Fifth Metatarsal Fracture

What is a fifth metatarsal fracture?

At OrthoArizona, metatarsal fractures are some of the most common fractures we see. We typically see several new patients per day with metatarsal fractures. Of all of the metatarsal fractures we see, fractures of the fifth metatarsal are by far the most common.

The fifth metatarsal can sustain a fracture (or break) in several different areas. The vast majority of fifth metatarsal fractures we see occur at the base of the fifth metatarsal compared to the shaft or neck of the metatarsal.

What causes fifth metatarsal fractures?

Causes include falls, direct blows, sports, motor vehicle accidents, bony stress overload, and twisting injuries with the latter being the most common cause. High-energy injuries tend to cause multiple metatarsal fractures and usually are not solely responsible for an isolated fifth metatarsal fracture.

Who gets fifth metatarsal fractures?

We see fifth metatarsal fractures in patients of all ages and activity levels but in our region they appear to occur most commonly in middle age or elderly females slightly more than other individuals. Some individuals may also have an anatomic predisposition to sustaining fifth metatarsal fractures. These patients normally have high arched feet and/or an alignment of the lower extremity that tends to load the outside part of their feet. Patients will sometimes be seen to have excessive wear of their shoes on the outer portion of the sole because of the pressure put on that part of the foot and shoe.

What are the symptoms of a fifth metatarsal fracture?

The main complaint seen in our patients is pain, swelling to the outer half of the foot, and associated bruising which can sometimes be seen in an acute injury. Patients also may have difficulty walking secondary to pain in the foot. Some people may experience some tingling or numbness into the lesser toes if they have a significant amount of swelling, but actual nerve injury is rare.

How is a fifth metatarsal diagnosed?

General diagnosis considerations:

Physical exam and X-ray is usually all that is needed to diagnose a fifth metatarsal fracture. At OrthoArizona, advanced imaging such as CT scans or MRI are usually only ordered to diagnose 5th metatarsal fractures when history and physical exam is suspicious for fracture but X-rays are negative.

Location specific diagnostic considerations:

At OrthoArizona, we see three main types of fractures of the fifth metatarsal.

Avulsion Fractures (pseudo-Jones Fractures)

Fractures of the base of the metatarsal are often referred to as an avulsion fracture. Here, a small piece of bone is pulled off the metatarsal by a tendon or ligament/fascia during a twisting injury of the foot or ankle. This type of fracture is sometimes called a “pseudo-Jones” fracture. It is very important to distinguish this type of fracture from a Jones Fracture as their treatments and outcomes are quite different.

Fractures of the Watershed region (Jones Fracture)

Watershed region fractures, also referred to as Jones fractures, are less common in our practice. These fractures are normally caused by inversion or twisting motion in activities such as athletics. However, fractures in this area also may be caused by repetitive stress overload of the bone. The area that these fractures occur has a unique blood supply with watershed area. A watershed area means that the blood supply in this region comes from each end of the bone but terminates in this region leaving it with much poorer blood supply relative to the rest of the fifth metatarsal. The poor blood supply may decrease the bones ability to heal compared to fractures in other regions of the bone.

We have seen a lot of confusion in the community regarding pseudo-Jones and Jones fracture. It is very important to get a proper diagnosis so proper treatment can be initiated. This is one area we strongly feel an opinion of a specialist is warranted!

Neck or Shaft Fractures

One additional region of the fifth metatarsal that can break is the shaft or neck of the bone. Fractures in this region are beyond the watershed zone and often are long oblique or spiral fractures.

Stress Fractures

The last type of fifth metatarsal fracture is a stress fracture. This is commonly in the watershed area. This type of fracture usually appears differently on X-rays and patients often have pain even before they sustain an injury. Many patients with a stress fracture have abnormal foot alignment, decreased bone density, or are involved in overuse of the foot.

How are fifth metatarsal fractures treated?

General treatment considerations:

The goal of treatment of fifth metatarsal fractures is successful healing of the bone and establishing a pain free gait pattern with normal weight bearing. Fifth metatarsal fractures can usually be treated non-operatively as they usually do not displace or angulate significantly. Additionally, the fifth metatarsal is unique compared to some of the other metatarsals because it has so much more motion. We will often demonstrate this to our patients on the uninjured. The increased motion compared to the second and third metatarsals allows our foot to tolerate SOME angulation or displacement without altering our gate or function. At OrthoArizona we have found that as long as the bone heals, the foot is not too picky about slight alterations in alignment or position. This is great news for patients because despite being a very common injury, fixing the metatarsal surgically is somewhat uncommon.

Location specific recommendations:

Avulsion Fractures (pseudo-Jones Fractures)

Treatment of avulsion fractures (pseudo-Jones fractures) tends to be with walking boots, casts, hard soled shoes, or bracing depending on the patient’s symptoms. Overall, patients with avulsion fractures have excellent outcomes and weight bearing as pain allows with a supportive device is usually recommended. It is very important for patients to understand that these injuries sometimes do not heal with solid bone. However, the fibrous tissue that bridges the injured bone is almost always solid enough to allow patients to participate in activities without restrictions. At OrthoArizona, we treat patients and not X-Rays findings. We do not recommend surgery just because the X-ray may not appear completely healed as long as the patient meets their goals.

Watershed Zone Fractures (Jones Fractures)

Watershed zone fractures (Jones fractures) can be treated several different ways. We prefer to base our practice on evidence AND our experience with EVIDENCE being the more important of the two. However, there is not enough evidence to suggest one treatment for everyone with a Jones fracture. Treatments vary from six weeks in a walking boot, to nonweightbearing cast for six weeks followed by a boot, to early surgical intervention. We feel that the decision for surgery should be based on the patient’s age, occupation, activity level, goals, foot structure, etc.  If patient and physician choose surgery, a single screw is often used.

Neck or Shaft Fractures

Fractures of the neck or shaft of the fifth metatarsal are treated similar to avulsion fractures.

Stress Fractures

Initial treatment of stress fractures is usually rest. There are different ways to rest the foot. We will sometimes recommend just eliminating certain activities, but in other cases may recommend resting the foot by wearing a hard soled shoe, walking boot, or even a cast. In certain cases, we may even recommend crutches, walker, or knee scooter to limit weight on the affected foot. Surgical intervention is typically reserved for patients who are not successful with conservative treatment. However, there are some fifth metatarsal stress fractures in certain patients that may have improved outcomes if treated surgically at their initial presentation. Additionally, a good medical history, physical exam of the foot, and metabolic work is crucial in patients with stress fractures to determine the reasons they developed a stress fracture.