Summary
A “Jones’ fracture” is a stress fractures of the base of the 5th metatarsal (Figure 1). Jones fractures occur in a manner that is similar to the way that you would break a paper clip (by wiggling it back and forth over and over again). Therefore, activities that repetitively load the foot (for example sports with running) may lead to a Jones’ fracture in predisposed individuals. These fractures tend to occur in people that have a high arched foot shape or a lower extremity alignment that results in increased loading to the outside part of the foot. Often these fractures can be treated without surgery. However, they have a tendency to recur because even after they have healed the underlying reason why they occurred (loading pattern of the foot) is still present. Therefore surgical treatment of Jones’ fractures is not uncommon.
Figure 1: Jones Fracture
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Figure 2: Location of Pain
Clinical Presentation
Individuals who suffer a Jones’ fracture will report pain in the outside of the midfoot (Figure 2). They will have difficulty bearing weight and will often walk with a limp. In most instances the patient will describe exactly when the fracture occurred, often after landing heavily or performing some other demanding but routine activity. However, in some instances the main symptom will be a chronic ache in the outside part of the foot – representing an incomplete stress fracture of the base of the fifth metatarsal. In many patients they will report a history of some pain in the foot prior to the actual fracture. Also, it is not uncommon to have symptoms bilaterally (both feet), although usually one side is more symptomatic.
Physical Examination
Patients with a Jones’ fracture will have pain at the fracture site (Figure 2). Often they will have high arched feet and/or an alignment of the lower extremity that will tend to load the outside part of their feet (Figure 3). It is common to see that they have worn their shoes on the outside part of the foot.
Figure 3: High arched foot strike pattern often seen in Jones’ Fracture patients
Imaging Studies
Plain x-rays will identify a Jones’ fracture. The fracture itself occurs at the area of the bone which receives the most force during walking and running. The fracture needs to be differentiated from a Dancer’s fracture which occurs when one of the ligaments pulls off (avulsed) the tip of the 5th metatarsal base (Figure 4). Notice in Figure 4A that the fracture line is further down the 5th metatarsal than a Dancer Fracture (figure 4B).
Figure 4: Jones Fracture (4A Left) vs Dancer’s Fracture (4B Right)
Treatment
Like most fractures a Jones fracture will usually heal if the foot is protected from the forces of weight bearing for a long enough period of time. However, the area of the bone that is fractured has a relatively poor blood supply so bone healing may be slowed. Furthermore, because the fracture is related to repetitive stress to the fracture site there is always a concern that the fracture may recur.
Non-Operative Treatment
Non-operative treatment usually includes:
- Non-weight bearing (or limited weight bearing) for 6-8 weeks (or more) until the fracture heals
- Crutches
- A protective boot such as a Cam walker
- X-rays to assess the fracture healing prior to resuming increased weight-bearing
- A gradual return to activities in a protective (stiff-soled) shoe once adequate healing has occurred.
Operative Treatment
Jones fractures occur because of repetitive loading to the bone. Although the fracture will usually heal with rest the underlying alignment of the foot or lower extremity will remain unchanged so recurrent fracturing or a delay in healing is common. For this reason surgery will often be recommended for many individuals with Jones’ fractures. This is particularly true for athletic individuals. The initial surgery involves stabilizing the fracture site by placing a strong screw through the middle of the bone (Figure 5). The recovery form this surgery is similar to that describe above for non-operative management, but return to high level activities tends to be substantially quicker.
Figure 5: Screw Fixation of a Jones Fracture
The surgery to place a screw across the fracture site can be associated with complications including:
- Infection
- Sural Nerve injury
- Wound healing problems
- Non-union (failure of the bone to heal, often due to continued loading to the area during a return to walking activities)
- Increased fracturing of the bone at the time of surgery. In some instances placing the screw across the fracture site will increase the fracture or resulting in further breakage of the 5th metatarsal
A patient that has a continued non-union of the Jones’ fracture, or a recurrent fracture after it had appeared to have healed may need more involved reconstructive foot surgery. This reconstructive surgery would repair the fracture (often with bone grafting) and in addition would change the inherent loading characteristics of the foot by cutting and repositioning one or more bones in the foot or lower leg. Common bone cutting procedures (osteotomies) may include:
- Lateralizing calcaneal osteotomy -Cutting the heel bone and shifting it more to the outside
- Dorsiflexing 1st metatarsal osteotomy -Cutting a wedge out of the top of the 1st metatarsal (the bone that the big toe is attached to) so that this bone can be realigned. This is done because often in people with high arched feet the 1st metatarsal is angled downward and acts like a “kick-stand” to force the foot to be excessively loaded on the outside.
Edited September 5th, 2009
