What is the diagnosis?

This is a fracture of the base of the fifth metatarsal where the 4th and 5th intertarsal junction occurs, which is classified as a Jones fracture.

• Pearl: The location of the fracture in the fifth metatarsal is extremely important and affects treatment. Lawrence and Botte developed classifications which used three zones. Fractures that are more proximal are Zone 1. These are pseudo-Jones or tuberosity avulsion fractures. Zone 2 is the intertarsal junction, These are Jones fractures. Zone 3 is the most distal and commonly involves diaphyseal stress fractures. [2]

Image 2: Drawing of the cuboid, fourth and fifth metatarsals. Brown indicates area of pseudo-Jones fracture, red indicates Jones fracture, and blue most commonly involved diaphyseal stress fracture. Author’s own creation

What is the mechanism of injury?

Usually either a medially directed force on a plantarflexed foot or a strong sudden adduction/inversion of the forefoot.

• Pearl: With a Jones or psuedo-Jones fracture pain should be acute. If a patient’s pain has been chronic this should raise suspicion of a stress fracture. [3]

What physical exam findings are expected?

Likely the patient will have difficulty bearing weight and ambulating. There may be swelling and ecchymosis. There is usually tenderness along the base of the fifth metatarsal. Passive inversion and resisted eversion can cause pain. 

Which imaging modalities can be used?

X-rays are the way to go. You need a lateral, AP, and oblique images of the foot.

What is the management in the ED?

Control the patient’s pain! Also with a Jones fracture the patient needs to be a put in a posterior ankle splint and cannot bear weight for approximately 6-8 weeks. This patient needs to follow up with orthopedics within the next 7 days.

• Pearl: While the majority of Jones fractures can be treated non-operatively, surgical treatment is often recommended to high level athletes to reduce time to heal[4, 5].

• Pearl: Zone 2 is a vascular watershed area. This can contribute to non-union rates as high as 30% [3].

• Pearl: Injuries to Zone 1 can weight bear as tolerated and use a hard sole. Zone 3 fractures are also non-weight bearing and also should be out in a posterior splint. 

When do you consult Orthopedics?

Typically Orthopedics consultation is not required for this type of injury. However, Ortho should be consulted whenever there is concern for neurovascular compromise, evidence of an open fracture, or severely displaced fracture.