CHAPTER 28

TREATMENT OF FIFTFI METATARSAL FRACTURE.S:Guidelines for Decision-Making

Stephen J. Milleu DPM, FACFAS

INTRODUCTION

Fractures of the fifth methtarsal present a unique set ofchallenges for treatment to the foot and ankle specialist.

Understanding the local anatomy, vascular supply,function, and dynamic stresses placed upon the bone, as

well as fracture classifications, mechanisms of injury, andexpected responses to treatment aid immensely in thedecision-making processes. The author will brieflysummarize the large amount of literature that has been

generated on this unique topic and leave rhe reader with a

succinct set of guidelines for treatment.

EPIDEMIOLOGY

Metatarsal fractures are among the most common injuriesto the foot. They are roughly 10 times the frequency ofLisFranct fracture-dislocations. Specifically, in 2 reviews, of10,988 foot fractures, the proximal fifth metatarsaldiaphl,5s2fmetaphyseal Jones fracture (acute and stress)

had a frequency of 0.7o/o-7.9o/o.','In children,6T0/o of allfoot fractures involve the metatarsal bones and most (41%)are of the fifth ray. In a study of industrial injuries, thefifth metatarsal - including base fractures - was the mostcommonly fractured at 23o/o followed by the thirdmetatarsal. Stress fractures, which are seen especially inmilitary, athletic and dancer populations, most commonlyaffect the second, third and fifth metatarsals at theirproximal third.'

Fractures of the base of the fifth metatarsal are morecommon than distal fractures of the shaft or head andneck. The proximal fifth metatarsal has been divided into3 zones. In one study of 237 patients with fractures of theproximal fifth metatarsal,620/o were female and 3B%o were

male. The most common proximal acute disruption was

tuberosity (zone I) fractures (93o/o) in this generalorthopedic population.a The incidence of true acute ]ones(zone II) fractures was found to be higher in the militarypopulation (25o/o).t Fractures in the more distal zone

III close to the diaphysis were mosr commonly stress-

induced fractures.

ANATOMYAND DYNAMICS

The fifth metatarsal is a long bone consisting of a head,

neck, shaft, base and tuberosity or styloid process. Themetaphyseal base tapers distally to the more tubulardiaphysis which, besides being more convex dorsally, isactually wider in cross-section from medial to lateral thanit is from dorsal to plantar. Also, the diaphyseal cortices

tend to be thinner on the dorsal and plantar sides than onthe medial and lateral sides. The bone often bows laterally.o

These are significant considerations when planningintrameduilary screw placement. The tuberosity protrudesIaterally and plantarward from the base.7

Proximal articulations of the fifth metatarsal are withthe cuboid bone and adjacent base of the fourthmetatarsal. Sturdy ligaments both dorsally and plantarlyconnect the cuboid to the base of the fifth metatarsal as

well as to the base of the fourth metatarsai. The 2 adjacentbases are also connected by ligaments. The long plantarligament extends from the distal calcaneous across the

cuboid and inserts into the base of the fifth metatarsal,

while more superficially, the lateral band of the plantarfascia sends a slip into the plantar tuberosiq,. It has been

suggested to be more responsible for tuberosiq, fractures

than the more prominent dorsal insertion of the peroneus

brevis tendon into the tuberosiry.'r The insertion of the

peroneus tertius tendon more distally onto the drorsal base

of the fifth metatarsal is thought to have minimalinfluence as a fracture force.

There are 3 main muscle slips that arise from the

fifth metatarsal: the flexor digiti minimi brevis from the

plantar base and the dorsal and plantar interossei from themedial surface with only the dorsal interossei opposed byits counterpart attached to the fourth metatarsal.

Occasional variations from the normal muscle anatomyinclude: part of the abductor digiti minimi muscle can

originate from the plantar aspect of the fifth metatarsal

base; if present, the abductor ossi metatarsi quinti muscleinserts into the styloid process; and, when present, theopponens digiti minimi muscle inserts into the lateralborder of the fifth metatarsal shaft.'o

r56 CHAPTER 28

Biomechanically, the fifth metatarsal functions withan independent axis of motion that allows primarilydorsiflexion and plantarflexion with inversion-eversion as

potential movements as well. Strong soft tissue

attachments that contain the base stabilize it against acute

and repetitive force attacks. Excessive acute and repetitive

strain loads on the bone are usually flexural, whereas

torque can occur with inversion injuries.

Two studies have investigated the vascular supply tothe fifth metararsal."''' The tuberosity is well supplied byfrom numerous random vessels that are directed from the

metaphysis. There is a nutrient artery supplying the

diaphysis but the proximal diaphyseal region contains a

watershed "no man's land" where there is a run-out of thenutrient artery before the metaphyseal vessels are

encountered. This area of poor vascular supply is thoughtto be the etiology of delayed union or nonunion offractures in this area, especially if the nutrient arteryis disrupted.'3

There are anatomic variations that may result inconfusion with fractures of the tuberosity of the fifthmetatarsal. The os peroneum, within the peroneus iongus

tendon, is usually situated lateral to the cuboid bone

whereas the os vesalianum within the peroneus brevis

tendon sits adjacent to its insertion. Also, the apophysis,

or growth center may be confused with a nondisplaced

tuberosity fracture in a child. The apophysis can be

identified by means of a smooth, radiolucent line runningparallel to the metatarsal shaft. This growth center first

Figure 1. Diaphyseal stress lracture in a 64-year-olddiabetic female n'ith metatarsus adductus and Charcotneuroarthropathv.

appears in males between ages 9-11 years and in females

from 11-14 years. The line obliterates by fusing with the

tubersiry 2-3 years after its appearance."'" \fhen the

apophysis is afflicted with osteochodrosis it is known as

Iselins disease; its pain and tenderness may mimic a

tuberosity fracture.'6't

MECHANISM OF INJURY

Foot plantarflexion with an adduction force applied tothe forefoot is the source of most acute injuries to the base

of the fifth metatarsal whether it causes a tuberosityfracture or Jones fracture or even a cervical fracture.

Hence, these injuries are often encountered in such sports

as basketball, football, soccer and tennis as well as danc-

ing and gymnastics. They are also seen in the general

population as the result of sudden inversion injuries such

as slipping while going down stairs or stepping over an

edge. The locking configuration of all the soft tissue con-

straints about the base make dislocation of the fifthmetatarsal-cuboid joint an exceedingly rare occurrence.

Stress fractures, which usually disrupt the proximaldiaphysis, are the result of repeated submaximaldistraction forces. One biomechanical study revealed thatthe peak stress point occurs approximately 3.38 to 4.05

centimeters distal to the tuberosiry when the load is

directed 30 to 60 degrees from the horizontal plane

relative to the long axis of the metatarsal.'' Structural and

bio-mechanical abnormalities can contribute to the

production of these repetitive load concentrations.Examples include uncompensated forefoot varus,'e rigidpes cavus, metatarsus adductus,'u talipes equinovarus,"

post Evan's caicaneal osteotomy," Charcot foot,"''a and

Charcot-Marie-Tooth disease." (Figure 1) Dancers,

distance runners and military trainees are especially

subject to fifth metatarsal stress fractures at the base or

proximal diaphysis although stress fractures of the second

metatarsal are more common.'3't6''6'"

CI/.SSIFICATION

Quill presented a useful classification for fracture patterns

thar occur in the proximal fifth metatarsal." He dividedthe fractures in this region of the bone into 3 areas,

sometimes referred to as zones': tuberosity avulsion

fractures (ZoneI),Jones fractures (Zone II) and proximaldiaphyseal stress fractures (Zone III). (Figure) Vogler

added three other iocations in his anatomic classification

to better define treatment options for the variousfractures of the complete fifth metatarsal: capitumfractures, cervical fractures and shaft fractures (Thble 1)."

CHAPTER 28 157

Each of the fracture patterns has its own unique location,mechanism of injury, treatment options, and prognosisregarding delayed union and nonunion.

Torg further subdivided the proximal diaphysealstress fractures, also applicable to Jones fractures, intothree subtypes based on their radiographic signs ofhealing: type I - acute or early union characterized by a

narrow fracture line and absence of intrameduilarysclerosis; type II - delayed union, involving fractures withwidening of the fracture line and evidence ofintramedullary sclerosis; and type III - nonunion, whichincludes fractures with complete sclerotic obliteration ofthe intramedullary canal (Thble 2).'"

There has been considerable confusion regardingthe exact definition ofthe "Jones fracture." Jones sufferedthe fracture himself in 1902 while dancing around a tentpole and recognized it as the result of an indirect force.3'

Stewart defined the true Jones fracture as a transverse

fracture at the junction of the proximal diaphysis andmetaphysis without extension distal to the fourth-fifthintermetatarsal articulation (Figure 2).3'lt is therefore, an

intraarticular fracture into the base fourth-fifth metatarsalfacet, often with medial comminution. The diagnosisshould not be applied for fractures that extend into the

Thble 1

ANAIOMIC DESCRIPTION OF FIFTHMETAIARSAL FRACTURESX

Tirberosity FractureInvolves tuberosity or sryloid process ("tennis

fracture").

Jones FractureArea in the junction of the diaphysis and metaphysis,usually involving the fourth and fifth intermetatarsalarticular facet.

Diaphyseal Stress FracturePathologic fracture of the proximal 1.5 cm of thefifth metatarsal shaft or diaphysis.

Segmental Shaft FractureFracture ofthe diaphysis distal to the stress fracturearea but proximal to the distal metaphysic and head.

Cervical FractureOblique or transverse fracture in the distal metaph-ysis usually within 1.5 cm of the metatarsal head.

Capitum FractureFracture of the head of the fifth metatarsal. usuallvimpaction ("tulip fracture").

Figure 2. True acute Jones fracture in a 50-year-oldlemale patient with muJtiple sclerosis.

Thble 2

TORG'S CLASSIFICATION OFPROXIMAL FIFTH METATARSAL

FRACTURES BASED ONRADIOGRAPHIC APPEARANCEX

Type I, Early UnionNo intramedullary sclerosis

Fracture line with sharp margins and no wideningMinimal cortical hypertrophyMinimal evidence of periosteal reaction to chronicstress

Type II, Delayed UnionFracture line that invoives both cortices withassociated periosteal bone unionWidened fracture line with adjacent radiolucencyrelated to bone resorptionEvidence of intramedullary sclerosis

Type III, Nonunion\7ide fracture linePeriosteal new bone and radiolucencyComplete obliteration of the intramedullary canal at

the fracture site by sclerotic bone

*Adapted fromfifth metatarsal

Strayer SM, Reece SG, Petrizzi NJ: Fractures of the proximalAm Fam Phvs, 59:25 16-2522,1999.

'Ad:pLed lr.m relerence' 5 anJ JJ

I58 CHAPTER28

metatarsocuboid articulation as those are tuberosityfractures. Also, a Jones fracture is an acute injury with nohistory of prodromal symptoms.'5 It is best seen with a

medial oblique radiograph of the foot.

TREAIMENT

Surgical Versus Nonsurgical

There has been tremendous debate in the literatureregarding whether to treat proximal fifth metatarsalfractures conservatively or surgically. Other than thefractures within zone of relative avascularity, most will heal

eventually with immobilization or protected weight-bearing, especially the tuberosity fractures.5'33 So, if time forreturn to active function is not critical, conservative

management is effective. For performance athletes, delayed

union zone fractures and displaced or intraarticularfractures, surgery may be an important consideration.'a

Tirberosity Fracture (Znne l)This avulsion fracture ("tennis fracture") almost always

heals with nonsurgical management when non-displaced.A hard-soled shoe or walking cast will usually result inrelief of symptoms at 3-4 weeks with signs of radiographicunion present by 8 weeks.5're'r2'25 However, the use of a

soft Jones dressing has been shown to reduce healingtimes to an average of 33 days.35 Functional braces workwell also.'

Figure 3. Surgical intervention for small tuberosiwfracture in;r 63-year-old man bv fragment excision andre-insertion of peroneus brevis tendon with bonea nchors-

For small displaced tuberosity fractures fragmentexcision and tendon re-attachment may be the best

approach. Larger displaced fractures or intraarticularfractures that are displaced with a step-off defect orinclude over 30o/o of the width of the fifth metatarsal-

cuboid joint are best surgicaily reduced and fixed.Methods to choose from are tension band, tension bandand pins, screws and hook plate technique. When used,

screws are best placed bicortical and at right angles to thefracture line (Figure 3).:'tt'tt

Acute Jones Fracture (Zone Il)The true Jones fracture can be treated with a non-weight-bearing cast for 6-8 weeks. For high-performance athletes

or patients who demand a rapid return to function, rigidfixation may be applied. The intraamedullary screw has

proyen to be the more efficient method of fixation,although there are other acceptable methods includingtension band wiring techniques.o'35'12 t, Screw sizes range

from 4.0 to 6.5, depending on local anatomy, and

cannulated may also be considered." The technique forinsertion is best described by Del-ee,a' Nunley,.5 and

Lehman (Figure 4).a' Delayed and non-unions of these

fractures can be typed and treated much the same as those

in the diaphyseal stress fractures zone.

Diaphyseal Stress Fractures (Zone III)Stress fractures through zone III where blood supply islimited are best treated according to radiographic appear-

ance of healing. Non-displaced type I fractures can be

treated with non-weight-bearing cast immobilization and

expect healing at about 7 weeks up to 93o/o of the time.3o'5'

Type II fractures can be casted but take much longer toheal (up to 20 weeks) and still may not unite. Internalfixation has been shown to resuit in faster healing.

Intramedullary screw achieves faster healing than inlaycorticocancellous bone grafting.3"'53 The principles forscrew fixation technique are the same as for the Jonesacute fracture. Type III fractures require internal fixationand bone grafting; healing may be assisted by electrical orultrasound bone growth stimulators which can be utilizedwith or without surgical intervention (Figure 5).to'5a

Shaft Fractures

Pure diaphyseal or shaft fractures are usually oblique.Casting is indicated if they are non-displaced, otherwiseK-wire tansfixation or interfragmentary screws can be

implemented. flansverse or comminuted fractures thatare less stable may require plate or external fixation(Figure 6)."

CHAPTER 28 r59

Figure 4A. Preop. Acute Jones lracture inlemale construction lvorker, successfullyintramedullary screw fixatjon.

26-vear-oldtreated lvith

Figure 48. Postop healed at 8 weeks.

Figure 5. Typical diaphyseal stress fracture fullnonunion. Notice its location distal to the fourth-fifthmetatatsal base articulation.

Figure 6. Diaphyseal or sha€t fiacture.

T60 CHAPTER28

Figure 7. Ceruical fracture of the fifth metatarsal.

Cervical Fractures

This fracture can present as impaction, transverse, orspiral "dancert fracture."5' It can be treated by closed

reduction with traction under local anesthesia followedby casting and usually heals well. Fixation may be

considered for failure to reduce, dorsal displacement, orspiral shearing (Figure 7).''"

Capitum Fractures

Fractures of the head of the fifth metatarsal are oftencaused by distal impaction ("tulip fracture") or directvertical impact. They usually heal well with protectedweightbearing. Severe comminution may require head

resection (Figure 8)."

COMPLICATIONS

The most difficult complications in treating proximalfifth metatarsal fractures are delayed or non-union. \X4ren

either occurs, treatment choices include ultrasound orelectrical bone growth stimulationt. 54'56'57 or surgical repair

with autogenous or prepared bone graft. Refracture can

occur after return to activity or when the screw fixationhas been removed, especially in athletes.5t Screw fractures,

screws missing the intramedullary canal, fracturemalalignment, and pain over the prominent screw head

have all been reported as complications.42'5e'60

One of the most frustrating complications ofsurgery on the base of the fifth metatarsal occurs whenthere is inadvertent damage to the sural nerve. Since thenerye courses and branches at the tuberosity, it is a

Figure 8. Capitum or "tulip" impaction factureinvolving the filth metatarsal head.

structure usually encountered during dissection.Knowledge of its usual expected location and careful

atraumatic technique helps avoid such complicationsand the need for further surgery to release and

decompress the nerve.61 62

CONCLUSION

The true Jones fracture is a very specific and defined

subtype of fifth metatarsal base fractures. Evaluation and

treatment of fifth metatarsal fractures in general are best

accomplished by dividing the long bone into anatomic

regions, each with its own characteristics. fleatment can

range from completely nonoperative care for all types ofthese fractures seen in a general orthopaedic practice33'63

to surgical repair for ail Jones fractures in elite athletes.6a

This paper provides information to help in the

decision-making for all other situations involving fifthmetatarsal fractures.

REFERENCES

1. losefsson PO, Karlsson M, Redlund-Johnell I, \Wendeberg B. Joneslracture. Surgical versus nonsurgical treatment. Clin Orthop Relat

Resl.994;299:252-5.2. Jossefsson PO, Karlsson M, Redlund-Johnell I, tll'endeberg B: Closed

treatment ofJones fracture. Good results in 40 cases after 11-26 years.

Actd Orthop Scand 199465:545-7.3. Rammelt S, Heineck J, Zwipp H. Metatarsal fractures. Injury. 20043)

Suppl 2:SB77-86.4. Dameron TB. Fractures of the proximal flfth metatarsal: selecting the

best treatment option. J Am Acad Orthop Surg 1995:3:710-4.5. Clapper MF, O'Brien TJ, Lyons PM. Fractures of the fifth metatarsal.

Analysis ofa fracture registry. Clin Orthop Relat Res 1995;315:238-41.

CHAPTER 28 t6t

21.

12.

14

15

16.

17

18.

19

t1.

10.

t3

8.

25.

27.

31.

\3.

Ebraheim NA, Haman SP, Jike Lu BA, Padanilam TG, Yeasting RAAnatomical and radiological considerations ofthe fifth metatarsal bone.Foot Ankle Intl 2000;21:212-5.Dameron TB, Jr. Fractures and anatomical r.ariations of the proximalportion ofthe fifth metatarsal. / Bone Joint SurgAm 1975;57:788-92.fuchli \X/R, Rosenthal DI. Avulsion fracture of the fifth metatarsal:experimental study of pathomechanics. AJR Am J Roentgenol1 984:143:889-9 1.

Theodorou DJ, Theodoru SJ, Kikitsubata Y, Botte MJ, Resnick D.Fractures of the proximal fifth metatarsal bone: anatomic and imagingevidence ofa pathogenesis ofavulsion ofthe plantar aponeurosis and theshort peroneal rcndon. Radiologt 2003;226:857 -65.McCarthy DJ. Anatomy. In: Fundamentals of Foot Surgery. McGlamryED (editor), Baltimore:-{/illiams & \X/ilkins;

1 987. p.3.Shereff MJ, Yang QM, Kummer FJ, et al. Vascular anaromy of the fifthmetatarsal. Foot Ankle 199 1; 1 1 :350-3.Smith J\Xr, Amoczky SP, Hersh A. The intraosseous blood supplv of thefifth metatarsal: Implications for proximal fracture healing. Foot Ankle1992;13:143-52.Arangio GA, Xao D, Salathe EP. Biomechanical study of stress in thefifth metatarsal. Clin Biomech 1997 12:160.Lawrence SJ, Botte MJ. Jones' fractures and related fractures of theproximal fifth metatarsal. Foot Ankle 1993 14:358-65.Rosenberg GA, Sferra ]J. Treatment strategies for acute fractures andnonunions of the proxirnal fifth metatarsal. J Am Acad Orthop Swrg2000;8:132-8.Mologne TS, Lundeen JM, Clapper MF, O'Brien TJ. Early screw fixa-tion versus casting in the treatment of acute Jones fractures. Am J SportsMed 2005:33:970-5.Ralph BC, Barrett -f, Kenyhercz C, DiDomenico lA. Iselin's disease:

a case presentation of nonunion and review of the differential diagnosis.

J Foot Ankle Surg 1999;38:40')-16.Orven RJ, Hickey FG, Finlay DB. A study of metatarsal fractures inchildren. Inj ury. 199 5 ;26:5 37 -8.Landorf KB. Clarifi.ing proximal diaphyseal fifth metatarsal fractures.The acute fracture versus the stress ftacwe. J Am Pocliatr Med Asoc1 999r89:398-404.f'heodorou DJ, Theodorou SJ, Boutin RD, Chung C, Fliszar E,

Kakitsubata Y, Resnick D. Stress fiactures ofthe lateral metatarsal bonesin metatarsus adductns foot deformity: a previously unrecognized associ-

ation. Sleeletal Radiol 1999 ;28:67 9 -84.Craigen MA, Clarke NM. Bilateral'Jones' fractures of the fifth metatarsal

following relapse of talipes equinovarus. Injury 199627 :599 -601.Davitt JS, Morgan JM. Stress fracture of the fifth metatusal after Evans'

calcaneal osteotomy: a report ofnvo cases. Foot Ankle Int 1998 19:710-2.Frykberg RG, Mendeszoon E: Management of the diabetic Charcot foot.Diabetes Metab Res Reu 2000;15 suppl 1:S59-565.Yue JJ, Marcus RE. The role of internal fixation in the treatment of Jonesfractures in diabetics. Foot Ankle Int 1996 17:559-62.\(einfeld SB, Haddad SL, Myerson MS. Metatarsal stress fractures. C/lzSporx Med 1997 ;16:319-38.Donahue S1tr, Sharkey NA. Strains in the metatarsals during the stance

phase of gait: implications for stress fractures. J Bone Joint Surg Am1999$1:1236-44.Donahue S-tr, Sharkey NA, Modanlou K{, Sequeira LN, Martin RB.Bone strain and microcracks at stress fracture sites in human metatarsals.

Bone 2000;27:827-33.

Quill GE Jr. Fractures of the proximal fifth metatarsal. Orthop ClinNorth Am 1995;26:353-61.Vogler H-{/, \Testlin N, Mlodzienski AJ, Moller FB. Fifrh metatarsalfractures. Biomechanics, classification, and treatment. Clin Podiatr MetlSurg 1995;12:725-47.TorgJS, Balduini FC, Zelko RR, Pavlov H, PeffTC, Das M. Fracturesof the base of the fifth metatarsal distal to the tuberosiry. Classificationand guidelines for non-surgical and surgical management. J Bone JointSurg Am 1984;66:209 -14.

Jones R. Fracture of the base of the fifth metatarsal bone b). indirectviolence. Ann Surg 1992;35:697 -7 00.Stewart IM. Jones fracture: fracture of the base of the fifth metatarsal.Clin Orthop 1960;16:190-8.Konkel KF, Menger AG, Retzlaff SA. Nonoperative treatment of fifthmetatarsa] fractures in an orthopaedic suburban multispecialq. practjce.Foor Ankle lnrl )00\;)o: -04--.O'Shea MI(, Spak V, Sant'Anna S, Johnson C. Clinical perspectiye ofthe treatment of fifth metatarsal fractures. J Am Podiatr Med AsocI 995:85:473-80.

Nunley JA. Fractures of the base of the fifth metatarsal: the Jonesfractwe. Orthop Clin North Am 2001;32:171-80.\iliener BD, Linder JF, Giattini JF. Treatment of fractures of the fifthmetatarsal: a prospective study. Foot Ankle Int 1997 18:267-9.Rettig AC, Shelbourne KD, ]X/ilckens J. The surgical treatment ofsymptomatic nonunions of the proximal (metaphyseal) fifth metatarsalin athletes. Am J Sports Med 7992,20:50-4.Carpenter B, Garrett A. Using a hook plate as alternate fixation for fifthmetatarsal base fracture.,/ -Fo ot Ankle Surg 2003;42:315-6.ZS, DeFronzo DJ. A comparison of bicortical and intramedullary screw

fixations of Jones' fracwes. J Foot Ankb Surg 2002;41:146-53.Horst F, Gilben BJ, Glisson RR, Nunley JA. Torque resistance afterfixation of Jones fractures with intramedullary screws. Foot Ankle Int2004;25:914-9.Giordano AR, Fallat LM. Strength analysis of intraosseous wire fixationfor avulsion fractures of the fifth metatarsal 6ase. J Foot Ankle Sury2004:43:225-30.RC, Torg JS, Pavlov H, Delee JC. Fractures of the base of the fifthmetatarsal distal to the tuberosity: a review. Foot Ankle 1987 7:245-52.Porter DA, Duncan M, Meyer S]. Fifth metatarsalJones fracture fixationwith a 4.5-mm cannulated stainless steel screw in the competitive andrecreational athlete: a clinical and radiographic evaluation. Am J Sports

Med 2005;33:726-33.Portland G, Kelikian A, Kodros S. Acute surgical management of Jones'fractures. Foot Ankk Int 2003;24:829 -33.Horst F, Gilbert BJ, Glisson RR, Nunley JA. Torque resistance afterfixation of Jones fractures with intramedullary screws. Foot Ankle Int2004.25:914-9.Kelly IP, Glisson RR, Fink C, Easley ME, Nunley JA. Intramedullaryscrew fixation ofJones lractures . Foot Ankle Int 2001;22;:585-9.

Johnson JT, Labib SA, Fowler R. Intramedullary screw fixation of thefifth metatarsal: an anatomic study and improved technique. Foot AnkleInt 2004:25:274-7.Rehman S, Kashyap S. Proximai fifth metatarsal stress fracture treated byearly open reduction and internal fsation. Orthopedic: 2004;27 :1 196-8.Pietropaoli MP, \(/norowski DC, \flerner F\7, Fortino MD.Intramedullary screw fixation ofJones fractures: a biomechanical study.Foot Anble Int 1999:20:560-3.Sammarco GJ. The Jones fracttre. Inst Course Lect 1993 42:201-5.Parkinson DE, Joseph R, Edelman R. Biomechanical principles oftension band wiring applied to fractures of the distal fibula and fifthmetatarsal base. J Foot Surg 1988;27:149-56.Torg JS. Fractures of the base of the fifth metatarsal distal to thetuberosiry. Orthopetlics 1990;13:737-7.Dameron TB. Fractures and anatomical variations of the proximalportion ofthe fifth metatarsal./ BoneJoint SurgAm 1975 57:788-92.Holmes GB Jr. Treatment of delayed unions and nonunions of theproximal fifth metatarsal with pulsed electromagnetic fields. Foot AnkleInt 199415:552-6.O'Mallev MJ, Hamilton VG, Munyak J. Fractures of the distal shaft ofthe fifth metatarsal. "Dancer's fracture". Am J Sports Med 1996:24:240-3.Owen RJ, Hickey FG, Finlay DB. A study of metatarsal fractures inchildren. Injury 199 5 :26:537 -8.Sharrard \X{rW, Sutcliff ML, Robson MJ, et al. The treatment of fibrousnon-union of fi'actures by pulsing electromagnetic stimulation. /.BazrJoint Surg Br 1982;64:189.Zelko RR, TorgJS, Rachun A. Proximal diaphyseal lractures ofthe fifthmetatarsal-trearment of the fractures and their complications in athletes.

Am J Sports Med 1979:7:95-701.Kavanaugh JH, Brower TD, Mann RV. The Jones lracture revisited.

J Bone Joint Surg Am 1978;60:776-82.Glasgow MT, Naranja RJ Jr, Glasgow SG, Torg JS. Aralysis of failedsurgical management of lractures of the base of the fifth metatarsal distalto the tuberosity: the Jones fracttre. Foot Ankle Int 1996;17:449-57.Donley BG, McCollum MJ, Murphy GA, Richardson EG. fusk of suralnerve injury with intramedullary screw fixation of fifth metatarsalfi'actures: a cadaver strdy. Foot Ankle Int 1999 20:182-4.Gould N, Trevino S. Sural nerue entrapment by avulsion lracture of thebase of the fifth metatarsal bone. Foot Ankle 1981 2:153-5.Zogby RG, Baker BE. A review of nonoperative treatment of Jones'fracwe. Am J Sports Med 1987;15:304-7.Low K, Noblin lD, Browne JE, Barnthouse CD, Scott AR. Jonesfractures in the elite football player. / Surg Orthop Adu 2004;13:156-60.

35

36

38

40.

41.

44

39.

41 .

42.

17

57.

46.

47

48

49

50.

51.

52.

53

54

55

56.

20

22

23

24

26

58

59

60

6l

52

63

28.

2)

30

32.

34.

64.