01Approach to the Critical Patient/attcp36

Immediate priorities

›Red flag findings requiring urgent action

›Open fracture with skin tenting or breach

›Emergent orthopedic consultation

›Wound irrigation and sterile dressing

›Neurovascular compromise

›Diminished or absent dorsalis pedis or posterior tibial pulses

›Sensory loss in sural or deep peroneal nerve distribution

›Compartment syndrome of the foot

›Pain out of proportion to injury

›Tense swelling of intrinsic foot compartments

›Emergent compartment pressure measurement if suspected

›Polytrauma context

›Systematic ATLS primary survey before isolated limb focus

›Foot injury may be missed during high-energy trauma workup

Key concepts

›Anatomic zone classification drives management

›Zone 1: tuberosity avulsion fracture, proximal to 4th-5th intermetatarsal articulation

›Most common proximal fifth metatarsal fracture

›Excellent blood supply, heals reliably nonoperatively

›Zone 2: Jones fracture, at the metaphyseal-diaphyseal junction

›Watershed vascular territory, high nonunion risk

›Requires orthopedic referral regardless of displacement

›Zone 3: diaphyseal stress fracture, distal to intermetatarsal articulation

›Chronic insidious onset, highest nonunion rate

›Often requires surgical management

›Torg classification guides prognosis within Zone 2

›Type I (acute): sharp fracture margins, no intramedullary sclerosis, no periosteal reaction

02History/hx48

Mechanism and onset

›Classic acute presentation

›Forced adduction applied to lateral foot while in plantar flexion

›Landing on the lateral aspect of the foot

›Pivoting or cutting movement in sport

›Audible or felt "pop" at the lateral midfoot

›Immediate lateral foot pain and inability to bear weight

›Stress or insidious onset pattern

›Prodromal aching or lateral foot pain weeks before acute event

›Suggests pre-existing stress reaction (Zone 3 pattern)

›Gradual onset in a runner or endurance athlete

›Pain reproducible with push-off phase of gait

Risk factors

›Athletic and activity-related risks

›Running, cutting, jumping sports (basketball, football, soccer)

›Recreational vs. competitive athlete status

›Directly impacts operative vs. nonoperative decision

›Relative energy deficiency in sport (RED-S) or female athlete triad

›Caloric insufficiency impairs bone healing

›Anatomic risk factors

›Pes cavus foot type

›Present in 42% of Jones fracture patients

›Forefoot adduction or metatarsus adductus

›Significant predictor of nonunion

›Hindfoot varus alignment

›Medical comorbidities

›Type 2 diabetes mellitus

›Significantly longer time to union

03Physical Exam/exam36

Musculoskeletal assessment

›Point tenderness localization

›Tenderness over metaphyseal-diaphyseal junction of fifth metatarsal

›1.5 to 2 cm distal to the tuberosity tip

›Distinguish from Zone 1 tuberosity tenderness (more proximal)

›Palpation along full fifth metatarsal shaft

›Swelling and ecchymosis

›Lateral midfoot swelling

›Ecchymosis tracking along the lateral border of the foot

›Weight-bearing status

›Inability or significant antalgic gait

›Pain with axial loading of the fifth metatarsal

Foot alignment

›Structural assessment

›Pes cavus deformity

›High medial arch

›Callosities under metatarsal heads

›Hindfoot varus alignment

›Forefoot adduction (metatarsus adductus)

›These findings elevate nonunion risk and guide surgical decision-making

Adjacent structure examination

›Ankle and midfoot

›Lateral ankle ligament palpation (ATFL, CFL)

›Distinguish from lateral ankle sprain

›Syndesmosis stress test if high-energy mechanism

›Lisfranc palpation at the tarsometatarsal joints

›Plantar ecchymosis sign for Lisfranc injury

›Navicular palpation for occult navicular stress fracture

04Differential Diagnosis/ddx32

Proximal fifth metatarsal fractures

›Zone 1 tuberosity avulsion fracture (S92.352)

›Most common proximal fifth metatarsal fracture

›Inversion mechanism with peroneus brevis or plantar fascia avulsion

›Fracture proximal to 4th-5th intermetatarsal articulation

›Excellent blood supply, reliable nonoperative healing

›Zone 2 Jones fracture (S92.352)

›At the metaphyseal-diaphyseal junction

›Watershed blood supply, high nonunion risk

›Zone 3 diaphyseal stress fracture (M84.375)

›Distal to the intermetatarsal articulation

›Chronic or insidious onset, periosteal reaction on imaging

›Highest nonunion rate, typically requires surgical management

Lateral ankle and foot injuries

›Lateral ankle sprain (S93.401)

›Inversion mechanism

›Tenderness over ATFL or CFL, not fifth metatarsal shaft

›Ottawa Ankle Rules guide imaging

›Peroneus brevis tendon avulsion or tear (M66.371)

›Tenderness posterior to fibula and along the tendon course

›MRI required for diagnosis

›Lisfranc injury (S93.301)

›Midfoot pain and swelling, plantar ecchymosis

›Weight-bearing radiographs show diastasis

Mimics on imaging

›Os vesalianum (Q74.2)

›Accessory ossicle at tuberosity

›Smooth, corticated, bilateral margins

05Laboratory Tests/lt27

Routine labs

›Laboratory workup for isolated acute Jones fracture

›Labs not routinely required for isolated acute fracture

›Clinical and radiographic diagnosis is sufficient in most cases

›Basic metabolic panel if perioperative planning

›Electrolytes, renal function prior to surgery

Metabolic bone evaluation

›Indicated for stress fracture pattern, recurrent fractures, or delayed healing

›25-hydroxyvitamin D level

›Deficiency is a recognized modifiable risk factor for nonunion

›Target repletion to > 50 nmol/l

›Calcium and phosphorus

›Assess for hypocalcemia or hypophosphatemia

›Alkaline phosphatase

›Elevation suggests metabolic bone disease or healing response

›PTH

›If calcium abnormal or metabolic bone disease suspected

›TSH

›Thyroid dysfunction affects bone turnover

Infection and pathologic fracture workup

›Indicated for atypical fracture pattern or concerning clinical features

›CBC with differential

›Leukocytosis may indicate osteomyelitis or pathologic process

›CRP and ESR

›Elevated in infection or inflammatory arthropathy

›Consider bone biopsy if pathologic fracture strongly suspected

Glycemic assessment

›HbA1c in diabetic patients

06Diagnostic Tests/dt59

Scoring Systems

›Torg classification for proximal fifth metatarsal fractures

›Type I (acute Jones fracture): sharp fracture margins, no intramedullary sclerosis, no periosteal reaction

›Best prognosis for nonoperative healing

›Nonoperative union rate approximately 76%

›Type II (delayed union): widened fracture line, periosteal reaction, evidence of prior healing attempts

›Intermediate prognosis

›Higher risk of nonunion with continued nonoperative management

›Type III (nonunion): complete obliteration of medullary canal by sclerotic bone

›Worst prognosis nonoperatively

›Almost always requires surgery with bone grafting

›Ottawa Foot Rules

›Validated clinical decision rule for radiography indication

›Bone tenderness at the base of the fifth metatarsal

›Bone tenderness at the navicular

›Inability to bear weight for four steps in the ED

›99% sensitivity for clinically significant fractures

›Negative Ottawa rules do not exclude Jones fracture if clinical concern exists

MRI

›Indications for MRI

›Nondisplaced fracture with inconclusive radiographs

›Can identify stress reactions and bone marrow edema before cortical fracture

›Occult fracture suspected on clinical grounds

›Distinguishing stress reaction from complete fracture

›Peroneus brevis tear suspected

›MRI findings in Jones fracture

›T2 and STIR hyperintensity in the fifth metatarsal metaphyseal-diaphyseal junction

›Bone marrow edema pattern

07Disposition/dispo26

Discharge criteria

›Criteria for ED discharge with outpatient management

›Isolated closed Jones fracture (Torg I or II) without neurovascular compromise

›Posterior splint in neutral position

›Non-weight-bearing with crutches

›Orthopedic referral within 5 to 7 days

›Pain controlled with oral analgesia

›Patient able to demonstrate safe non-weight-bearing with crutches

›Reliable follow-up confirmed

Admission criteria

›Indications for hospital admission

›Open fracture requiring operative irrigation and debridement

›Compartment syndrome of the foot

›Emergent fasciotomy

›Neurovascular compromise requiring urgent surgical exploration

›Polytrauma with multiple injuries requiring inpatient monitoring

Urgent orthopedic consultation

›Triggers for same-encounter orthopedic involvement

›Displaced fracture (> 2 mm displacement)

›Open fracture

›Neurovascular compromise

›Compartment syndrome signs

›Active athlete with desire for early operative fixation

›Direct surgeon-to-athlete discussion regarding risks and return-to-play timelines

Follow-up planning

›Outpatient follow-up schedule

›Orthopedic evaluation within 5 to 7 days

›Serial foot radiographs every 2 to 4 weeks during healing

08Treatment/t60

Nonoperative management

›Indications for conservative management

›Acute Torg I Jones fracture in low-demand or sedentary patient

›Patient who declines surgery after informed discussion of nonunion risk

›Nonunion rate approximately 24% with conservative management for acute fractures

›Short leg non-weight-bearing cast protocol

›Short leg non-weight-bearing cast for 6 weeks

›Neutral ankle position

›Posterior splint initially until swelling subsides, then circumferential cast

›Followed by protected weight-bearing in a CAM boot for 1 to 6 weeks

›Duration based on clinical and radiographic healing assessment

›Total healing time 10 to 12 weeks

›Monitoring during conservative management

›Radiographic reassessment every 2 to 4 weeks

›If no healing progression by 6 to 8 weeks, reconsider operative management

Surgical management

›Indications for operative management

›Active athlete seeking faster return to sport

›Displaced fracture (> 2 mm)

›Torg II or III (delayed union or nonunion)

›Failure of conservative management

›Patient preference after risk-benefit discussion

›Intramedullary screw fixation (standard technique)

›Solid or cannulated intramedullary screw placed percutaneously

›Screw diameter 4.5 to 6.5 mm based on canal diameter

›Screw must span the entire fracture zone

›Union rate 96 to 97% with surgical fixation

›Compared to approximately 76% with nonoperative management

09Special Populations/sp67

Pregnancy

›Physiologic considerations

›Physiologic changes affecting fracture management in pregnancy

›Increased ligamentous laxity due to relaxin

›Weight gain increases mechanical load on the lateral column

›Nutritional demands for calcium and vitamin D are increased

›Non-weight-bearing compliance may be more difficult as pregnancy progresses

›Core strength reduction and balance changes in third trimester

›Imaging considerations

›Foot radiographs are acceptable with abdominal shielding

›Radiation dose to fetus from foot X-ray is negligible

›MRI preferred over CT if cross-sectional imaging needed

›Avoid gadolinium in first trimester unless essential

›Treatment modifications

›Nonoperative management strongly preferred during pregnancy

›Surgical fixation deferred to postpartum period when possible

›Regional or spinal anesthesia preferred over general anesthesia if surgery necessary

›NSAIDs contraindicated after 20 weeks gestation

›Risk of premature closure of ductus arteriosus

›Acetaminophen is the analgesic of choice throughout pregnancy

›Vitamin D supplementation 1000 to 2000 IU daily

›Supports both maternal and fetal bone mineralization

Geriatric

›Physiologic considerations

›Age-related changes relevant to Jones fracture

›Reduced bone mineral density increases fracture and nonunion risk

›Impaired periosteal healing response

›Comorbidities (diabetes, peripheral vascular disease) more prevalent

›Older age independently associated with delayed union

›Fall risk and mobilization

›Non-weight-bearing with crutches may be unsafe in patients with balance impairment

›Consider knee scooter or wheelchair alternatives

›Physical therapy assessment for safe mobility aids

›Social support assessment for non-weight-bearing compliance

›Medication safety

›NSAIDs with caution in geriatric patients

›Increased risk of GI bleeding, renal impairment, cardiovascular events

›Prefer acetaminophen as first-line analgesic

›Opioid risk in elderly

›Increased fall risk, delirium risk

›Use lowest effective dose for shortest duration

›Review for polypharmacy contributing to bone fragility

›Corticosteroids, PPIs, anticonvulsants

›Metabolic bone disease

›Screen for osteoporosis if not previously evaluated

›DEXA scan referral at follow-up

›Bisphosphonate therapy if indicated

›Consider timing relative to fracture healing

Pediatrics

›Anatomic considerations

›Apophysis of the fifth metatarsal tuberosity in skeletally immature patients

›Iselin disease: apophysitis of the fifth metatarsal tuberosity

›Apophysis is normally visible on radiographs and should not be mistaken for fracture

›Apophysis runs parallel to the metatarsal shaft; fracture lines are transverse or oblique

›Jones fracture can occur in adolescents and pediatric athletes

›Increasingly recognized in competitive youth sports

›Imaging interpretation

›Comparison views of the contralateral foot if ossicle vs. fracture uncertain

›MRI preferred for stress reactions before cortical fracture is visible

›Treatment considerations

›Acute Jones fracture in pediatric and adolescent patients

›Nonoperative management with non-weight-bearing cast for 6 to 8 weeks appropriate in most cases

›Remodeling capacity is higher in younger patients

›Competitive adolescent athletes

›Earlier operative discussion given return-to-sport timelines

›Discuss with parents and patient regarding season implications

›Analgesic dosing

›Acetaminophen 15 mg/kg orally every 4 to 6 hours (maximum 75 mg/kg/day)

›Ibuprofen 5 to 10 mg/kg orally every 6 to 8 hours (maximum 40 mg/kg/day)

›Short-course NSAIDs acceptable for acute pain management

10Background/b53

Epidemiology

›Incidence and prevalence

›Jones fracture is the second most common proximal fifth metatarsal fracture

›Zone 1 avulsion fractures are more common overall

›Bimodal distribution: athletic young adults and older adults with bone fragility

›Disproportionately common in basketball, football, and soccer athletes

›Pes cavus foot type present in 42% of Jones fracture patients in case series

›Forefoot adduction is a significant predictor of nonunion

›Outcomes

›Nonoperative union rate approximately 76% for acute Torg I fractures

›Conservative treatment failure (nonunion or refracture) approximately 16% even for traumatic fractures

›Surgical fixation union rate 96 to 97%

›Refracture rate approximately 10% after fixation; reduced with orthotic correction

›Return to sport after surgical fixation: 7 to 12 weeks

›Meta-analytic data (Wang et al. 2020) strongly favor operative management for active patients

Pathophysiology

›Vascular anatomy

›The metaphyseal-diaphyseal junction represents a watershed vascular territory

›Metaphyseal perforators supply the proximal zone

›Nutrient artery supplies the diaphysis

›Watershed zone has limited collateral perfusion

›This tenuous blood supply is the primary reason for high nonunion rates in Zone 2

›Biomechanical factors

›Forced adduction with the foot in plantar flexion concentrates stress at Zone 2

›Peroneus brevis pulls proximally while the fracture shears laterally

›Pes cavus and hindfoot varus increase lateral column loading

›Elevated stress at the fifth metatarsal base with each step

›Repetitive microtrauma can convert a stress reaction into a complete fracture

11Patient Discharge Instructions/pdi33

copy discharge instructions

›Diagnosis and overview

›You have been diagnosed with a Jones fracture

›This is a specific type of break in the fifth (outer) metatarsal bone of your foot

›This fracture has a higher risk of not healing than other foot fractures

›It requires close follow-up with an orthopedic (bone) specialist

›Weight-bearing restrictions

›Non-weight-bearing on the injured foot until cleared by orthopedics

›Use crutches or a knee scooter to avoid putting weight on the foot

›Do not walk on the foot even for short distances

›Keep the splint dry and intact

›Cover with a plastic bag while showering

›Do not remove or modify the splint

›Pain management

›Acetaminophen (Tylenol) 500 to 1000 mg every 6 hours as needed for pain

›Ibuprofen (Advil, Motrin) 400 to 600 mg every 8 hours with food if tolerated

›Avoid if you have kidney problems, stomach ulcers, or are pregnant

›Elevate the foot above heart level to reduce swelling and pain

›Ice to the injured area 20 minutes on, 20 minutes off for the first 48 to 72 hours

›Place a cloth between the ice and skin to avoid frostbite

›Follow-up instructions

›Orthopedic appointment within 5 to 7 days of discharge

›This is essential and should not be missed

›Serial X-rays will be taken every 2 to 4 weeks to track healing

›Recovery time is typically 10 to 12 weeks for nonoperative management

›Surgery may be recommended at your follow-up visit depending on X-ray findings and your activity level

›Return to the emergency department immediately for

›Increasing pain in the foot or leg that is not controlled by medications

12References/r22

Guidelines and key sources

›Primary clinical references

›Silver S, Williams E, Plunkett ML. Common Foot Fractures. American Family Physician. 2024. PMID 38393796

›Comprehensive review of Zone 1, 2, and 3 fifth metatarsal fracture classification and management

›Metzl JA, Bowers MW, Anderson RB. Fifth Metatarsal Jones Fractures: Diagnosis and Treatment. Journal of the American Academy of Orthopaedic Surgeons. 2022. PMID 34932521

›Evidence-based guidance on operative vs. nonoperative management

›Bušková K, Bartoníček J, Rammelt S. Fractures of the Base of the Fifth Metatarsal Bone: A Critical Analysis Review. JBJS Reviews. 2021. PMID 34673663

›Detailed review of risk factors including pes cavus, diabetes, and peripheral vascular disease

›Surgical outcome studies

›Attia AK, Taha T, Kong G et al. Return to Play and Fracture Union After the Surgical Management of Jones Fractures in Athletes: A Systematic Review and Meta-Analysis. American Journal of Sports Medicine. 2021. PMID 33740393

›Supports operative management for athletes: higher union rates, faster return to sport

›Wang Y, Gan X, Li K, Ma T, Zhang Y. Comparison of Operative and Non-Operative Management of Fifth Metatarsal Base Fracture: A Meta-Analysis. PloS One. 2020. PMID 32790794

›Meta-analytic evidence favoring surgery for active patients

›Kavanagh AM, Burgess BJ, Garras D, Therien AD, Vora A. Rate of Bony Union After Jones Fracture Fixation in the General Population. Journal of Foot and Ankle Surgery. 2024. PMID 40056968

›Weight-bearing and postoperative protocols

›Looney AM, Renehan JR, Dean DM et al. Rate of Delayed Union With Early Weightbearing Following Intramedullary Screw Fixation of Jones Fractures. Foot and Ankle International. 2020. PMID 32691621

›Waverly BJ, Sorensen MD, Sorensen TK. Early Weightbearing Protocol in Operative Fixation of Acute Jones Fractures. Journal of Foot and Ankle Surgery. 2018. PMID 29685559

›Bucknam RB, Scanaliato JP, Kusnezov NA et al. Return to Weightbearing and High-Impact Activities Following Jones Fracture Intramedullary Screw Fixation. Foot and Ankle International. 2020. PMID 31904264

›Consensus and sports medicine guidelines

›Balboni JM, Semelsberger SD, Boggiano VJ et al. Jones Fractures in Elite Athletes - 2025 International Foot and Ankle Sports Consensus and Systematic Review. Knee Surgery, Sports Traumatology, Arthroscopy. 2025. PMID 41451757

›Porter DA. Fifth Metatarsal Jones Fractures in the Athlete. Foot and Ankle International. 2018. PMID 29228800

›Roche AJ, Calder JD. Treatment and Return to Sport Following a Jones Fracture of the Fifth Metatarsal: A Systematic Review. Knee Surgery, Sports Traumatology, Arthroscopy. 2013. PMID 22956165

›Coleman MM, Guyton GP. Jones Fracture in the Nonathletic Population. Foot and Ankle Clinics. 2020. PMID 33543727

Evidence & Review

Evidence & Review