Fifth Metatarsal Fractures: Excellent Summary of Treatment by Dr Lindsey Klassen

     The above slide is from a 4 day conference I just attended in Los Angeles, California, of course virtually. Dr. Lindsey Klassen gave a wonderful presentation on fifth metatarsal fractures summarized by this last slide. 

Modifying Boot with Metatarsal Fracture

Oblique Fracture at the Head of the Fifth Metatarsal Left Foot

2 one quarter inch felt layers to place in Removable Boot 

to off weight the 5th metatarsal fracture. It goes under the 

lining of the boot

Fifth Metatarsal Fracture Post Sprain: Email Advice

Hi Dr. Blake,

My mom, a long time supporter of yours, sent me your blog after I learned last week that I fractured my 5th metatarsal on my left foot. For a quick background, I am a 30 y/o female. I have not exercised regularly since October thanks to grad school applications, but otherwise lead an active lifestyle; until recently, public transport and walking were major components of my daily life.

I fractured my foot one month ago...walking down the staircase. It was that simple. I've sprained my right ankle many times and the situation felt very similar to previous falls but my actual foot took the brunt of the fall, and my ankle remained unscathed. After ~48 hours of being unable to bear weight, I visited two NPs, one at a general immediate care facility and one at ortho-specific immediate care. Both took xrays, and both confirmed no fracture. Ortho NP put me in a walking boot and said I should be fine in 2 weeks. I did have some pain initially bearing weight in the boot but it was an otherwise overnight transformation: my swelling went down immediately and I was able to bear weight w/o the boot (though limping) pain free the next morning. I thought I would back to normal in no time!
Dr. Blake's comment: This is always a dilemma since it can take up to a month for a small stress fracture to show up on x-ray. It will be hot on a bone scan and MRI in a few days, but these are more expensive tests and not used in the screening process.

Three weeks went by, however, and my healing had plateaued. I made it into a podiatrist one week ago who ordered new xrays (weight bearing this time) and immediately found the fracture. His diagnosis was "5th metatarsal base fracture" but I never recall him mentioning "Jones." He told me that I'll need to be in boot 6-8 more weeks and my injury was a bit tricky because the specific area receives little bloody supply.
Dr. Blake's comment: This is the area of a Jones fracture just in front (towards the toes) of where the 4th and 5th metatarsals join together.


Told me to stay off my feet as much as possible and make some lifestyle modifications (note to work from home as much as I need) but never mentioned complete non-weight bearing nor suggested anything like crutches. Wasn't super interested in the prospect of surgery and said the next step will be a bone simulator if it comes to that. Follow up apt in 3 weeks.
Dr. Blake's comment: Many insurance companies require 3 months of treatment for fractures before they approve a bone stimulator, however the doctor should start the process on Jones fractures, sesamoid fractures, and navicular fractures, since they are the slowest to heal and surgery potential is high.
 

Of course, I googled 5th metatarsal fractures and immediately Jones fractures met his description of my injury, but the standard treatment (NWB for at least 6 weeks) was a different than his. I am now working from home 2-3 days a week, Ubering to work (as opposed to metro), getting groceries delivered, etc. Prior to my diagnosis, I was much less conservative and was actually walking up to as much as 2 miles some days of the week (it's so hard not to do this living in a city) in my boot.
Dr. Blake's comment: There is a protocol for Jones of non weight bearing for sure. You can have someone non weight bearing in a boot by floating the fifth metatarsal with adhesive felt padding. Therefore they can walk, and still off load the bone. The secret is creating 0-2 pain level for healing, and what it requires to accomplish that. If it is a Jones fracture, we definitely off weight for a while, but we want the weight bearing for bone mineralization and swelling reduction. It is a fine line. Maybe he does not think it is unstable, which is how it sounds, if it was only picked up on the 3rd set of xrays. Maybe there is no gap, just changes in the bone reflecting healing. If you can take a photo, and email mail of the xray images, I can let you know what I think.

You aren't able to view my xrays or examine me, so I know your insights are limited. Still, I am wondering if my doc's treatment plan sounds potentially reasonable assuming a Jones' fracture or if I need to second guess him and go down a far more conservative route and eliminate all weight bearing. I've read a few academic journals and the consensus about treatments seem to be...all over the place. For what it's worth, my symptoms are probably improving, at least in terms of swelling and bruising, and certainly not deteriorating. Some days I am a little more tender and swollen than others, but compression socks and a session with frozen vegetables always do the trick and get me back to my "baseline." I'm not taking any pain meds (especially not NSAIDs) nor am I a smoker. Taking calcium, D3, and magnesium supplements and trying to up my calorie intake. I also assume that, in terms of WB, it can't hurt that I weigh less than 110 lbs. 

Any insight you have would be so appreciated.

Best,
Dr. Blake's comment: Send me the images, have the doctor float the bone in the boot, use crutches with the boot if you can not achieve 0-2 pain level. Start doing contrast bathing twice daily to flush out pain from the swelling. This is a must since you want to make decisions on the fracture pain, not on the pain from swelling. Push for the bone stimulator process to begin, even if you do not need it in the end.



Since I had been on vacation, she tried to contact me again:

Hi again Dr. Blake,

I got a hold of my medical chart online so I have a few more pieces of info. My diagnosis on the chart is "L 5th metatarsal styloid process fracture" and he also noted that it is nondisplaced. From my understanding (which could be completely flawed), styloid fractures fall in the same group as zone1/tuberosity/avulsion/pseudo Jones fractures, aka the GOOD type of fracture to have. I'm wondering why, then, he said I was dealing a stubborn fracture that receives little blood flow and there is a chance I could have delayed or nonunion--these seem like hallmark Jones characteristics.

Thanks,
Dr. Blake's comment: Yes, that is good news and the styloid process fractures tend to heal just fine. Still, take a photo and send. You can ask the office to take a photo of each of the xrays and email to you. Maybe they will do it.


Then the patient responded with good news!!

Thanks so much for your reply on your blog! I decided to just call my podiatrist and I have good news: I do NOT have a Jones fracture. It didn't occur at the very base of the 5th metatarsal, but it was not distal enough to be a Jones fracture; therefore it is still in zone 1 and he confirmed that it's still receiving adequate blood supply. He told me that if it had been a Jones fracture, he would have put me in a hard cast and would not have let me leave his office without crutches. 

Here's what's interesting: he said it was not an avulsion fracture, either (or a pseudo Jones). I've been hard pressed to find any online sources that do not classify styloid process fractures (my official diagnosis) as avulsion fractures, but I suppose that was not the mechanism of action that caused the injury. I'll ask him to clarify this on Friday during my follow up. I am also curious to hear more about his mentioning of poor blood supply. I suppose he meant that feet in general receive less blood supply compared to the rest of the body. His treatment plan (8-12 weeks in walking boot) also seems to be more aggressive than those of other avulsion fractures (or anything in zone 1), but I read in one of your earlier posts that you think these types of fractures tend to be undertreated; perhaps his philosophy aligns with yours.

In any event, I hit the 6 week mark last week, and since then, my foot has started to feel much better. Best way I can describe it is that it feels more like a regular foot that can do its job again. I feel like I could walk more normally on it when my cast is off (he gave me permission to do a little walking around my apartment w/o the cast so long as I concentrated my weight in my heal) but I'll wait until my appointment before I get clearance. To the naked untrained eye, it does not look like my foot is injured. However, if you look closely, I have a bump where the fracture is. I am not sure if that is the callus and/or residual inflammation.  

The only thing bothering me now is my walking boot, whose front straps occasionally press against the area of the fracture and cause tenderness (just depends on the day). He said that had he come to me first, he would have put me a different type of walking cast with air pockets, so maybe that one would be a bit better. Also, the muscle atrophy, which is all the way up my thigh, is pretty bad, and my pants are baggier. I'm starting to do some NWB floor exercises, and will probably ask for a physical therapy order.

I will ask for both sets of x-rays next visit and will be sure to share. As for the old ones, I took them sitting down on a large x-ray table. My x-rays at his office were taken in a completely different manner (standing up, bearing weight) which he explained was key. I gave him my old x-rays but they were taken at awkward angles and were incompatible with his computer.

My own images are attached. Don't be alarmed by the fact that my right ankle is bigger than left--that's old scar tissue from a previous injury. 

If you end up sharing this on your blog, feel feel to abbreviate for brevity :)

Thanks again,

Sunday's Video of the Week: Why Jones Fractures have Poor Blood Supply

   © Kiankhoon | Dreamstime Stock Photos

The right foot is highly inverted as it strikes the ground right on the fifth metatarsal without much shoe protection.

  This is a wonderful video on the anatomy of proximal fifth metatarsal fractures. It wonderfully explains the poor blood flow to the area we call a "Jones Fracture" making it hard to heel. It does not explain that due to the attachment of major tendons and ligaments at the base of the fifth metatarsal (peroneus brevis, peroneus tertius, and 4/5 metatarsal base ligament attachments) the area to one side of the Jones Fracture  is very solid. The area just distal to these attachments, towards the toes, where you get the Jones fracture is a highly stressed area (more relative motion/stress with loading of the fifth metatarsal head). The area in front of an immobile area has more mobility, and in this area, can break easier and take longer to heal. 

     Podiatists also have many tricks to help these bones heal, and minimize or eliminate the need for surgery and/or non-weightbearing. Custom made functional foot orthotic devices can be made to off weight and stabilize the fracture (this has to be built into the design--you can not assume your orthotic device has this function). See some of my posts on orthotic modifications for supinators. Kinesiotaping of the midfoot can immobilize the fracture area and decrease the stresses.

 The use of removable casts with off weighting techniques (ample use of 1/2 inch adhesive felt with cut outs) or ZeroG removable boots with EvenUps can get a better result that the weakness of non-weightbearing. Exogen bone stimulators are vital is the healing of these fractures and are used for 9 months. Designing return to activity programs with the above minimizes the de-conditioning that can occur. From the day you broke your foot, you could be on a stationary bike for 1-2 hours with the weight in the heel. 

    What are other areas of concern? Of course with any bone injury, bone density and Vit D3 levels are important. Making sure you are getting 1500 mg of calcium and 1000 units of Vitamin D. Making sure that your shoes do not break down to the outside and you have become too inverted/supinated.

Remember that your treatment regimen is between you and your physician. The more you learn, the better questions you can ask, and ultimately, the faster you will heal. 

http://youtu.be/_CItUTjO_jA

Discussion of a Fifth Metatarsal Base Fracture

Here I discuss X-rays of my patient Joseph with a 5th Metatarsal Base Fracture.


http://www.showme.com/sh/?h=0zrkv44 
I hope this new way of teaching is helpful, or at least a positive change of pace. Rich

Fifth Metatarsal Fractures: Non Jones Type

These images are from a new patient I will see next week. She is almost 3 months post injury and her X-rays show a wide gap still. Here are all the thoughts that are meandering through my brain. 

Here is the standard Lateral view with quite a large gap noted 

A Jones Fracture to the Fifth Metatarsal is normally 1 inch closer to the toes. This AP view still shows some displacement.

This Oblique view makes the fracture clearer and you can see if goes into the joint of the 5th metatarsal cuboid. 

The fracture clearly goes across to the joint. 

     This 5th metatarsal avulsion fractures following some inversion twist of the foot are typically under treated. Because they do not have the stigma of a true Jones fracture (historically more serious), they can be less aggressively treated. Sometimes this is okay, and sometimes not. Again, the goal is to create a pain free environment, which I believe has happened. X-rays for foot fractures, since the healing normally takes place internally first, can not really reflect the strength of the bone. But, I do not like the gap and I do not like the fact that the joint is involved (possibly future arthritis). 

     So, what are all the steps we need to make happen? 

1) Establish a pain free environment if not already occurring

2) Make sure Bone Strength is good (questioning about VitD3 and Calcium, bone density, healthy diet)

3) Stabilize the fifth metatarsal with orthotic devices, accommodative padding, and kinesiotaping (there   are special techniques in orthotic devices for the outside of your foot)

4) Set workout goals that do not over stress this area

5) Avoid anti-inflammatories since they can slow down bone healing

6) Ice Pack 10 minutes twice daily, and contrast baths once daily to reduce inflammation

7) Due to the gap, seek approval for Exogen Bone stimulator

8) Have patient talk to a surgeon to find out what the process of fixing if the above does not work (well informed)

9) Advise on possible future arthritis

10) Only get future X-rays if treatment has plateaued (there are many cases of pain free non healing)

    

Fifth Metatarsal Base Fractures: Xray Review and Discussion

Email Regarding Good vs Bad Pain (Weaning off Crutches after Foot Fracture)

Brooke broke her right fifth metarsal on 6/16/11 and was placed on crutches and a removable boot with accommodation. My initial visit was 6/22/11 and followup on 7/6/11 now 4 days ago.On the 7/6 visit, I discussed with Brooke trying to wean off the crutches with the full protection of the removable boot.

Base of 5th Met Fx

Hi Dr. Blake, I was in last Wed. when you got me started walking without my crutches. All has been going really well until today  (7/9/11) when I woke up with soreness at the site of the break.

Yesterday I tried wearing a Superfeet insole that I had on hand in my boot, and I'm wondering if this is what caused the pain. Or maybe I just overdid it and walked too much yesterday. I was on my feet for a couple hours straight in the afternoon.

It's not sharp pain. I would describe it as slight tenderness when I put weight on it. Probably pain level is around 1.5-2 out of 10. So not really bad, but definitely more than I've had in the last week (which has been 0). Do you think I should stay off if it completely and go back to the crutches for a day or two? Is this amount of pain OK? Can I keep walking on it without crutches?
Dr Blake's Note: Her pain level is less than the restrictions she prescribes needs. However, I find patients are very protective since they want do have no setbacks.I am not wearing the insole today.
Thanks so much for your help!
Best,

Brooke

Here is my response to Brooke. 
Brooke, Hope you don't mind I put your question on my blog this week. Of course no names, but I get this question all the time. Hopefully, you have read the post on good and bad pain, but when it comes to yourself, logic and reality sometimes do not match. It is hard to stay objective with your own body. Definitely level 2 is good pain, even if it is in the fracture area (weakest link in the chain right now). I find people over protective, which is okay because we have to feel good with what is going on as we Listen To Our Bodies. It would be fine to slow down the no crutches by at least bringing them with you for the next several days, or go back on them for a few hours after the pain (but not 2 days back on the crutches with only level 2 pain). Not sure of the role of the Superfeet, but if you feel pain again, take it out, and see if the pain dissipates. Experiment. If the pain increases over the next several days, then we know we have to slow down and go back on the crutches. See yesterday's post on Activity and Pain Scale Log and consider doing one yourself and emailing me. Hope this helps. Rich

http://www.drblakeshealingsole.com/2010/04/good-pain-vs-bad-pain-athletes-dilemma.html

http://www.drblakeshealingsole.com/2011/07/email-activity-followup-excellent.html
Here is Brooke's response on 7/12/11
Hi Dr. Blake, this is very helpful. Thank you. I did read your post on Good vs. Bad Pain. It makes sense, although at the time I read it I wasn't totally sure how it applied to me since I'm not an athlete and my pain isn't happening because of working out. I reread it, and I guess just putting weight on it and walking counts as my work out these days. What you say about sharp pain versus soreness makes sense, and I don't have sharp pain. My pain didn't disapate after a day, but I'll keep an eye on it and consider tracking it.

thanks so much for your response. I'm very eager to be done with these crutches!

By all means, use this for your blog!
Best,

Brooke

Base of 5th Met Fracture Side View