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Pediatric Jones Fracture

Pediatric Jones Fracture

Pediatric Jones Fracture

 

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

Pediatric Jones Fracture ICD-9

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

Pediatric Jones Fracture 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.
  • 22% of pediatric foot fractures occur in the 5th metatarsal base. 90% of fifth-metatarsal fractures occurr in children older than 10 years.
  • MOI: For true Jones Fracture 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 or may be due to avulsion at the origin of the abductor digiti minimi..

Pediatric Jones Fracture 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 brevis inserts over a broad area on the dorsolateral aspect of the tuberosity.
  • Peroneus tertius inserts 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 brevis tendon.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 5th metatarsal (Donley, Foot Ankle Int 20:182;1999)

Pediatric Jones Fracture 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.

Pediatric Jones Fracture 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.

Pediatric Jones Fracture 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; 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  intrameduallary screw fixation 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.
  • Zone 3; Acute Displaced Diaphyseal Fracture: Treatment =consider closed reduction and pinning vs intrameduallary screw fixation.

Pediatric Jones Fracture Associated Injuries / Differential Diagnosis

Pediatric Jones Fracture 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

Pediatric Jones Fracture Follow-up Care

  • Non-operative treatment for acute true Jones fractures may take up to 21 weeks.
  • Adult 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),

Pediatric Jones Fracture Review References

  • Kay RM, JAAOS 2001;9:308
  • 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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