Jones Fracture 825.25

synonyms: Jones fracture, true Jones fracture, 5th metatarsal tuberosity fracture, Jones fracture nonunion. 5th metatarsal diaphyseal stress fracture

Jones Fx ICD-9

• 825.25 (closed fracture of metatarsal bone)
• 825.35 (open fracture of metatarsal bone)

Jones Fx Etiology / Epidemiology / Natural History

• True Jones fracture is in the proximal meta-diaphyseal junction of the 5th metatarsal base in which the main fracture line extends into the 4th-5th metatarsal articulation.
• MOI: For true Jones fx believed to occur from a large adduction force applied to the forefoot with the ankle in plantarflexion. (Lawrence SJ, Foot Ankle 1993;14:358). Tuberosity avulsion fractures result from the pull of the Peroneus brevis or the lateral band of the plantar aponeurosis.

Jones Fx Anatomy

• relative avascularity of this area, a nonweightbearing cast is the treatment of choice. Zogby RG, Baker BE: A review of nonoperative treatment of Jones fracture.  Am J Sports Med 1987;15:304-307.
• Base of the 5th MT has 2 articulations: (1)cuboid-fifth metatarsal articulation, (2)fourth-fifth intermetatarsal articulation.
• Peroneus brevisinserts over a broad area on the dorsolateral aspect of the tuberosity.
• Peroneus tertiusinserts into the dorsal surface of 5th metatarsal base.
• Lateral band of the plantar aponeurosis inserts on the plantar surface of the styloid.
• Os peroneum is a sesamoid bone in the Peroneus longus tendon near the proximal fifth metatarsal adjacent to the cuboid. Present in 15% of patients (Daeron TB Jr, JBJS 1975;57A:788).
• Os vesalianum is an ossicle in the Peroneus brevistendon.Present in 0.1% of patients (Daeron TB Jr, JBJS 1975;57A:788). .
• Secondary center of ossification appears between 9 and 11 years in girls and 11 and 14 in boys. Complete union with the shaft occus in less than 2 years.
• Sural nerve and its terminal branches are at risk in surgery involving the peroneal tendon complex and the 5^th metatarsal (Donley, Foot Ankle Int 20:182;1999)

Jones Fx Clinical Evaluation

• Patients with acute tuberosity avulsion fractures, or true Jones fractures complain of lateral foot pain and swelling after an injury.
• Patients with diaphyseal stress fractures will complain of preceding pain in the lateral aspect of the foot.

Jones Fx Xray / Diagnositc Tests

• A/P, lateral and obliqueviews of the affected foot.
• Acute fractures demonstrate sharp fracture lines without widening or radiolucency and minimal cortical hypertrophy.
• Nonunions demonstrate wide fracture lines with periosteal new bone formation and obliteration of the medullary canal with intrameduallar sclerosis.

Jones Fx Classification / Treatment

• Zone 1; Nondisplaced Tuberosity Avulsion Fx: common. Treatment = hard-soled shoe or walking cast until pain subsides. Generally heal in 8 weeks.
• Zone 1; Displaced Tuberosity Avulsion Fx(intra-articular extension with >2mm step-off): uncommon. Treatment = ORIF with screw or Kirschner wire fixation.
• Zone 1; Symptomatic Tuberosity Avulsion Fx Nonunion: Treatment = excision of small fragments which do not violate insertion of Peroneus brevis; ORIF for large fragments (Rettig AC, ALSM 1992;20:50).
• Zone 1; Asymptomatic Tuberosity Avulsion Fx Nonunion: Treatment = activity as tolerated.
• Zone 2; Acute Nondisplaced True Jones Fracture: Treatment = non-weight-bearing short leg cast for 6 to 8 weeks. Consider initial intrameduallary screw fixationfor high level athletes (Mindrebo N.AJSM, 1993;:720), or if there is intramedullary sclerosis and a lucent fracture line at the 8 week follow-up.
• Zone 2; Acute Displaced True Jones Fracture: Treatment = intrameduallary screw fixation.
• Zone 2; True Jones Fracture Nonunion: Treatment = intrameduallary screw fixation.
• Zone 3; Acute Nondisplaced Diaphyseal fracture: Treatment = non-weight-bearing short leg cast for 6 to 8 weeks. Consider initial intrameduallary screw fixationfor high level athletes, or if there is intramedullary sclerosis and a lucent fracture line at the 8 week follow-up.
• Zone 3; Acute Displaced Diaphyseal Fracture: Treatment = intrameduallary screw fixation.
• Zone 3; Diaphyseal Stress Fracture with neutral heel: Treatment = intrameduallary screw fixation.
• Zone 3; Diaphyseal Stress Fracture with flexible cavovarus heel: Treatment = intrameduallary screw fixation of the 5th metatarsal with dorsiflexion osteotomy of the 1st metatarsal (DenHartog BD, JAAOS 2009;17:458).

Jones Fx Associated Injuries / Differential Diagnosis

• Metatarsal fracture
• Metatarsal stress fracture
• Metatarsalgia
• Navicular Stress Fracture

Jones Fx Complications

• Nonunion: 7-28% for acute true Jones fractures treated with non-weight bearing casts. (Rosenberg GA, JAAOS, 2000;8:332).
• Delayed union:
• Sural nerve palsy
• Infection
• Refracture
• Painful hardware

Jones Fx Follow-up Care

• Non-operative treatment for acute true Jones fractures may take up to 21 weeks.
• Median time to union = 7.5 weeks for screw fixation, 14.5 weeks for NWB casting. Median return to sports = 8.0 weeks for screw fixation, 15.0 weeks for NWB casting. (Mologne TS, AJSM, 2005;33:970),

Jones Fx Review References

• Instructional course lectures 93 vol 42:201, chapter 17; Sanunarco JG, The Jones Fracture
• Rockwood and Green's Fractures in Adults 6th ed, 2006
• Josefsson PO, Karlsson M, Redlund-Johnell I, et al: Jones fracture: Surgical versus nonsurgical treatment.  Clin Orthop 1994;299:252-255.
• Torg JS, Balduini FC, Zelko RR, et al: Fractures of the base of the fifth metatarsal distal to the tuberosity: Classification and guidelines for nonsurgical and surgical management.  J Bone Joint Surg 1984;66A:209-214.
• Rosenberg GA, JAAOS, 2000;8:332
• Dameron TB Jr, JAAOS 1995;3:110
• Quill GE JR, CORR 1995;26:353
• Nunley JA, Orthop Clin NOrth Am, 2001;32:171
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