From the Guidelines
Surgery is generally recommended for zone 1 fifth metatarsal fractures due to the high risk of nonunion or delayed union, as highlighted in the 2024 update of the ACR Appropriateness Criteria for stress fractures 1.
Key Considerations
- Zone 1 fifth metatarsal fractures are considered high-risk stress fractures, which can lead to serious complications if not managed properly 1.
- The decision to operate on these fractures is often based on the risk of nonunion or delayed union, rather than the size of the fracture fragment or the degree of displacement.
- The 2024 update of the ACR Appropriateness Criteria for stress fractures emphasizes the importance of identifying and managing high-risk stress fractures, including those in the fifth metatarsal base, to prevent complications such as nonunion or delayed union 1.
Surgical Indications
- The specific indications for surgery in zone 1 fifth metatarsal fractures are not clearly defined in the provided evidence, but the general principle is to operate on high-risk fractures that are likely to result in nonunion or delayed union if treated conservatively.
- The 2002 American College of Foot and Ankle Surgeons guidelines suggest that surgery is the usual treatment for these fractures, especially when conservative management is not effective 1.
Surgical Procedure
- The surgical procedure for zone 1 fifth metatarsal fractures typically involves open reduction and internal fixation (ORIF) using tension band wiring, screws, or plates to stabilize the fracture.
- The goal of surgery is to restore proper bone alignment, maintain joint congruity, and allow earlier mobilization, particularly important for athletes or physically active individuals who require faster return to activities.
From the Research
Zone 1 Fifth Metatarsal Fracture Requirements for Surgery
- Zone 1 fractures are generally expected to heal with conservative management 2, 3, 4, 5
- Nonoperative treatment is commonly recommended for avulsion fractures of the tuberosity of the base (zone 1) 3, 4, 5
- Internal fixation may be considered for displaced fractures, but is not typically required for zone 1 fractures 3, 4, 5
- Conservative treatment options for zone 1 fractures include functional immobilization and early mobilization 2, 3, 5, as well as the use of a hard-soled shoe or a controlled ankle motion (CAM)-walker boot 6
Indications for Surgery
- Surgery may be considered for zone 1 fractures that develop nonunions 2
- Percutaneous fixation of fifth metatarsal base nonunions, without fracture site preparation, has been shown to achieve excellent results 2
- However, most studies suggest that zone 1 fractures can be treated conservatively, and surgery is not typically required 3, 4, 5, 6
Treatment Outcomes
- Studies have shown that patients with zone 1 fractures can achieve excellent outcomes with conservative treatment, including early functional therapy 5 and the use of a CAM-walker boot or hard-soled shoe 6
- The average time to return to prior activity levels and the rate of bone healing may vary depending on the treatment method, but similar clinical and functional results can be achieved with different conservative treatments 5, 6