An avulsion fracture of the fifth metatarsal also known as a pseudo-Jones fracture or a dancer fracture is a type of fracture that occurs where a tendon attaches to the bone at this point (the peroneus brevis tendon). When an avulsion fracture occurs, the tendon pulls off a tiny fragment of bone. These fractures are usually not badly out of place.

Fractures of the proximal portion of the fifth metatarsal could also be classified as avulsions of the tuberosity or fractures of the shaft within 1.5 cm of the tuberosity. Tuberosity avulsion fractures cause pain and tenderness at the bottom of the fifth metatarsal and follow forced inversion during plantar flexion of the foot and ankle. Local bruising, swelling, and other injuries could also be present. Nondisplaced tuberosity fractures are usually treated conservatively, but an orthopedic referral is indicated for fractures that are comminuted or displaced, fractures that involve quite 30 percent of the Cubo-metatarsal articulation surface, and fractures with delayed union. Management and prognosis of both acute (Jones fracture) and fatigue fracture of the fifth metatarsal within 1.5 cm of the tuberosity depend upon the sort of fracture, supported Torg’s classification. Type I fractures are generally treated conservatively with a non-weight-bearing short leg cast for 6 to eight weeks. Type II fractures can also be treated conservatively or could also be managed surgically, counting on patient preference and other factors. All displaced fractures and sort III fractures should be managed surgically. Although most fractures of the proximal portion of the fifth metatarsal respond well to appropriate management, delayed union, muscle atrophy and chronic pain could also be long-term complications

Causes

• The repetitive impact – to the metatarsals bone with weight-bearing exercises cause microfractures, which consolidate to stress fractures.[rx]
• The most common location of metatarsal stress fractures – anatomically second metatarsal neck as it is less flexible and prone to torsional forces given its strong ligamentous attachment to the 1 and 2 cuneiforms and the second metatarsal bone is the longest of the metatarsals, subjected to the most force.[rx]
• Heavy impact – The force of a jump or fall down from height can result in a broken ankle. It can happen in metatarsal bone fractures even if you jump from a low height.
• Missteps – You can cause a fracture of the ankle if you put your foot down awkwardly abnormally. Your ankle might twist or roll your foot joint to the side as you put weight on it. It can also happen in stare up or stare down unawkwardly.
• Sports – High-impact sports such as football cricket, hockey, volley boll involve intense movements that place stress on the joints, including the ankle bone fracture examples of high-impact sports include, cricket, racer of the bike, soccer, football, Horseback riding, Hockey, Skiing Snowboarding In-line skating, Jumping on a trampoline and basketball.
• Car collisions – The sudden, heavy impact of a car accident, bike accident can cause metatarsal bone fractures. Often, these types of injuries need surgical repair. The crushing types of injuries common in car accidents may cause breaks that require surgical repair.
• Falls from height – Tripping, and falling when walking on uneven surfaces can break bones in your ankles and metatarsal bone, phalanges fractures, as can landing on your feet after jumping down from just a slight height.
• Missteps – Sometimes just putting your foot down the wrong way can result in a twisting injury that can cause a broken bone. Fracture also occurs when stairs up or stairs down, especially older people.
• Unconsciously Toilet Use – It is a very common and day by day increasing incidence of fracture of the ankle joint, foot bone, metatarsal bones, tarsal bone, phalanges, especially high comodo using time and lower limb fractures.
• High hell Use – It is the most common cause of fracture in the ankle, foot, lower limb fracture, especially for women, abnormal arch, foot angle, the lake of the flat foot, abnormal sole of your footwear, muscle, tendon, cartilage, ligament weakness in the knee, ankle joints.
• On a battlefield – with the increasing of technology, nuclear weapons, one country is involved in the war from one country to another country. On the battlefield, millions of armies and general people are falling in injury that is gradually causing ankle, foot, metatarsal, tarsal bone fractures.
• Have osteoporosis –  a disease of your bone that weakens your bones gradually due to inadequate intake of calcium or vitamin D.
• Weak low muscle mass or poor muscle strength – lack agility or older age muscle strength, mass, power, endurance become weak, and poor balance conditions make you more likely to fall and cause a fracture.
• Walk or do other activities in the snow or on the ice – or do activities that require a lot of forwarding momenta, such as in-line skating and skiing,  Skiing Snowboarding, in-line skating, Jumping, playing lead to fracture of the bone in the lower limb.

Symptoms

Symptoms of bone fractures include

• Intense pain, swelling, tenderness, limited range of motion is the first
• Pain with or after normal activity
• Pain that goes away when resting time and then returns when standing, walking, or during activity
• Pinpoint pain at the site of the fracture when touched
• Swelling but no bruising may be present if it becomes microtrauma
• Bruising or discoloration that extends to nearby parts of the foot bones.
• Pain with walking and weight-bearing
• Swelling in the heel area
• Pain may decrease with rest but increases again with activity.
• Pain at the site of the fracture, which in some cases can extend from the foot to the knee.
• Significant swelling may occur along the length of the leg or may be more localized.
• Blisters may occur over the fracture site after some days.
• Bruising that develops soon after the injury time.
• Inability to walk; it is possible to walk with less severe breaks, and fractures so never rely on walking as a test of whether or not a bone has been fractured.
• Change in the color and appearance of the ankle will look different from the other ankle.
• Bone protruding fracture through the skin is a sign that immediate emergency care is needed. Fractures that pierce the skin require attention because they can lead to severe infection and take a prolonged time to recover.
• This pain may occur or feel in the setting of acute trauma or repetitive microtrauma over weeks to months. One should be suspicious of stress fracture with pain or pain of worsening quality or duration over time.

Diagnosis

Laboratory tests should be done as an adjunct in overall medical status for surgical treatment.

• CBC, ESR test
• Random blood sugar, glucose, and routine diabetes test if the patient has diabetes mellitus.
• Microscopic urine examination test, and stool test.
• ECG, EKG test for heart abnormality is present
• Ultrasonography test in some cases.
• Normalized hemoglobin, hematocrit test
• Coagulation profile with bleeding time and coagulation time test, prothrombin time (PT) test for surgery if needed,
• Thromboplastin time and platelet counts will be needed for operative intervention.
• Serum creatinine test,
• Serum lipid profile
• Serum uric acid test

Treatment

Initial First Aid

• Get medical help immediately – If you fall on an outstretched leg, play cricket gets into a car accident, or are hit while playing a sport and feel intense pain in your leg area, then get medical care immediately. Cause significant pain in your leg, foot, ankle joint, and part of your leg closer to the base of your leg. If the accident is major you keep your leg at the same heart position and then clean and treat any wounds on the skin of the injured leg.
• Aggressive wound care – It is very important for patients to reach a safe position with the proper ventilation needed for contaminated wounds. Injured are clear with disinfectant material [rx]
• ICE and elevation – It help for prevention swelling, edema
• Rest – Sometimes rest is all, that is needed to treat a traumatic fracture of the foot, ankle, tarsal and metatarsal fracture. Sometimes rest is the only treatment needed to eradicate healing of a stress or traumatic fracture of a metatarsal bone fracture.
• Compression – a bandage will limit swelling, edema, and help to rest the joint. A tubular compression bandage is frequently used but should be removed at night by easing it off gradually. Put it on again before you are from out of bed in the morning. Mild to moderate pressure that is not too uncomfortable or too tight, and does not stop blood flow, is ideal. Depending on the amount of swelling. pain, edema you may be advised to remove the bandage for good after 48 hours.
• Elevation – Elevation initially aims to limit and reduce any swelling. For example, keep the foot upright on a chair or pillow to at least hip level when you are sitting. When you are in bed, put your foot on a pillow. Sometimes rest is the only treatment that is needed, even in fractures.
• Splinting – The toe may be fitted with a splint to keep it in a fixed position.
• Rigid or stiff-soled shoes – Wearing strong stiff-soled shoes to protect the toe and help keep it properly positioned. Use of a postoperative splint, shoe, or boot walker is also helpful.
• Avoid the offending activity – Because fractures result from repetitive stress, the trauma it is important to avoid the activity that led to the fracture more seriously. Crutches or a wheelchair, or other types of supporting splint are sometimes required to offload weight from the foot to give it time to heal.
• Immobilization, casting, or rigid shoe – A stiff-soled shoe or another form of immobilization may be used to protect the fractured bone while it is healing. The use of a postoperative shoe or boot walker is also helpful.
  
• Casting, or rigid shoe – A stiff-soled shoe or another form of immobilization may be used to protect the fractured bone while it is healing. The use of a postoperative shoe or boot walker is also helpful.
• Stop stressing the foot – If you’ve been diagnosed with a stress fracture, avoiding the activity that caused it is important for healing. This may mean using crutches or even a wheelchair.

Do no HARM for 72 hours after injury

• Heat—hot baths, electric heat, saunas, heat packs, etc has the opposite effect on the blood flow. Heat may cause more fluid accumulation in the fracture joints by encouraging blood flow. Heat should be avoided when inflammation is developing in the acute stage. However, after about 72 hours, no further inflammation is likely to develop and heat can be soothing.
• Alcohol stimulates the central nervous system that can increase bleeding and swelling and decrease healing.
• Running, and walking may cause further damage, and causes healing delay.
• Massage also may increase bleeding and swelling. However, after 72 hours of your fracture, you can take a simple message, and applying heat may be soothing the pain.

Medication

The following medications may be considered by your doctor to relieve acute and immediate pain, long term treatment

• Antibiotic – Cefuroxime or Azithromycin, or  Flucloxacillin or any other cephalosporin/quinolone, meropenem antibiotic must be used to prevent infection or clotted blood removal to prevent further swelling, inflammation, and edema.
• NSAIDs – Prescription-strength drugs that reduce both pain and inflammation. Pain medicines and anti-inflammatory drugs help to relieve pain and stiffness, allowing for increased mobility and exercise. There are many common over-the-counter medicines called non-steroidal anti-inflammatory drugs (NSAIDs). They include first choice NSAIDs is Ketorolac, then Etoricoxib, then Aceclofenac, naproxen.
• Muscle Relaxants –  These medications provide relief from spinal muscle spasms, spasticity.  Muscle relaxants, such as baclofen, tolperisone, eperisone, methocarbamol, carisoprodol, and cyclobenzaprine, may be prescribed to control postoperative muscle spasms, spasticity, stiffness, contracture.
• Calcium & vitamin D3 – To improve bone health, blood clotting, helping muscles to contract, regulating heart rhythms, nerve functions, and healing fractures. As a general rule, too absorbed more minerals for men and women age 50 and older should consume 1,200 milligrams of calcium a day, and 600 international units of vitamin D a day to heal back pain, fractures, osteoarthritis.
• Neuropathic Agents – Drugs(pregabalin & gabapentin) that address neuropathic—or nerve-related—pain. This includes burning, numbness, tingling sensation, and paresthesia.
• Glucosamine & Diacerein, Chondroitin sulfate – can be used to tighten the loose tendon, cartilage, ligament, and cartilage, ligament regenerates cartilage or inhabits the further degeneration of cartilage, ligament. The dosage of glucosamine is 15oo mg per day in divided dosage and chondroitin sulfate approximately 500mg per day in different dosages, and diacerein minimum of 50 mg per day may be taken if the patient suffers from osteoarthritis, rheumatoid arthritis, and any degenerative joint disease.[rx]
• Topical Medications and essential oil – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation in acute trauma, pain, swelling, tenderness through the skin. If the fracture is closed and not open fracture then you can use this item.
•  Antidepressants – A drug that blocks pain messages from your brain and boosts the effects of endorphins in your body’s natural painkillers. It also helps in neuropathic pain, anxiety, tension, and proper sleep.
• Corticosteroids – Also known as oral steroids, these medications reduce inflammation. To heal the nerve inflammation and clotted blood in the joints.
• Dietary supplement – To eradicate the healing process from fracture your body needs a huge amount of vitamin C, and vitamin E. From your dietary supplement, you can get it, and also need to remove general weaknesses &  improved health.
• Cough Syrup – If your doctor finds any chest congestion or fracture-related injury in your chest, dyspnoea, post-surgical breathing problem, then advice you to take bronchodilator cough syrup.

What To Eat and What  to avoid

Eat Nutritiously During Your Recovery

All bones and tissues in the body need certain micronutrients in order to heal properly and in a timely manner. Eating a nutritious and balanced diet that includes lots of minerals and vitamins is proven to help heal broken bones and all types of fractures. Therefore, focus on eating lots of fresh food produce (fruits and veggies), whole grains, cereal, beans, lean meats, seafood, and fish to give your body the building blocks needed to properly repair your fracture. In addition, drink plenty of purified mineral water, milk, and other dairy-based beverages to augment what you eat.

• Broken bones or fractures bones need ample minerals (calcium, phosphorus, magnesium, boron, selenium, omega-3) and protein to become strong and healthy again.
• Excellent sources of minerals/protein include dairy products, tofu, beans, broccoli, nuts and seeds, sardines, sea fish, and salmon.
• Important vitamins that are needed for bone healing include vitamin C (needed to make collagen that your body essential element), vitamin D (crucial for mineral absorption, or machine for mineral absorber from your food), and vitamin K (binds calcium to bones and triggers more quickly collagen formation).
• Conversely, don’t consume food or drink that is known to impair bone/tissue healing, such as alcoholic beverages, sodas, fried fast food, most fast food items, and foods made with lots of refined sugars and preservatives.

Surgery

Zones and fracture patterns of the fifth metatarsal base.

The most common fracture of the fifth metatarsal base is an avulsion of the tuberosity. Although originally thought to be caused by the overpull of the peroneus brevis tendon when the foot supinates or adducts abruptly, literature has supported the notion that the lateral band of the plantar fascia is the primary cause.3 I treat the overwhelming majority of tuberosity fractures during a hard-soled shoe or short Controlled Ankle Movement boot with full weight-bearing permitted. The more symptomatic patients with lower pain tolerances typically do better with the walker boot. Patients are encouraged to transition to regular shoes as soon as they feel comfortable, which is typically 3 to 4 weeks after the injury. I don’t routinely obtain follow-up radiographs because fibrous unions are common, are usually asymptomatic, and don’t change my treatment recommendations.

Occasionally, i will be able to see a patient with an outsized Zone I tuberosity avulsion that involves a big amount of the joint surface. If substantial joint displacement is noted (more than 2 to three mm), i will be able to consider open reduction and internal fixation. computerized tomography is extremely helpful in evaluating the extent of the joint involvement and displacement if plain films are equivocal. For these relatively uncommon variants, i exploit a little fragment screw placed obliquely through the tuberosity and across the medial cortex of the proximal fifth metatarsal in lag fashion. A partially threaded cannulated 4.0-mm screw with a washer works well. I expose the fracture through a longitudinal incision centered on the dorsal aspect of the tuberosity and place the screw percutaneously. Postoperatively, I keep these patients non-weight bearing for the primary 2 to three weeks during a splint, then advance to protected weight-bearing during a cast or boot until 6 weeks after surgery.

A true Jones fracture is an acute injury that happens in Zone II of the fifth metatarsal base. Treatment for these fractures is controversial. Nonoperative treatment during a non-weight-bearing short leg cast has been the normal treatment4 and remains widely practiced. Clapper et al5 reported an average time to heal of 21 weeks and a 28% nonunion rate from a series of 25 patients with a real acute Jones fracture. i like the utilization of a walker boot, and permit weight bearing as tolerated in patients who prefer to avoid surgery. Anecdotally, we’ve not appreciated a better nonunion rate with this approach compared to the non-weight bearing during a cast. for many cases, however, I offer operative treatment to the patient. The surgery is comparatively simple with low morbidity and it facilitates faster and better union rates with more aggressive rehabilitation. Most practitioners recommend surgical intervention altogether high-performance athletes, but I apply this to any patient who desires a more reliable, shorter healing period, albeit with the danger of surgery.

Acute Zone II Jones fracture

For patients electing surgery for an acute Jones fracture, I like to recommend percutaneous intramedullary screw fixation. The procedure is often performed under an ankle block as an outpatient. A guide pin is placed under fluoroscopy through a little incision. The start line is critical to optimize screw placement. A “high and inside” starting location on the bottom of the fifth metatarsal facilitates maintaining an intramedullary screw position with avoidance of cortical break-out during a bone with curved morphology. i exploit a cannulated entry system but place a solid, partially-threaded screw, usually 4.5 or 5.5 mm in diameter. The ideal screw length is simply long enough for the threads to be distal to the fracture (Figure 36-3). Typically, the screw traverses about half the metatarsal length. I don’t routinely bone graft the acute Jones fractures. Postoperatively, patients are non-weight bearing during a splint for two weeks, then full weight-bearing during a walker boot until 6 to eight weeks postoperatively. Activity is progressed supported symptoms and radiographic healing. Return to full activity, including sports, may take up to three months.

Appropriate intramedullary screw position with ideal screw length

Zone III injuries within the proximal diaphysis of the fifth metatarsal typically stress fractures (Figure 36-4). Patients often report prodromal symptoms, but radiographic findings are variable. Torg et al have classified these as acute or chronic.6 Acute fractures are typically characterized by a radiolucent line with sharp margins and minimal bone hypertrophy. Chronic stress fractures, including delayed and nonunions, typically demonstrate a widened lucent line with resorption, intramedullary sclerosis, and periosteal reaction. Acute proximal diaphyseal stress fractures are treated almost like acute Jones fractures, and expectedly are equally controversial. Non-weight-bearing during a short leg cast is an accepted treatment, although i will be able to typically allow weight-bearing during a walker boot and add the utilization of an external bone stimulator.

Zone III diaphyseal acute fatigue fracture

Depending on the patient’s preferences and goals, i like intramedullary screw fixation for acute and chronic Zone III stress fractures. it’s critical to assess hindfoot alignment, and varus position may be a contributing factor both in terms of etiology and recurrent fractures. i will be able to add a hindfoot osteotomy in severe cases, or if the patient has failed previous screw fixation. The percutaneous technique for screw fixation is the same as noted for Jones fractures. For nonunions and delayed unions, i will be able to also make alittle incision over the fracture site and débride the bone and animal tissue. The defect is then full of autograft, usually a little dowel of bone from the calcaneus or iliac crest. The postoperative protocol includes non-weight bearing for two weeks during a splint, followed by protected weight-bearing during a walker boot until 6 to eight weeks after surgery. For high-risk cases (ie, revision surgery or nonunions), I also use an external bone stimulator, and therefore the rehabilitation process is a smaller amount aggressive.

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References

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