Orthopedics

Feature Article 

Functional Outcomes for Nonoperatively Treated Proximal Fifth Metatarsal Fractures

Hannah A. Dineen, MD; Timothy D. Murphy, MD; Sabrina Mangat, BS; Eric Z. Lukosius, MD; Feng-Chang Lin, PhD; Brett J. Pettett, MD; Stephen J. Peoples, DVM; Shepard R. Hurwitz, MD

Abstract

Fractures of the proximal fifth metatarsal are relatively common and can be treated with a variety of treatment modalities. The goals of the current study were to answer the following questions: (1) Is there a difference in functional outcomes with different nonoperative treatment modalities for avulsion and Jones fractures? (2) What is the long-term functional impairment? This study included 53 patients who were treated for proximal fifth metatarsal fracture at 1 university health care system between 2004 and 2013. Treatment methods included shoe modification, cast, and boot. Patients completed a telephone questionnaire that included selected questions from the Musculoskeletal Outcomes Data Evaluation and Management System (MODEMS). Treatment groups were stratified as shoe modification or immobilization, and the results of the MODEMS survey were compared. At most recent follow-up, no significant difference was found between the 2 patient groups (P=.062) for self-reported effects of the injury on work and quality of life. No significant difference was found for frequency of use of pain medication (P=.157), patient satisfaction with current symptoms (P=.633), ambulatory status (P=.281), or pain level with strenuous activity (P=.772). Obese patients were more likely to have severe pain with strenuous activity (P=.015). Most (87%) patients were able to ambulate without the need for assistive devices. Of the study patients, 79% could wear dress shoes, excluding high heels, comfortably. The findings showed that patients who were treated with a variety of nonoperative methods for closed proximal fifth metatarsal fracture had acceptable functional outcomes, regardless of treatment method. [Orthopedics. 2017; 40(6):e1030–e1035.]

Abstract

Fractures of the proximal fifth metatarsal are relatively common and can be treated with a variety of treatment modalities. The goals of the current study were to answer the following questions: (1) Is there a difference in functional outcomes with different nonoperative treatment modalities for avulsion and Jones fractures? (2) What is the long-term functional impairment? This study included 53 patients who were treated for proximal fifth metatarsal fracture at 1 university health care system between 2004 and 2013. Treatment methods included shoe modification, cast, and boot. Patients completed a telephone questionnaire that included selected questions from the Musculoskeletal Outcomes Data Evaluation and Management System (MODEMS). Treatment groups were stratified as shoe modification or immobilization, and the results of the MODEMS survey were compared. At most recent follow-up, no significant difference was found between the 2 patient groups (P=.062) for self-reported effects of the injury on work and quality of life. No significant difference was found for frequency of use of pain medication (P=.157), patient satisfaction with current symptoms (P=.633), ambulatory status (P=.281), or pain level with strenuous activity (P=.772). Obese patients were more likely to have severe pain with strenuous activity (P=.015). Most (87%) patients were able to ambulate without the need for assistive devices. Of the study patients, 79% could wear dress shoes, excluding high heels, comfortably. The findings showed that patients who were treated with a variety of nonoperative methods for closed proximal fifth metatarsal fracture had acceptable functional outcomes, regardless of treatment method. [Orthopedics. 2017; 40(6):e1030–e1035.]

Fractures of the proximal fifth metatarsal are relatively common and are categorized into 3 types: avulsion fractures, Jones fractures, and proximal diaphyseal stress fractures. Avulsion fractures result from inversion of the hindfoot, which generates tension along the band of the plantar aponeurosis that inserts onto the base of the fifth metatarsal, and this type of fracture frequently occurs as an intra-articular fracture at the cuboid surface.1,2 Jones fractures are more distal than avulsion fractures and are located within 1.5 cm of the tuberosity, in the metadiaphyseal region of the metatarsal, also known as the watershed region because of its precarious blood supply.3,4 Proximal diaphyseal stress fractures occur just distal to the area of Jones fractures and are believed to be caused by repetitive overuse.4 Jones fractures are associated with a longer healing period than avulsion fractures and can result in nonunion, with nonunion rates of 7% to 28% reported.5 These fractures can be treated nonoperatively. Jones fractures are sometimes treated operatively, especially among athletes and patients with unsuccessful nonoperative management, because of concerns about nonunion.4 Avulsion fractures are typically treated with a variety of nonoperative methods.4 Numerous studies have shown success with treating Jones fractures nonoperatively with immobilization and non-weight bearing.4,6–11 Recent findings suggested that Jones fractures can be treated with early weight bearing with good results and no need for routine follow-up.6 Significant data are available on the union rates of proximal fifth metatarsal fractures, but little is known about functional outcomes. A variety of non-operative treatment modalities are used, including casts, walking boots, hard-soled shoes, carbon fiber inserts, plaster slippers, and bandages.7 The goals of the current study were to answer the following questions: (1) Is there a difference in functional outcomes with different nonoperative treatment modalities for avulsion and Jones fractures? (2) What is the long-term functional impairment?

Materials and Methods

Between January 1, 2004, and May 1, 2013, a total of 297 patients treated at a single university health care system were identified as having fifth metatarsal fractures according to International Classification of Diseases, Ninth Revision, coding. Patients were seen at the emergency department, the hospital, and the outpatient clinic. This study included 22 orthopedic providers. A retrospective study was performed of patients who met the study criteria during a 1-year period.

Of the 297 patients who had proximal fifth metatarsal fractures during the study period, 123 met the study criteria according to the exclusion criteria described later. These patients were asked to participate in this study, which was approved by the institutional review board at the study institution. Of the eligible patients, 53 agreed to participate and completed the telephone questionnaire. Exclusion criteria included age older than 60 years on the date of injury, chronic fracture, polytrauma, neuropathic fracture, multiple ipsilateral foot injuries, and operative treatment. Radiographic follow-up was not required. Only fifth metatarsal fractures that were deemed appropriate for nonoperative treatment by the treating provider were included in this study. After informed consent was obtained, survey data were collected by 2 trained interviewers (S.M., E.Z.L.) with a script that consisted of a 10-question survey that included selected questions from the Musculoskeletal Outcomes Data Evaluation and Management System (MODEMS) questionnaire. To identify the functional outcomes of these patients, variables studied included frequency of use of pain medication, need for assistive devices while ambulating, overall state of health, amount of pain with various activities, effect of foot symptoms on quality of life, and ability to wear various shoes comfortably. The authors also noted differences among patients, regardless of treatment type, for several independent factors, such as body mass index and smoking status.

Treatment methods included controlled ankle motion boots, hard-soled shoes, carbon fiber inserts, short leg casts, and regular shoes. Treatment groups were stratified into 2 methods of nonoperative management, which included immobilization (weight bearing in a controlled ankle motion boot) and shoe modification (hard-soled shoe or carbon fiber insert). Non–weight-bearing short leg casts were excluded because of low frequency of use (n=4). Union status was not assessed because union rates are well reported and the goal of this study was to evaluate functional outcomes, regardless of union status.

Statistical Analysis

Descriptive statistics were reported as frequency (percentage) for categorical variables and mean (range) for continuous variables. Other variables also were compared between treatment groups. Pearson's chi-square test was used for categorical variables, and the Kruskal–Wallis test was used for continuous and ordinal variables. Data were analyzed with SPSS software (IBM SPSS Inc, Chicago, Illinois). P≤.05 was considered significant. Before data collection, the study was designed with an effect size of 0.4 for a sample size of 60 under 0.8 statistical power and 0.05 type I error. However, after the data were collected, the current effect size was 0.28, and 123 subjects would be needed to achieve the same statistical power under the current effect size and type I error probability.

Results

The study included 53 patients (41 women and 12 men), with mean age of 42 years (range, 24–63 years) and average body mass index of 30.7 kg/m2 (range, 18.1–50.2 kg/m2) (Table 1). Of the patients, 7 were current smokers or had quit smoking more than 6 months ago. Treatment methods included a boot (30 patients), hard-soled shoe (17 patients), non–weight-bearing short leg cast (4 patients), and carbon fiber insert (2 patients). The treating provider (T.D.M.) classified 11 fractures as Jones fractures and 42 as avulsion fractures (Table 2).

Characteristics of the Patient Population (N=53)

Table 1:

Characteristics of the Patient Population (N=53)

Treatment Modality by Fracture Type

Table 2:

Treatment Modality by Fracture Type

At most recent follow-up, no difference was found between the 2 groups for self-reported health (P=.361) or self-reported effects of the injury on work and quality of life compared with 1 year previously (P=.062). In addition, no significant difference was found for frequency of use of pain medication (P=.157), patient satisfaction with current foot symptoms (P=.633), ambulatory status (P=.281), or pain with strenuous activity (P=.772) (Table 3). At the time of injury, no significant difference was found for self-reported effects on work (P=.540) and quality of life (P=.506) between the 2 treatment groups. Obese patients were more likely to have severe pain with strenuous activity (P=.015), whereas 77% of patients had no pain or mild pain with strenuous activity. No difference was found for the amount of pain with strenuous activity between smokers and nonsmokers, regardless of treatment group (P=.698). Most (87%) patients ambulated without the need for assistive devices, and most (53%) patients reported that they could wear any kind of men's or women's shoes. In addition, 79% could wear dress shoes, excluding high heels, comfortably. When the results of the 2 treatment groups (ie, shoe modification and immobilization) were compared, few functional differences were noted. No statistically significant difference was found between treatment groups for perceived previous or current state of health (P=.361, P=.620) or need for pain medication (P=.157). In addition, no significant difference was found for satisfaction with current symptoms between the 2 groups (P=.633). The effect on ambulatory status and the need for assistive devices was minimal, with 87% of patients requiring no support or assistance. No significant difference was noted for ambulation (P=.252). Regardless of treatment type, no significant difference was found between amount of pain with different activities (Figure 1). When completing strenuous physical activity, such as performing heavy physical work, skiing, or playing tennis, 77% of patients reported no pain or mild pain. No significant difference was noted between types of treatment (P=.775).

Patient-Reported Answers on Questionnaire

Table 3:

Patient-Reported Answers on Questionnaire

Self-reported pain level during activities for patients in both immobilization and shoe modification groups. Strenuous activity was defined as heavy physical work, skiing, and tennis. Moderate activity was defined as moderate physical work, jogging, and running. Light activity was defined as walking, housework, and yardwork.

Figure 1:

Self-reported pain level during activities for patients in both immobilization and shoe modification groups. Strenuous activity was defined as heavy physical work, skiing, and tennis. Moderate activity was defined as moderate physical work, jogging, and running. Light activity was defined as walking, housework, and yardwork.

More than half of patients who had a fifth metatarsal fracture had no limitations of shoe wear, and 53% of patients could wear any kind of men's or women's shoe, including high heels (Figure 2). No significant difference was found between the shoe modification and boot treatment groups with regard to shoe wear (P=.965). Most patients had minimal foot or ankle pain with strenuous activity (77%). However, patients with body mass index of greater than 30 kg/m2 had increased foot or ankle pain with strenuous activity (P=.015) compared with those with body mass index of less than 25 kg/m2.

Types of shoe that patients could wear comfortably. Light gray represents the shoe modification group. Dark gray represents the shoe immobilization group. No significant difference was found between groups (P=.96).

Figure 2:

Types of shoe that patients could wear comfortably. Light gray represents the shoe modification group. Dark gray represents the shoe immobilization group. No significant difference was found between groups (P=.96).

Discussion

Despite numerous studies of union rates, few studies have reported on functional outcomes of proximal fifth metatarsal fractures. Previous studies evaluated single treatment methods and functional outcomes, but few have evaluated strictly functional outcomes based on the treatment method. There is still controversy about the ideal nonoperative treatment method for proximal fifth metatarsal fractures. Smith et al12 performed a meta-analysis of treatment methods and noted the need for further studies to determine the best treatment method based on functional outcomes. The current study found no significant long-term difference between shoe modification and immobilization for proximal fifth metatarsal fractures that can be treated nonoperatively.

Shahid et al13 compared Aircast walking boots (DJO, LLC, Vista, California) with below-knee walking casts for avulsion fractures and found that patients who used walking boots had improved pain levels and function 9 weeks after injury. Thus, there is evidence that less rigid immobilization can confer benefit, but the degree of benefit is unknown. Gray et al14 found that treatment with a plaster slipper was superior to treatment with an elastic Tubigrip support bandage (Tubigrip, Jacksonville, Florida) at 2 weeks, with less pain and improved functional outcomes; however, no difference was found at 6 weeks. Wiener et al15 recommended minimal immobilization and evaluated the use of a cast vs a soft Jones dressing for avulsion fractures. They found that patients with soft dressings returned to preinjury activity earlier. Additionally, all patients had fracture union, regardless of treatment modality.15 At the study institution, patients were treated with hard-soled shoes, carbon fiber inserts, fracture or controlled ankle motion boots, short leg casts, or open reduction and internal fixation, at the discretion of the provider. No long-term difference was seen between pain levels years after injury, ability to wear shoes, or pain with various activities between those treated with immobilization and those treated with less rigid non-operative methods.

Despite the volume of literature on short-term outcomes, little information is available on long-term function. Bigsby et al1 studied functional outcomes for all fifth metatarsal fractures (avulsion, Jones, and diaphyseal fractures) at 1 year with the Foot Function Index and 36-Item Short Form validated questionnaires. They found that 25% to 33% of patients still had pain at 1 year. However, fewer than 10% of patients reported limitation of activity.1 The current study evaluated long-term outcomes, with earliest follow-up of 2 years and latest follow-up of up to 10 years after injury. During that time frame, 77% of patients had no pain or only mild foot pain with strenuous activity and 87% did not use assistive devices for ambulation.

Limitations

Limitations of this study include a retrospective design that did not include baseline information about preinjury pain and function. Follow-up was not standardized, and the 2-year entry was chosen for consistency with other follow-up studies. Additionally, this study used a previously published but modified version of the MODEMS questionnaire, with the justification that the selected questions were more applicable and easier to understand via telephone. An additional limitation may be the lack of radiographic follow-up. The study did not investigate union rates because these rates are well reported and accepted and functional outcomes are usually good, regardless of radiographic union status.6,16 Finally, this study may have had an element of selection bias. Although the authors identified 297 fifth metatarsal fractures, they excluded patients with polytrauma and neuropathic fractures because these fractures have a different mechanism of injury than an isolated fifth metatarsal fracture. This decision allowed 41% of the coded fifth metatarsal fractures to be included. Of the remaining 123 patients, only 43% were available to participate, either because they were lost to follow-up or because they refused to participate.

The current results are similar to those reported by other authors for the overall prognosis for recovery. Clapper et al17 evaluated 68 avulsion fractures among military personnel and found that all fractures had united uneventfully by 4.7 weeks, with return to full active military service. Egol et al18 found that 85% of patients with avulsion fractures returned to baseline function by 6 months. The current study sought to answer questions about pain with everyday activity as well as functional status and found that most patients had minimal pain or interference with daily life. Vorlat et al19 examined 38 patients with proximal fifth metatarsal fractures and found that age, sex, and fracture type did not affect outcomes. However, they noted that a longer period of non-weight bearing was associated with worse functional outcomes. Therefore, they recommended shorter periods of non-weight bearing. In the current study, all patients in the nonoperative treatment groups were treated with weight-bearing modalities. Vorlat et al19 also found that 26% of patients reported problems with shoes, and few had cosmetic concerns.

Conclusion

Proximal fifth metatarsal fractures are treated with several nonoperative approaches, and it may be confusing for providers to know which method is best. The current study found no significant difference for functional outcomes between patients treated with immobilization and those treated with shoe modification. At final follow-up, most patients had resolution of pain, required minimal pain medication, and had few functional impairments or compromise of shoe wear, regardless of nonoperative weight bearing treatment modality. The study findings suggest that patients can expect little functional impairment after this injury, regardless of whether they are treated with immobilization or shoe modification.

References

  1. Bigsby E, Halliday R, Middleton RG, Case R, Harries W. Functional outcome of fifth meta-tarsal fractures. Injury. 2014; 45(12):2009–2012. doi:10.1016/j.injury.2014.06.010 [CrossRef]
  2. Richli WR, Rosenthal DI. Avulsion fracture of the fifth metatarsal: experimental study of pathomechanics. AJR Am J Roentgenol. 1984; 143(4):889–891. doi:10.2214/ajr.143.4.889 [CrossRef]
  3. Jones R. Fracture of the base of the fifth metatarsal bone by indirect violence. Ann Surg. 1902; 35(6):697–700.
  4. Chuckpaiwong B, Queen RM, Easley ME, Nunley JA. Distinguishing Jones and proximal diaphyseal fractures of the fifth metatarsal. Clin Orthop Relat Res. 2008; 466(8):1966–1970. doi:10.1007/s11999-008-0222-7 [CrossRef]
  5. Rosenberg GA, Sferra JJ. Treatment strategies for acute fractures and nonunions of the proximal fifth metatarsal. J Am Acad Orthop Surg. 2000; 8(5):332–338. doi:10.5435/00124635-200009000-00007 [CrossRef]
  6. Ferguson KB, McGlynn J, Jenkins P, Madeley NJ, Kumar CS, Rymaszewski L. Fifth metatarsal fractures: is routine follow-up necessary?Injury. 2015; 46(8):1664–1668. doi:10.1016/j.injury.2015.05.041 [CrossRef]
  7. Dameron TB Jr, . Fractures of the proximal fifth metatarsal: selecting the best treatment option. J Am Acad Orthop Surg. 1995; 3(2):110–114. doi:10.5435/00124635-199503000-00006 [CrossRef]
  8. Fetzer GB, Wright RW. Metatarsal shaft fractures and fractures of the proximal fifth metatarsal. Clin Sports Med. 2006; 25(1):139–150. doi:10.1016/j.csm.2005.08.014 [CrossRef]
  9. Konkel KF, Menger AG, Retzlaff SA. Non-operative treatment of fifth metatarsal fractures in an orthopaedic suburban private multispecialty practice. Foot Ankle Int. 2005; 26(9):704–707. doi:10.1177/107110070502600907 [CrossRef]
  10. Lawrence SJ, Botte MJ. Jones' fractures and related fractures of the proximal fifth metatarsal. Foot Ankle. 1993; 14(6):358–365. doi:10.1177/107110079301400610 [CrossRef]
  11. Torg JS, Balduini FC, Zelko RR, Pavlov H, Peff TC, Das M. Fractures of the base of the fifth metatarsal distal to the tuberosity: classification and guidelines for non-surgical and surgical management. J Bone Joint Surg Am. 1984; 66(2):209–214. doi:10.2106/00004623-198466020-00007 [CrossRef]
  12. Smith TO, Clark A, Hing CB. Interventions for treating proximal fifth metatarsal fractures in adults: a meta-analysis of the current evidence-base. Foot Ankle Surg. 2011; 17(4):300–307. doi:10.1016/j.fas.2010.12.005 [CrossRef]
  13. Shahid MK, Punwar S, Boulind C, Bannister G. Aircast walking boot and below-knee walking cast for avulsion fractures of the base of the fifth metatarsal: a comparative cohort study. Foot Ankle Int. 2013; 34(1):75–79. doi:10.1177/1071100712460197 [CrossRef]
  14. Gray AC, Rooney BP, Ingram R. A prospective comparison of two treatment options for tuberosity fractures of the proximal fifth metatarsal. Foot (Edinb). 2008; 18(3):156–158. doi:10.1016/j.foot.2008.02.002 [CrossRef]
  15. Wiener BD, Linder JF, Giattini JF. Treatment of fractures of the fifth metatarsal: a prospective study. Foot Ankle Int. 1997; 18(5):267–269. doi:10.1177/107110079701800504 [CrossRef]
  16. Quill GE Jr. Fractures of the proximal fifth metatarsal. Orthop Clin North Am. 1995; 26(2):353–361.
  17. Clapper MF, O'Brien TJ, Lyons PM. Fractures of the fifth metatarsal: analysis of a fracture registry. Clin Orthop Relat Res. 1995; 315:238–241.
  18. Egol K, Walsh M, Rosenblatt K, Capla E, Koval KJ. Avulsion fractures of the fifth metatarsal base: a prospective outcome study. Foot Ankle Int. 2007; 28(5):581–583. doi:10.3113/FAI.2007.0581 [CrossRef]
  19. Vorlat P, Achtergael W, Haentjens P. Predictors of outcome of non-displaced fractures of the base of the fifth metatarsal. Int Orthop. 2007; 31(1):5–10. doi:10.1007/s00264-006-0116-9 [CrossRef]

Characteristics of the Patient Population (N=53)

Characteristic Value Missing Data Points
Age, mean (range), y 42 (24–63) 0
Sex, No. (%)
  Male 12 (22.6) 0
  Female 41 (77.3) 0
Body mass index, mean (range), kg/m2 30.7 (18.1–50.2) 24
Fracture type, No. (%)
  Avulsion 42 (79.2) 0
  Jones 11 (20.7) 0
Treatment method, No. (%)
  Controlled ankle motion boot 30 (56.6) 0
  Hard-soled shoe 17 (32.1) 0
  Short leg cast 4 (7.6) 0
  Carbon fiber insert 2 (3.8) 0
Smoker, No. (%) 7 (13.2) 0

Treatment Modality by Fracture Type

Treatment Modality No. (%)

Jones Fracture Avulsion Fracture
Controlled ankle motion boot 9 (81.8) 21 (50.0)
Hard-soled shoe 1 (9.1) 16 (38.1)
Short leg cast 1 (9.1) 3 (7.1)
Carbon fiber insert 0 2 (4.8)

Patient-Reported Answers on Questionnaire

Questions/Answers No. (%) P

Total Shoe Modification Boot
1. In general, how would you say your health is? .361
  Excellent/very good 33 (62.2) 14 (26.4) 16 (30.2)
  Good 12 (22.6) 3 (5.7) 8 (15.1)
  Fair/poor 8 (15.1) 2 (3.8) 6 (11.3)
2. Compared with 1 year ago, how would you rate your health in general now? .062
  Much/somewhat better 13 (24.5) 4 (7.6) 7 (13.2)
  Same 35 (66.0) 14 (26.4) 19 (35.8)
  Somewhat worse/much worse 5 (9.4) 1 (1.9) 4 (7.6)
3. During the past week, how often have you taken pain medication, including prescription or over-the-counter medications? .157
  3 or more times per day 12 (22.6) 7 (13.2) 4 (7.6)
  1–2 times per day or a few days 6 (11.3) 2 (3.8) 4 (7.6)
  Once a week or not at all 35 (66.0) 10 (18.9) 22 (41.5)
4. Smoker 7 (13.2) N/A
5. If you had to spend the rest of your life with the symptoms you have right now, how would you feel about it? .633
  Very/somewhat dissatisfied 17 (32.1) 5 (9.4) 11 (20.8)
  Neutral 11 (20.8) 5 (9.4) 5 (9.4)
  Somewhat/very satisfied 25 (47.2) 9 (17.0) 14 (26.4)
6. Which of the following statements best describes your ability to get around most of the time during the past week? .281
  No need for support or assistance 46 (86.8) 15 (28.3) 27 (50.9)
  Mostly walked without support or assistance, and if needed assistance, required use of cane or walker 7 (13.2) 4 (7.55) 3 (5.7)
Authors

The authors are from the University of North Carolina at Chapel Hill (HAD, TDM, SM, EZL, F-CL, BJP, SRH), Chapel Hill, North Carolina; and Stephen Peoples Consulting, Inc (SJP), Winona Lakes, Indiana.

Dr Lin is a previous Blue Ribbon Article Award recipient (Orthopedics, January/February 2017).

Dr Dineen, Dr Murphy, Ms Mangat, Dr Lukosius, Dr Pettett, and Dr Hurwitz have no relevant financial relationships to disclose. Dr Lin has received a grant from the National Institutes of Health (UL1TR001111). Dr Peoples is a paid consultant for Limacorporate SpA, Lima USA, Inc, Implantcast GmbH, Exactech, Inc, Tornier, Inc/Wright Medical Group, BioPoly LLC, Vivorte, LLC, FH Orthopedics, Inc, Ortho Development, Inc, and the Cleveland Clinic Foundation.

Correspondence should be addressed to: Shepard R. Hurwitz, MD, University of North Carolina at Chapel Hill, Bioinformatics 3rd Fl, Mason Farm Rd, Chapel Hill, NC 27599 ( shurwitz@abos.org).

Received: April 02, 2017
Accepted: September 05, 2017
Posted Online: October 23, 2017

10.3928/01477447-20171012-02

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