure 2. Three-dimensional rendering of a fifth metatarsal in both anteroposterior and lateral planes with base fractures designated by roman numerals. The oblique hashed line represents a dancer’s fracture. The solid line represents a transverse distal shaft fracture.
gender in consecutive decades of life demonstrated a peak in the third decade of life among males and a peak in the seventh decade of life among females (Figure 3). Fisher’s exact test determined the difference between age and gender to be statistically significant (P < .05).
Discussion
Location was assessed from imaging obtained at the initial patient encounter. Fractures were stratified as a metatarsal base fracture (zone 1, zone 2, zone 3), shaft fracture, dancer’s fracture, or stress fracture (Figures 1 and 2). Mechanism of injury was ascertained from the initial patient encounter. Mechanism of injury was stratified into twisting, fall, crush, indirect trauma, or unknown if the patient was unable to recall a specific mechanism of injury contributing to their fracture.
Statistical Analysis A logistic regression analysis was utilized to assess risk factors and mechanism of injury to as independent variables in an effort to predict statistical significance for fracture location. Fisher’s exact test was used to assess whether a positive predictive value existed between age and gender in fracture distribution. A P value
