Professional sports teams are fairly resilient and used to dealing with sports injuries. It’s a part of life. Last year, the Oklahoma City Thunder managed to play without Russell Westbrook for 36 games because of a knee injury. Their star, Kevin Durant, seemed to pick up the slack and excelled in his usual fashion. He averaged 35 points and 6.3 assists a game and the Thunder went 20-7. Durant played 81 games last year, logged in more minutes (20,717) than any other NBA player since 2007, and was selected as the NBA’s MVP.
Durant is known as Mr. Constant. During his career, he has missed only 16 games. According to a recent ESPN article, Durant logged additional minutes during the off season in 2010 when he played in USA World Cup games in Turkey, and in 2012 when he played on the Olympic team in London. It was obvious that last season took a toll on him when he opted out of playing for the USA Men’s Basketball team that won the World Cup in Madrid this past summer. Durant was drained physically and mentally.
As the Thunder marched into the NBA season, they had high hopes of having another winning season and contending for the Western Conference title and NBA championship with a healthy roster that was rested. Unfortunately, they had a rude awakening a couple of weeks ago when Durant fractured the outside of his right foot at the base of the fifth metatarsal bone. His fracture has been classified as a Jones fracture. Now, many people in the sports world are wondering if the injury could have been prevented by restricting his play. It seems that Durant’s great strength may have been his biggest weakness.
Durant and his team of medical experts considered all options, but they made a joint decision that surgery was his best option. Last week, surgery was performed at a clinic in Charlotte, North Carolina. General Manager Sam Presti reported that Durant will be re-evaluated in six weeks.
Of course, fans and sportswriters are already trying to predict when he will return. AP Sports even estimated that he will be back at the beginning of December and have 65 games remaining. Sam Presti said that Durant will be evaluated in six weeks, but that does not mean he will return that soon. In fact, the odds are slim that he will return that fast. A Jones fracture is a difficult condition that may take longer to recover. The typical time for full recovery is around 20 weeks. Durant is the Thunder’s greatest asset, and they are not going to jeopardize his longevity with an early return unless he is fully capable of performing at peak levels.
A Jones fracture is in the fifth metatarsal on the lateral side of the foot. It is the long bone that connects to the little toe. Fractures in the fifth metatarsal are the most common, especially among athletes. The following are the three types of fractures at the proximal fifth metatarsal: Avulsion fracture, Jones fracture, and Shaft fracture. The proximal metatarsal has been classified into three zones.
Fifth metatarsal fractures
Zone 1 Avulsion Fractures account for over 90 percent of the fifth metatarsal fractures. Non-displaced fractures in this zone are usually treated non-operatively and do well with conservative treatment.
Avulsion fractures are located at the base of the fifth metatarsal. They are usually an acute fracture caused by an extreme and sudden hindfoot inversion injury (twisting or rolling of the ankle). This results in an extreme tension in the lateral band of the plantar aponeurosis and peroneus brevis tendon that are inserted into the proximal base of the fifth metatarsal. The tension is so great that it causes the base of the metatarsal to fracture. The fracture can be an incomplete or complete separation. Non-displaced fractures in this zone are usually treated non-operatively and do well with conservative treatment.
Zone 2 Jones fractures account for approximately 4 percent of the fifth metatarsal fractures. It can be acute or chronic injury. Jones fractures are recognized for prolonged healing, nonunion and complications. The fracture extends from the lateral aspect of the fifth metatarsal toward the fourth and fifth metatarsal facet. The location is the principal cause of the problem. It has a poor blood supply to promote healing. Also, the muscles, tendon and plantar fascia that attach to the tuberosity of the fifth metatarsal cause excessive motion that contributes to nonunion.
The fracture can be the result of an acute injury that applies a sudden and extreme adductive force to the lateral border of the forefoot that is in a plantar flexed ankle position. It can also be a chronic injury that results from a long-term stress fracture. Inherent foot and leg shapes can also impede healing. People who have a high arch in their foot or walk on the outside of their foot are more prone to get a Jones fracture.
This fracture can be treated non-operatively or operatively, but the treatment of this fracture is controversial. Non-operative treatment is standard protocol for this fracture if there is no displacement but many. Many studies indicate poorer union rates with non-operative treatment and long times to achieve union.
It is not uncommon for Jones fractures to recur if the bone fracture was not aligned properly, or if it did not union during non-operative treatment. Also, recurrence can be influenced by age, inherent foot shapes, improper physical therapy, and failing to gradually ease back to normal activities. Operative treatment may be required to correct these deficiencies and to prevent the bone from breaking again.
Operative treatment is typically pursued for larger displacements (>2 mm) and if the cuboid joint articulation is involved (>30 percent). Operative treatment is also pursued for patients with a delayed union, and for athletes with an acute fracture.
Operative treatment provides higher union rates, less risk of recurrence, shorter recovery time, and earlier return to sport. Operative treatment is typically selected for younger and professional athletes.
Zone 3 Shaft (Stress) fractures account for approximately 3 percent of the fifth metatarsal fractures. These fractures occur at the distal (end of joint) to the fifth metatarsal joint in the proximal diaphysis (shaft). A chronic stress fracture is caused by repetitive cyclic overloads that can result from a sudden increase in walking or running. It is commonly seen in athletes. Over time, the stress fracture can become a complete break. This fracture can be treated non-operatively or operatively. This type of fracture has an increased risk of nonunion, and is the hardest to heal. Operative treatment is the primary course of action, especially among athletes.
* Conservative Treatment
Zone 1 Avulsion fractures that are non-operative require protected weight bearing with use of a stiff sole shoe, boot, or a cast. Weight bearing activities can advance as tolerated by pain. Patients may return to work but it is not unusual for symptoms to persist for 6 months.
Zone 2 Jones fractures (in recreational athletes) and Zone 3 Stress fractures that are non-operative require a non-weight bearing short leg cast for 6 to 8 weeks. If radiographs confirm delayed or nonunion, an external, low-level Pulsed Electromagnetic Field Bone Stimulator (PEMF) device can be used as a non-surgical option to increase healing rates. This is followed by 6 to 8 weeks in crutches and Cam walker boots to gradually transition into full weight bearing. Stiff-sole shoes should be worn when the fracture heals. Typical healing time is around 15-22 weeks.
* Operative Treatment
Operative treatment for Zone 1 Avulsion fractures is rare but can happen if there is a substantial joint displacement or if tuberosity avulsion involves a significant amount of joint surface. Open reduction and internal fixation is performed. Typically small fragment screws are placed across the medial cortex of the proximal and obliquely through the tuberosity.
Operative treatment is recommended for Zone 2 Jones fractures if there is displacement (>2-3 mm), and for competitive and elite athletes. Operative treatment will minimize possibility of nonunion or prolonged restriction from activity. An Intramedullary Screw Fixation procedure is the most common procedure for Jones Fractures. A surgical incision is made at the base of the fifth metatarsal and an X-ray machine is used to help guide the placement of the screw, drawing the two fractured ends together. Screws are not removed unless they cause discomfort. Other procedures like tension banding percutaneous pinning, and external fixation may be used as well.
Reconstructive surgery is sometimes needed to alter the shape of the foot or alignment. These procedures include the following:
* Implanting bone grafts in the fracture site
* Lateralizing Calcaneal Osteotomy procedure is performed to shift and reposition the heel to the outside
* Dorsiflexing 1st metatarsal osteotomy is performed on people with high arches to realign the 1st metatarsal (big toe) if it is angled downward
Operative treatment is recommended for Zone 3 Stress fractures with sclerosis or non-union cases, and for athletic people. Internal compression fixation with plates and screws are commonly used. In some cases, bone grafts are surgically implanted in the fracture site. A dynamic pressure plate can be used for a transvers fracture and secured with monofilament K-wire. Oblique fractures can be addressed by use of cortical or cancellous screws.
Post–operative treatment includes a non-weight bearing cast for 6 to 8 and gradual transition into full weight bearing during the next 6-8 weeks. This is accomplished by the use of a weight bearing removable boot and shoe Orthosis. Low impact activity can gradually begin until the fracture site is not tender. Patients usually return to full activity within 20 to 21 weeks.
Possible complications of surgery are infection, damage to the blood vessels, sural nerve damage, blood clots and bleeding, wound healing, non-union, increased fractures that occurred during operative treatment, and risks associated with anesthesia. Non-union complications are present in Zone 2 Jones Fracture because of poor blood supply; and the use of smaller diameter screws associated with delayed or non-union
The complications for fixations include a high failure among elite athletes and for athletes that return to sport prior to radiographic union. Re-fracture distractions or mal-reductions after fixation are also attributed to adverse effects on the metatarsal shaft and medial cortex often requiring reconstructive surgery. Lastly, there may be discomfort from the screws and difficulty with shoe wear.
The populations at greatest risk for fifth metatarsal fractures include athletes, people with diabetes greater than 25 years of age, and elderly women with osteoporosis. The Jones fracture is a serious injury that can limit full mobility and cause further complications. If treated correctly and in a timely fashion, most patients will regain full function. This can be a debilitating injury if it is not treated in time.
The type of treatments selected for fifth metatarsal fractures depend on the location of the fracture, the type of fracture, and other related symptoms. Both conservative and operative treatments have good outcomes but careful consideration is required to select the appropriate treatment that will help restore full function.
Contact Dr. Sigle at the Foot & Ankle Center of Illinois at (217) 787-2700 to explore your treatment options. Dr. Sigle’s clinic locations are in Springfield and Decatur. He is also has clinic at the SIU School of Medicine, Division of Orthopaedics. Visit www.myfootandanklecenter.com for additional information on foot care.
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