01Approach to the Critical Patient/attcp30

Immediate priorities

›Limb threat screen

›Open fracture concern

›Skin breach over 5th metatarsal region

›Gross contamination

›Exposed bone

›Neurovascular compromise

›Dorsalis pedis pulse abnormal

›Posterior tibial pulse abnormal

›Cap refill delayed

›Compartment syndrome of foot concern

›Pain out of proportion

›Pain with passive toe motion

›Tense compartments

›If open fracture suspected, initiate antibiotics and tetanus pathway, urgent orthopedics, transfer if no OR capability

›Analgesia and immobilization first-pass plan

›Early splinting to control pain and displacement

›Non-weight-bearing default until definitive plan

›Post-immobilization neurovascular documentation

›Imaging decision points

›Foot radiographs standard

›3-view foot series

›Post-splint films if alignment concern

›If midfoot pain pattern, evaluate for Lisfranc injury in parallel

›Consultation triggers

›Displacement

›Articular involvement suspicion

›Comminution

02History/hx24

Injury and risk context

›Symptom and timeline

›Time since injury

›Ability to bear weight after injury

›Progressive pain pattern suggesting stress mechanism

›Mechanism

›Inversion injury with forefoot adduction

›Axial load to lateral forefoot

›Repetitive loading and training volume change

›Baseline function and demands

›Competitive athlete status

›Occupational standing or walking requirements

›Risk factors for delayed union or nonunion

›Smoking or nicotine use

›Diabetes mellitus

›Peripheral vascular disease

›Vitamin D deficiency risk

›Prior 5th metatarsal fracture

›Chronic steroid exposure

›Medication and bleeding considerations

›Anticoagulant or antiplatelet therapy

›NSAID use pattern

›Associated injury screen

›Ankle pain suggesting lateral ligament injury

›Midfoot pain suggesting Lisfranc injury

03Physical Exam/exam25

Focused foot and ankle exam

›Inspection and skin

›Swelling over lateral midfoot

›Ecchymosis over 5th metatarsal base

›Skin tenting

›Open wound near fracture site

›Palpation

›Point tenderness at 5th metatarsal base

›Point tenderness at metadiaphyseal junction pattern

›Midfoot tenderness over tarsometatarsal joints

›Function

›Antalgic gait

›Inability to bear weight due to pain

›Peroneus brevis pain with resisted eversion

›Neurovascular

›Dorsalis pedis pulse

›Posterior tibial pulse

›Capillary refill

›Light touch over superficial peroneal nerve distribution

›Adjacent joint and injury patterns

›Ankle ligament laxity pattern

›Proximal fibula tenderness if high-energy or rotational injury

›PITFALLS

›Zone 1 avulsion fracture misclassified as Jones fracture

›Lisfranc injury missed when lateral foot pain dominates

›Stress fracture Zone 3 misclassified as acute Jones fracture

04Differential Diagnosis/ddx22

Lateral foot pain after injury

›5th metatarsal tuberosity avulsion fracture

›Pain most proximal at tuberosity

›Peroneus brevis or plantar fascia insertion mechanism

›5th metatarsal diaphyseal stress fracture

›Gradual onset

›Prodromal pain with running

›Cuboid fracture

›Lateral midfoot pain with compression

›Lisfranc injury

›Midfoot swelling

›Plantar ecchymosis

›Lateral ankle sprain

›ATFL tenderness

›Pain not maximal at 5th metatarsal

›Peroneal tendon injury

›Pain with resisted eversion

›Retromalleolar tenderness

›Occult fracture

›Normal initial radiographs with persistent focal bony tenderness

›Coding anchors

›ICD-10 S92.35XA fracture of fifth metatarsal bone, unspecified foot, initial encounter for closed fracture

›SNOMED CT concept: fracture of fifth metatarsal bone

05Laboratory Tests/lt12

Selective labs only

›Routine labs usually unnecessary

›Isolated closed Jones fracture without planned procedure

›Normal vitals and low-energy mechanism

›Procedural pathway labs

›If procedural sedation planned, local protocol labs only

›If operative fixation likely, CBC and electrolytes per receiving service

›Open fracture or systemic risk labs

›CBC for infection or bleeding concern

›Creatinine and electrolytes if significant comorbidity

›Bone health labs for recurrent stress pattern

›25-OH vitamin D level arranged outpatient

›Calcium and phosphate arranged outpatient

06Diagnostic Tests/dt47

Scoring Systems

›Fracture zone classification

›Lawrence and Botte proximal 5th metatarsal zones

›Zone 1 tuberosity avulsion

›Zone 2 metadiaphyseal junction Jones fracture

›Zone 3 proximal diaphyseal stress fracture region

›Management implications

›Zone 2 higher nonunion risk than Zone 1

›Zone 3 highest stress-related nonunion risk pattern

›Stress fracture and nonunion classification

›Torg classification for 5th metatarsal stress injury

›Type I early or acute

›Type II delayed union pattern

›Type III nonunion pattern

›Management implications

›Type II to III stronger consideration for operative fixation

Radiographs

›Standard imaging

›Foot 3-view series

›AP view

›Oblique view

›Lateral view

›Alignment and displacement descriptors

›Fracture line at metadiaphyseal junction

›Intra-articular extension to 4th to 5th intermetatarsal joint suspicion

›Displacement estimate

›Additional imaging considerations

›Weight-bearing views if Lisfranc concern and patient tolerates

07Disposition/dispo17

ED disposition and follow-up

›Discharge criteria

›Closed injury

›Pain controlled with oral regimen

›Neurovascularly intact after immobilization

›Safe non-weight-bearing plan with crutches or walker

›Urgent orthopedics criteria

›Open fracture

›Neurovascular compromise

›Marked displacement or angulation

›Suspected Lisfranc injury

›High-performance athlete with rapid return needs

›Follow-up timing

›Ortho or fracture clinic within 3 to 7 days

›Earlier if swelling threatens skin or pain escalating

›Weight-bearing plan

›Zone 2 Jones fracture default non-weight-bearing until ortho plan

›Strict adherence emphasized due to nonunion risk

08Treatment/t67

Immediate life-saving interventions

›Limb-threatening scenarios

›If open fracture suspected, cover with sterile dressing, initiate antibiotics, tetanus pathway, urgent orthopedics

›If neurovascular compromise, urgent reduction or alignment correction if deformity, immediate specialist involvement

›If compartment syndrome concern, emergent orthopedics, fasciotomy pathway activation

Immobilization and Splinting

›Lower extremity splint options

›Posterior short leg splint

›Foot in neutral position

›Toe box clearance

›Posterior short leg plus stirrup

›Additional inversion-eversion control

›High swelling expectation

›Immobilization principles

›Swelling phase avoidance of circumferential cast

›Two-finger tightness check at wrap

›Padding over malleoli and heel

›Post-splint checks

›Pain trend after immobilization

›Toe cap refill

›Dorsalis pedis pulse

›Sensation over dorsal foot

Reduction

›Reduction usually not required

›Nondisplaced Jones fracture typical

›If significant angulation or displacement, urgent orthopedics for reduction plan

›Analgesia and anesthesia support

›Oral analgesia first-line when stable

09Special Populations/sp27

Pregnancy

›Imaging considerations

›Radiographs acceptable with shielding when needed

›CT avoidance unless critical diagnostic need

›Analgesia considerations

›Acetaminophen preferred first-line

›NSAID avoidance in later pregnancy per obstetric guidance

›Disposition and mobility

›Fall risk mitigation with crutches

›Obstetric notification if significant trauma mechanism

Geriatric

›Higher complication risk

›Falls risk with non-weight-bearing plan

›Home supports and mobility aids needs

›Bone health pathway

›Fragility fracture context evaluation

›Osteoporosis follow-up planning

›Medication safety

›Opioid delirium risk

›NSAID renal and GI risk

Pediatrics

›Normal variants

›5th metatarsal apophysis mimicking fracture

›Accessory ossicles

›Growth plate considerations

›Physeal injury alternative diagnoses

›Lower threshold for pediatric orthopedics input if uncertain

›Immobilization adaptation

10Background/b21

Epidemiology

›Common fracture pattern in lateral foot injuries

›Inversion mechanism association

›Higher incidence in running and cutting sports

›Complication burden

›Zone 2 Jones fracture higher nonunion and delayed union rates than Zone 1 patterns

Pathophysiology

›Anatomic risk zone

›Metadiaphyseal junction watershed blood supply region

›Increased risk of delayed union and nonunion

›Force vector association

›Forefoot adduction with hindfoot inversion

›Peroneus brevis and plantar fascia forces contributing to fragment motion

Therapeutic Considerations

›Nonoperative strategy rationale

›Nondisplaced fractures with strict non-weight-bearing

›Immobilization to reduce micromotion at fracture site

›Operative strategy rationale

›Earlier union and return-to-sport goal in selected patients

›Displacement or high-demand athletics consideration

›Evidence framing

›Higher nonunion risk supports stricter immobilization than tuberosity avulsion fractures

›Class IIa recommendation concept for early orthopedic referral in athletes and displaced fractures

›ACEP Level C alignment for shared decision-making and follow-up planning in low-risk closed injuries

11Patient Discharge Instructions/pdi22

copy discharge instructions

›Jones fracture of the 5th metatarsal

›Non-weight-bearing on the injured foot

›Keep splint on and dry

›Elevation above heart level as much as possible for 48 to 72 hours

›Ice 15 to 20 minutes at a time, several times per day, skin protection barrier

›Pain control plan

›Acetaminophen as directed on label or as prescribed

›Ibuprofen as directed on label or as prescribed if safe for you

›Avoid alcohol or driving if taking opioid medication

›Splint warning signs

›Increasing pain not relieved by elevation and medication

›New numbness or tingling in toes

›Toes pale, blue, cold, or difficult to move

›Splint too tight, wet, cracked, or slipping

›Return to ED now

›Severe worsening pain

›New weakness or loss of toe movement

›Fever or wound drainage

›New shortness of breath or chest pain

›Follow-up

›Orthopedics or fracture clinic appointment in 3 to 7 days

›Bring imaging results if seen outside the same health system

12References/r9

Clinical guidelines and evidence sources

›Proximal 5th metatarsal fracture classification sources

›Lawrence and Botte proximal 5th metatarsal zones

›Torg classification for 5th metatarsal stress fracture and nonunion

›Orthopedic society guidance

›AAOS patient and clinician education resources on foot fractures

›Sports medicine consensus statements on Jones fracture operative indications

›Emergency medicine guidance

›ACEP procedural sedation clinical policy for monitoring and safety (Level B)

›ACEP Level C evidence framing for discharge planning and follow-up reliability

Evidence & Review

Evidence & Review