Jones Fracture ORIF 28485

synonyms: closed intramedullary screw fixation

Jones Fx Technique CPT

• 28476 (percutaneous skeletal fixation of metatarsal fracture)
• 28485 (open treatment of metatarsal fracture, includes internal fixation)

Jones Fx Technique Indications

• Acute nondisplaced true Jones fracture in a high-level athlete
• Acute displaced true Jones fracture
• True Jones fracture nonunion
• Acute nondisplaced diaphyseal fracture in a high-level athlete
• Acute displaced diaphyseal fracture
• Diaphyseal stress fracture

Jones Fx Technique Contraindications

• Tuberosity avulsion fractures of the 5th metatarsal base

Jones Fx Technique Alternatives

• ORIF with bone grafting (Torg JS, JBJS, 1984;66A:209).
• Non weight bearing cast immobilization
• Electrical Stimulation (see Nonunion) (Holmes GB Jr, Foot Ankle Int 1994;15:552).

Jones Fx Technique Pre-op Planning / Special Considerations

• Ensure appropriate cannulated screws are available.  Considered cannuated compression screws available from various manufactures
• Bone grafting is generally not needed if intramedullary reaming is done. 

Jones Fx Technique Technique

• Sign operative site
• Pre-operative antibiotics, +/- regional block
• General endotracheal anesthesia
• Semilateral decubitus position (bean bag or large hip bump). All bony prominences well padded.
• Foot can be placed over the c-arm.  Ensure adequate AP, oblique and lateral views of the 5th MT can be obtained.
• Prep and drape in standard sterile fashion.
• 1-3cm lateral incision parallel to the plantar border of the foot beginning at the level of the tuberosity and extending proximal. Take care to avoid the sural nerve.
• Place intramedullary guide-Entry point is high and inside to the midline on the lateral view.  Place wire down the shaft of the 5th metatarsal. Guide wire should extend to the curvatue of the 5th MT shaft.
• Measure screw length. Usually 40-55mm.
• Drill proximal cortex and across any sclerotic intramedullary fracture areas with a cannulated drill bit.  
• Place 4.5mm or 6.5mm partially threaded cannulated screw. Countersink the screw head to decrease chance of postoperative painful hardware.  May use fully threaded screw is bone proximal to fracture is overdrilled.  Needs to have lag screw configuration to allow compression.
• Varify appropriate intramedullary screw placed and fracture reduction with c-arm.
• Irrigate.
• Close in layers.

Jones Fx Technique 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 Technique Follow-up care

• Post-op: place in bulky dressing with posterior splint, non-weight bearing.
• 7-10 Days: place in weight-bearing short leg cast.
• 6 Weeks: xray foot. If callus formation is noted place in cam-walker, WBAT. If no callus formation is noted continue weight-bearing short leg cast.
• Patients may return to sport when painfree and radiographic evidence of union is seen on xray. Generally 7-8weeks.  Gradual return to sport is indicated.  Physical therapy, gradual progression to full weight bearing, swimming/elliptical/biking before running.  
• A foot orthosis is recommended for use until athletes complete their competitive careers. Orthosis = extended steel shank or carbon fiber plate (Wright RW, AJSM 2000;28:732).
• 3 Months: recheck xrays.

Jones Fx Technique Outcomes

• 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),
• 100% clinical healing. Mean return to sport = 7.5 weeks (Porter DA, AJSM, 2005;33:726).

Jones Fx Technique 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