fifth met base fractures - torg

7/27/2019 Fifth Met Base Fractures - Torg

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vatively, but an active athlete w ith delayed union willben efitfrommedu llarycurettageand bon e-graftin g,sw ill fractu res th at h ave progressed to sym ptom atic n onunion.

Fractures of the proxim al part of the fifth m etatarsalcan be separated into tw o types: those involving the tubero sity an d tho se inv olv in g th e pro xim al part o f the d iap hy sisd istal to th e tu berosity . R ece ntly it h as b een reco gn ized th atthe latter group, Jones fractures, m ay be difficult to treat.

A lthough reports in the literature have indicated thepote ntia l d if fic ulti es in th e t re atment o f J on es fr ac tu re st2 46 ,p re va ilin g g uid elin es fo r th eir m an ag emen t a re amb ig uo us .A pp aren tly the v aried clinical a nd ro en tg en og rap hic m an ifestations of these fractures have not been correlated w iththeir response to treatment. In this paper we describe ac la ssific atio n o f th ese fra ctu re s a nd a p la n o f tre atm en t b as edon clinical and roentgenographic criteria that w ere developed to define acute fractures, delayed unions, and nonunions.

Mater ia l a nd Meth od sBetween 1973 and 1982 two of us (J. S. T. and R. R.

Z.) treated forty-three patients w ith forty-six fractures ofthe proxim al part of the diaphysis of the fifth m etatarsal.A ll of the patients w ere evaluated clinically and roentgenographically before and after treatm ent. F ollow -up evaluations were done in 1983 by another one of us (F. C. B.).and the forty-six fractures w ere follow ed for a m ean of 40.2months (range, six to 108 months). The fractures wereclassified and the results of treatm ent w ere evaluated retro sp ectively afte r rev iew ing all clinic ch arts, h osp ital reco rd s, a nd r oe nt ge nogr ams .

A ll patients w ere interview ed at follow -up, sixteen byp erso na l in te rv iew a nd e xamin atio n a nd th irty b y te le ph on e,to obtain inform ation regarding recurrence of sym ptom s,rein ju ry , refractu re , an d activ ity leve l . T reatm en t m eth od sand results w ere then correlated w ith the fracture types.

The m ean age of all of the patients at the tim e of injuryw as 18.6 years, the youngest being fourteen and the oldest,tw en ty -n in e y ea rs o ld . T hirty -n in e o f th e fo rty -th re e p atie ntsw ere betw een the ages of sixteen and tw enty-tw o years old.

ABSTRACT: Between 1973 and 1982 forty-six fractures of the base of the fifth metatarsal, distal to thetu berosity, w ere treated an d follow ed for a m ean of fortym on ths (ran ge, six to 108 m onth s). R oentgenographiccr iteria w ere u sed to d efin e th ree ty pes o f frac tu res: ac utefractures characterized by a narrow fracture line anda bsen ce o f in tramed ullary sclero sis; th ose w ith d ela ye dunion, with widening of the fracture line and evidenceof intram edullary scleross; and those with non-unionand complete obliteration of the medullary canal bys cle ro tic bone.Of the twen ty -f iv eacute f racture s in thi s s er ie s,fifteen w ere treated w ith a non-w eigh t-bearin g toe-toknee cast, and fourteen of them healed in a mean ofseven weeks. Only four of the other ten, which weretreated with various weight-bearing methods, prog ressed to u nio n.

Of the twelve patientswi th delayedunion ,one refused treatm ent, one was treated w ith a bone graft, andten w ere treated in itially b y immobilization of the lim bin a plaster cast and weight-bearing. O f these ten fractures, seven healed in a mean of 15. 1 months and threeeventu ally requ ired grafting for n on -union . O f th e nin enon-u nion s in the series, w hich w ere treated p rim arilywith medullary curettage and bone-grafting, eighthealed in a m ean of three months.

In a ll, tw en ty fra ctu res w er e trea ted su rg ica lly w ithan autogenouscorticocancellousraftthat was inlaidafter thorough curettage and drilling of the scleroticb on e th at o blitera ted th e in trame du lla ry ca vity . O f th esetw enty fractu res, nineteen p rogressed to com plete h ealing and one, to asym ptom atic non-union. There were noo th er comp lica tio ns a sso cia ted w ith th e p roc ed ur e.

W e con clud ed that the treatm en t of choice for acutefractu res is immobilization of the lim b in a toe-to-kneecast w ith non -w eight-bearing. F ractu res w ith d elayedunionmay eventuallyhealif they are treatedconser

* Sports Medicine Center. University of Pennsylvania. WeightmanH all E 7. 235 South 33rd Street. Philadelphia. P ennsylvania 19104.t G annett M edical Clin ic. 10 C entral A venue. Cornell U niversity.I th ac a,N ew Y or k 1 48 33 .

Department of Radio logy. The Hospital for Special Surgery. 535East 70th Street. New York. N .Y . I0()21.

VO L. 66-A, N O. 2. FE BRU AR Y 1984 20 9

Fractures of the Base of the Fifth MetatarsalD istal to the Tuberosity

C LA SSIFIC ATIO N A ND GUID ELINE S FO R NON-SUR GICA L A ND SUR GICA L MAN AG EM ENTBY JOSEPH S. TORG, M.D.*, FREDERICK C. BALDUINI, M .D.*, PHILADELPHIA, RUSSELL R. ZELKO, M.D.t, ITHACA,

HELENE PAVLOV, M.D4, NEW YORK, N.Y. HOMAS C. PEFF, M .D.*, AND MARIANNE DAS, B.S.*,PHILADELPHIA , PENNSYLVANIA

1ro@ n the 1)epartinent of O rt/zopa edic Surgery. U niversity of P ennsylvania Sc/zoo! of M edicine. P hilad elphia.ciiid the D epartment of University H ealth Sciences. C ornell Unitersitv, Ithaca


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21 0 J. S. TORG ET Al..T here w ere forty-one m ale and tw o fem ale patients.

All of the patients were engaged in som e form of athletic endeavor at the tim e of injury. Sixteen fractures w ereasso ciated w ith p lay in g ba sk etb all; fifteen , w ith fo otb all;six. w ith soccer: five, w ith baseball; and one fracture each,w ith g ymn astic s, la cro sse . fie ld -h oc ke y. a nd v olle yb all.

T he fo rty -s ix in ju rie s w ere c la ss ifie d a s a cu te fra ctu re s.delayed unions. or non-unions on the basis of the follow ingc lin ic al a nd r oe nt ge nogr aphic c rit er ia .

T he cha rac teristic featu res o f th e acu te fractu res w ere:no history of previous fracture (although the patient m ayhave had pain or discom fort), no intram edullary sclerosis(F ig. I-A ), a fracture line w ith sharp m argins and no w idening or radiolucency. and m inim um cortical hypertrophy orevidence of periosteal reaction to chronic stress. Thesero en tg en og rap hic featu res are n ot ch aracteristlc o f an acu tefractu re in the u su al sen se of th e term . P re sumab ly th e acu tefractures in our series were located at the site of a preexisting stress concentration or w ere in the lateral part ofthe cortex and becam e disabling w hen they extended acrossthe entire diaphysis. M ost im portant was the absence ofin trame du lla ry s cle ro sis (F ig . 1 -A ).

T he d istin guish in g featu res of the de lay ed u nio ns w ere:a previous injury or fracture, or both; a fracture line thatin volve d b oth co rtices w ith associated p erio steal new b one;a w idened fracture line w ith adjacent radiolucency due tob one reso rp tion : and ev id enc e o f in tram ed ullary sclero sis(F ig . 2 -B ).

The features of the non-unions were: a history of repetitiv e trauma an d recurren t symp toms. a w id e fractu re lin ew ith periosteal new bone and radiolucency. and com pleteobliteration of the m edullary canal at the fracture site bysclerotic bone (the hallm ark of non-union) (Fig. 3-A ).Twen ty -six o f th e fo rty -six fractures w ere tre ated n on

o pe ra tiv ely w ith a n o rth osis w ith c on tin ue d weig ht-b ea rin g.im mobilization in a plaster boot with continued w eightbearing, or immobilization in a plaster boot w ith nonweig ht-b ea rin g. T he o th er tw en ty fra ctu re s w ere tre ate d w ithm edullary curettage and an autogenous inlay bone graft forsymp tomatic delaye d u nio n o r no n-un io n.

T he c rite ria fo r a s uc ce ss fu l re su lt a fte r tre atm en t w ere :( 1 ) no sym ptom s. (2) roen tgen ograp hic evid ence of solidunion of the fracture, and (3) roentgenographic signs ofrecanalization of the niedullary canal w ith no m edullarysclerosis.

Twen ty -o ne o f th e forty -six fractu res in th is stud y w eredescribed in a previous prelim inary report@ . They are ineluded in the present study because none had been categorized as to fracture type and none were tIeated by nonweig ht-b ea rin g immob iliz atio n. In th e p re v@uusre po rt It w asconcluded that these fractures alL slow to heal and oftenreq uire b on e-graftin g. an d th at th e in itial treatm ent do es n otappear to influence the result@ . C om parison of the resultsfor the fractures that w ere treated initially w ith w eightbearing and those for the fractures that w ere treated w ithnon-w eight-bearing is an im portant aspect of the presentstu dy . A ls o, in th e p re vio us re po rt fo llow-u p was te rm in ate dat the conclusion of both non-surgical and surgical treatm ent, but Dam eron and K avanaugh et al. found that thesepatients have a tendency tow ard re-fractures. especiallyw hen they are treated surgically and follow ed for less thantwenty -two month s.Sur gic al T ec hn iq ue

A consistent finding in the presence of non-union ofthis fracture was obliteration of the m edullary canal bydense, sclerotic bone along the m argins of the fracture. Itis our opinion that the tendency of this fracture to progress

FIG. I-A FIG. I-BF ig . I .A : O bliq ue ro en tg en og ram o f th e fifth m etatarsal. d em on stratin g an acu te fra ctu re d istal to th e tu bero sity . T here is so me co rtica l h yp crtro ph y.a n i nd ic ato r o fc hro )n ic s tr es s. b ut t he fr ac tu re l in e is n arr ow . i nv o)l ve s b oth c orti ce s. a nd . m os t i mp orta nt. i s n ot a ss oc ia te d s si th i ntra me du lla ry s cl ero si s.F ig . 1 -B : A fter treatm en t in a n on -w eig ht-b earin g to e-to -k nee cast fo r six w eek s. th ere w as co mp lete h ealin g. A ro en tg en og ram n iad e n in e m on th sa ft er t he i ni ti al i nj ur y s ho s@sma in te na nc e o f f ra ct ur e- he al in g.

THE JOURNAL OF BONE ANt) JOINT SURGERY

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Fiu. 2-A Fi. 2-B Fib. 2-CF ig . 2 -A : O bliq ue ro en tg cn og ran l o f th e fifth m eta tarsal. d em on stratin g an acu te fra ctu re d istal to th e tu bero sity . T he p atien t w as in itially treatedw ith a w alk ing cast fo r six w eeks.Fig. 2-B: 1-our m onths after injury the fracture line is seen to involve both cortices. and there is som e angular deformity. a moderate degree ofin tram ed ullary s clero sis. an d w id en in g o f th e fractu rc h ue.F ig . 2 -C ': T wo y ears h atci co mp lete h ealin g o f th e fractu re h as o ccu rred w ith m in im um d efo rm ity . an d th ere is recan aliza tio n o f th e m ed ullary ca nal.

to de lay ed u nio n o r no n-u nion o r to re fractu reafter It h ashealed is due to the formation at the fracture site of thisp oorly o rgan iied. sclero tic h one . v hich im pairs h ealin g andth e stren gth o f th e u nio n. lh c p urp ose o f su rg ica l tIcatn ien tis to: ( 1) re-establish the continuity of the niedullary canalby rem oving the sclerotic bone. and (2) facilitate healingof the fracture by insertIng an inlay boric graft.

T he base of the fifth m etatarsal is approached througha curvilinear dorsolateral incision: the fracture site is cxposed subperiosteally; and a rectangulat section of bonem easuring 0.7 by 2.0 centim eters. centered over the t'racture, is outlined by four drill-holes (Fig. 4-A ) and rem ovedw ith a sharp O steO tO ilie. T he tiiedullary cavity is then curetted or drilled. or both. until all of the sclerotic bone hasb een ren io ved an d th e c on tin ult\ o f th e iiic du lla ry can al h asbeen re-established ( Fig . 4-B . A n autogenous corticocancellou s b on e graft I1@easu rin g0 .7 b y 2 .0 cen tim ete rs is th en

O f th e fo rty-six in ju ries. tw enty-fiv e w ere classified asa cute fra ctu re s: tw elv e, as d elayed u nio ns@ an d nine. as no n

Fi(. IA FIG. 3-BF ig . 3 -A : O bliq ue ro en ig en og ram d em on stratin g n on -u nio n. N ote th e s@id en in g o f th e fractu re lin e. co rtical h yp ertro ph y. an d d en se in tram ed ullarys cl er os is c omp le te ly o bl it er at in g t he i nc du1l ai@ c av it y.F ig . 3 -B : E ig ht m on th s after su rg ica l treatm en t th ere is h ealin g o f th e fractu re an d recan aliza tio n o f th e m ed ullary c an al.

V OL.. 66-A , N O. 2. FEB RU AR Y 1984

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rem oved from the anterom edial aspect of the distal end ofth e tib ia th rou gh a seco nd in cisio n, b eing carefu l to co ntou rthe graft w ith a high-speed bun so that the cortical portiono f th e g ra ft fits a cc ura te ly in to th e re cta ng ula r c ortic al d ete ctand does not protrude into the m edullary canal and occludeit (F ig . 4 -C ). T he p er io ste um , s ub cu ta ne ou s tiss ue , a nd s kinare closed sequentially in layers, and attention is turned tothe graft site in the tibia. To prevent the formation of astress-raiser, th e sectio n o f b on e rem ov ed from th e fractu resite is placed in the tibial defect before the periosteurn.subcutaneous tissue, and skin are closed. A non-w eightb earin g p laster b oo t is a pp lied. an d immob iliza tio n is m aintam ed for six w eeks.

Results


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21 2 J. S. TORG ET At..unions. T en of the tw enty-five acute fractures w ere treatedw ith som e form of immobilization and w eight-bearing andth e o th er fifte en . w ith immob iliz atio n a nd n on -w eig ht-b ea ring. O f the ten acute fractures that were managed withw eight-bearing (Figs. 2-A and 2-B ), six w ere immobilizedin a plaster boot for an average of 6.3 weeks (range, threeto tw elve w eeks): three w ere supported by an orthosis, w ithactivity being lim ited by pain; and one had no protectionand activity w as perm itted as tolerated. O f these ten fractures, asym ptom atic delayed union developed in four, butthey w ent on to clinical and roentgenographic healing aftera mean of 1 1.5 months (range. seven to fifteen months)(F ig . 2-C ). A t fo llo w-u p. fifty -fo ur to sev en ty -eig ht m onths(m ean , sev en ty -o ne m onths) afte r in ju ry . all fo ur fractu resw ere asym ptom atic, and the patients w ere participating infull activities. O f the other six fractures, tw o had sym ptom atic delayed union and four, sym ptom atic non-union. A ll

operation. the patient w as asym ptom atic and engaging infu ll ac tiv it ies .

O fth e tw elv e fractu res th at w ere first seen w ith d elay edunion, ten were treated initially by im mobilization andweight-bearing in a below-the-knee cast for four to ninew eeks (m ean, 6.0 w eeks), one w as treated surgically. ando ne p atient refu sed treatm en t. E ig ht o f th e tw elv e fractu resin th is g rou p eve ntu ally u nited a t e ig ht to tw en ty -six n@o nth s(m ean, 14.8 m onths) after treatm ent. The other four, ineluding the one that w as treated initially by operation andth e th re e th at failed to un ite after treatm en t by w eigh t-b earin g an d immob ilizatio n. w ere treated su rg ically . A ll fo ur o fth ese fractu res h ealed in tw elv e w eeks. A ll tw elve fractu resin the group were asymptomatic. and all patients were participating in full activities at follow-up at eleven to 108m onths (m ean, 44.3 m onths).

A ll of the nine non-unions in the series w ere treated

Ft;. 4.A FIG. 4-B Fi. 4-CF ig . 4 -A : S uh perio steal ex po su re o f th e b ase o )f t he fifth m etatarsal. d istal to th e tu bero sity . th ro ug h a d orso lateral cu rv ilin ea r in cisio n rev eals th ef ra ct ure li ne a nd a ss oc ia te d c orti ca l h vp er tro ph y. A re cta ng ul ar p ie ce o f h on e m ea su ri ng a pp ro xit ii ate lv 0 .7 b y 2 .( ) c en tim ete rs . c en te re d o ve r t he l ate ra las pect o f th e fractu re. is o utlin ed w ith fo ur d rill-h oles .Fig. 4-B: The piece of bone is excised w ith an osteotonie. and the sclerotic hone in the medullary canal is removed ss itli a curet or drill. or both.tO re-establish the continuity of the m edullarv canal.Fig. 4-C: An autogenous cortical graft. ob tained frotii the anteromedial aspect of the distal part of the tibia. is carefully contoured with a high-speedburr and placed in the prev iously created defect. The p erio steurn. subcutaneous tissues. and skin are then closed in layers. and im rnohiliiation in a

non-w eight-bearing toe-to-knee cast is continued for six w eeks.

s ix w ere tre ate d w ith med ulla ry c ure tta ge a nd b on e-g ra ftin g,and all healed after tw elve to fourteen w eeks (m ean. 12.6w eeks). A t follow -up at six to fifty-eight m onths (m ean,th irty -fo ur m on th s) afte r injury . all six w ere asymp tomaticand th e p atien ts w ere e ng ag in g in fu ll a ctiv ities.O f the fifteen ac ute fractu res th at w ere initially treate dby n on-w eig ht-b earin g a nd immob ilizatio n in a p laster b ootfor an average of 6.5 weeks (range. six to nine weeks),fourteen healed after a mean of 7.4 weeks (range, six totwelve weeks), and the patients w ere asym ptom atic andparticipating in full activities at the tim e of follow -up attwelve to seventy-six m onths (m ean. 34.4 m onths) afterinjury (Figs. 1-A and 1-B ). The rem aining patient, w hoseacute fracture w as treated in a non-w eight-bearing belowthe-knee cast for six w eeks, had a sym ptom atic non-union.T he fra ctu re h ealed tw elv e w eek s after m edu llary cu rettag eand bone-grafting. A t follow -up, tw enty-one m onths after

by us with m edullary curettage and bone-grafting (Fig.3-A). Eight healed in a mean of 12.2 weeks (range. ten tosixteen w eeks) and one, in a patient w ho disregarded instructions not to bear w eight postoperatively. did not heal.A t th e tim e o f fo llo w-u p. eigh t to sev enty-eigh t m on th s afteroperation (m ean. 32.7 m onths). one patient had an asym ptom atic non-union, one com plained of vague discom fort inthe fo ot desp ite roen tg en og ra ph ic ev id en ce of h ealing o f thefracture. and seven had asym ptom atic healing of the fracture. A ll patients w ere participating in full activities (F ig.3-B).

O f the tw enty fractures in this series that w ere treatedby bone-grafting for sym ptom atic delayed union or nonunion, nineteen (95 per cent) had healed, both clinicallya nd ro en tg en og ra ph ic ally , a t tw elv e to s ix te en wee ks (mea n,1 2.3 w eek s) after o peratio n. In th e rem aining fractu re th erew as a persistent non-union but it w as asym ptom atic at fol


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21 3RA CT URE S O F T HE B ASE O F T HE FIFT H M ET AT ARSA Llow -up. There w ere no distal tibial fractures through thed on or site an d n o o th er comp lica tio ns.

A t the conclusion of treatm ent, forty-five fracturesd em on strated so lid un io n as w ell as reso lu tion o f m edu llarysclerosis roentgenographically. In no patient did a subsequent reinjury or re-fracture occur. A t final follow -up allfo rty -th re e p atie nts (fo rty -six fra ctu re s) w ere p artic ip atin gin full activities. W ith the exception of the one patient w hoh ad m ild discomfort, all w ere asymp tomatic.

DiscussionFractures of the proxim al end of the fifth m etatarsal

m a y in vo lv e th e tu be ro sity o r a 1 .5 -c en tim ete r-lo ng se gmen to f b on e dista l to th e tu bero sity . It is im po rtant to ap preciatethis distinction because of the difference in the w ay that thetw o fractures respond to treatm ent. In a study by D am eronof 100 fractures involving the tuberosity that w ere treatedw ith an e lastic b an dag e. o r w ith p artia l w eig ht-b earin g w ithcrutche s if the symptom s w ere seve re, a ll b ut o ne h ad h ealedclin ically at th ree w eek s an d ro entgen og raph ica lly at eig htw eek s. In co ntrast to th ese fin din gs. K avan au gh et al. , D ameron. and Zelko et al. reported that fractures through theproxim al part of the diaphysis are potentially disabling injuries in athletes. O ur experience w ith forty-six such fractu res is in ag reem en t w ith this o bserv ation .

Jones. in 1902, w as the first to describe diaphysealfractures of the fifth m etatarsal, w hen he reported on foursuch injuries. all of w hich apparently healed w ith conservative m anagem ent. In 1927, C arp recognized that thesefractures tend to heal poorly; he found that of tw enty-onefractures union w as delayed in five. In 1960, Stew art notedthat bone-grafting w as needed to secure union of som e ofthese fractures, and also that there m ay be considerablevariation in the duration and severity of symptoms afterinjury. Dameron reported that five (25 per cent) of thetwenty diaphyseal fractures in his series required bone-graftin g for symptom atic n on-u nio n. K av an au gh et al. n oted th atin their series union w as delayed in tw elve (66.7 per cent)of eighteen fractures that w ere treated conservatively. Intheir total group of tw enty-three fractures, thirteen (56.5per cent) w ere eventually treated surgically using an intram edullary screw for fixation. In our series sym ptom aticdelayed union or non-union developed in tw enty (43.5 perc ent) o f fo rty -six fractu res an d w as treated su rg ic ally .

O f D am eron's tw enty patients. nine w ere treated w itha p la ste r c as t a nd e le ve n, w ith e la stic b an da ge s a nd c ru tc he s.Fifteen of the fractures had conservative treatm ent only,w ith tw elve healing at betw een tw o and tw elve m onths aftertreatm ent and the other three healing after fifteen, tw enty,and tw enty-one m onths. T he rem aining five patients in thes erie s w ere tre ate d w ith a s lid in g b on e g ra ft fo r symptomaticnon-union at four, seven, eight, fourteen, and fifteenm onths. B ased on these findings, D am eron concluded thatin itial treatm ent d id n ot ap pear to in flu en ce th e result. S imilarly, K avanaugh et al. found that several of their patientsw ho w ere tre ated w ith n on -w eig ht-be aring an d a p laster ca stfor ten to tw elve w eeks show ed no evidence of healing, and

th ey c on clu de d th at p la ste r immob iliz atio n a nd n on -w eig htbearing w ere probably unnecessary. Zelko et a). , in a prelim in ary rep ort o n the first tw en ty -on e patien ts in o ur series(n one o f w hom h ad b een treated w ith n on -w eigh t-b earin g),concluded that the clinical course did not appear to be influe nce d b y th e u su al c on serv ativ e treatm en t.

Subsequent to the report of Zelko et al. our series offractures w ere classified as already described, and fifteenof the acute ones w ere treated w ith non-w eight-bearing ina plaster cast. Fourteen of the fifteen healed in a m ean of6.5 weeks. This finding is in sharp contrast to that in theinitial ten acute fractures, which were all treated w ith aw eight-bearing cast. O f these ten fractures. four healed inan average of 1 1.5 m onths, while asym ptom atic delayedunion or non-union developed in the other six and boneg ra ftin g wa s n ec es sa ry .

The failure of the fractures to unite in the patients ofK av an au gh e t a l. , d esp ite tre atm en t w ith a n on -w eig ht-b ea ring cast, may be explained by the fact that they were notacu te fractu res b ut w ere reinjurie s in p atien ts w ith de lay edu nio n th at re qu ire d e ith er p ro lo ng ed immob iliz atio n o r b on egrafting.

On th e b asis o f o ur ex pe rien ce w ith a cu te fra ctu res ofthe base of the fifth m etatarsal distal to the tuberosity. w eb elie ve th at immob iliz atio n in a n on -w eig ht-b ea rin g p la ste rboot is the treatment of choice. When there is a delayedunion it is apparent that, given enough tim e (m ean, 14.8m onths in our series), union w ill occur in virtually all patien ts if v ig orou s activ ity is av oid ed. H ow ev er, fo r ath leteswho d esire to re tu rn to c ompe titio n n on -o pe ra tiv e tre atm en tusu ally w ill n ot b e accep tab le.

A s described in the literature, delayed union and nonunion are treated by tw o basic surgical techniques: ( 1) intram edullary fixation using a screw , and (2) a sliding orinlay bone graft. Common to both of these methods is rem oval of the sclerotic bone plug from the m edullary canal.It is our belief that the poorly organized, sclerotic intram edullary bone that form s w hen union is slow contributesto th e freq uent d elay in h ealin g, re-fractu re, an d n on -u nio nafter this injury. C om plete union is achieved only w hen them edullary canal is recanalized. W e believe that intram edu lla ry c ure tta ge h as te ns th is p ro ce ss in v ig oro us , p hy sic allyac tive indiv idua ls .

In trame du lla ry sc rew fix atio n is a sso cia te d w ith s ev era lproblem s. To approach the lesion from the proxim al end ofthe tuberosity and place a Leinbach or an AO malleolarscrew, as noted by Kavanaugh et al. , is technically difficult.A lso, as reported by these authors, this technique is assoc ia te d w ith a 4 5 p er c en t ra te o f p erio pe ra tiv e c omp lic atio ns.In th eir th irteen p atien ts, th ree intram edu lla ry screw s fractured at operation, tw o m issed the m edullary canal, and oneh ad to be rem ov ed be cause o fp ain . In tram ed ullary curettag eand inlay bone-grafting, on the other hand, are technicallys imp le , a re n ot a ss oc ia te d w ith p er io pe ra tiv e c omp lic atio ns ,and have resulted in a 95 per cent rate of union. W e believethat it is the procedure of choice for delayed union or nonu nio n o f th ese fra ctu re s.

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21 4 J. S. TORG ET AL.Conclusions

On the basis of our experience. it appears that theselection of the best form of treatm ent for these fracturesshould be based on the presence or absence of m edullarysclero sis adjacen t to th e fracture site. In o ur serie s, fo urteen(93 per cent) of the fifteen fractures with no associatedin trame du lla ry sc le ro sis w ere s uc ce ss fu lly tre ate d w ith n onweight-bearing and immobilization in a plaster boot for sixto e ig ht w ee ks . W e th ere fo re b elie ve th at th is is th e tre atm e nto f c ho ic e fo r fra ctu re s in vo lv in g th e b ase o f th e fifth meta ta rsal distal to the tuberosity w hen roentgenogram s dem ons tr af e n o i nt ramedull ary s cle ro si s.

O n the other hand, if roentgenogram s show evidence

Of intramedullary sclerosis partially obliterating the medullary cavity and if the patient engages in non-jum ping activities, such as football, baseball, or soccer, it m ay take along tim e for the fracture to heal or for an asym ptom aticdelayed union to develop. Thus, in serious amateur orp ro fe ssio na l a th le te s, it m ig ht b e p re fe ra ble to e xp ed ite h ea ling by surgical m eans.If roentgenogram s dem onstrate non-union w ith densesclero tic b one ad jacen t to th e fracture line an d a comp letelyobliterated m edullary cavity, m edullary curettage and autogenous inlay bone-grafting are recommended for all athletes and should be considered in non-athletes who ares ymp tomatic d urin g th eir u su al a ctiv itie s.

References1 . CA RP, L ouis: Fracture of th e Fifth M etatarsal B one. W ith Special R eference to D elay ed U nion. A nn . Surg. . 8 6: 308-320. 1 927.2. D AM ER ON .T . B . . JR .: Fractures and A nato mical V ariations of the Proxim al Portion of the Fifth M etatarsal. J. B one and Joint Surg. . 57-A : 788-792, Sept. 1975.3. JO NE S. RO BE RT : Fracture of the Base of the Fifth M etatarsal B one by In direct V iolence. A nn. Surg. . 35: 697-700, 1902.4. K AVA NAU GH .J. H .; BROW ER, 1. D .; and M ANN . R. V .: The Jones Fracture Revisited. J. Bone and Joint Surg. . 60-A: 776-782. Sept. 1978.5. STEWA RT . I. M .: Jones's Fracture: Fracture of th e B ase of the Fifth M etatarsal. C lin. O rthop. . 16: 190-198, 1960.6. ZELKO, R. R . : TO RG . J. S. ; and RACHU N. ALEXIS: Proximal Diaphyseal Fractures of the Fifth M etatarsal Treatment of the Fractures and TheirC om plications in A thletes. A m. J. Sports M ed. , 7: 95-101 . 19 79.

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