From the Guidelines
The initial outpatient primary care management of an acute nondisplaced fracture of the proximal fifth metatarsal in a 68-year-old male should focus on simple immobilization, as this approach is appropriate for small, nonarticular, or minimally displaced fractures. According to the American College of Foot and Ankle Surgeons, as reported in the American Family Physician in 2002 1, the diagnosis of such fractures is based on a history of trauma, focal pain on palpation, and confirmation with radiographic studies. Given the nondisplaced nature of the fracture, immobilization can be achieved with a walking boot or hard-soled shoe for 4-6 weeks, allowing weight-bearing as tolerated.
- Key aspects of management include:
- Immobilization to prevent further injury and promote healing
- Pain control, which may involve acetaminophen or NSAIDs like ibuprofen, considering the patient's medical history and potential contraindications
- Elevation of the foot to reduce swelling
- Application of ice for the first 48-72 hours to minimize pain and inflammation
- Follow-up is crucial, with a scheduled appointment in 1-2 weeks to assess healing progress through repeat X-rays, ensuring that the fracture is not displacing and that healing is on track.
- It's essential to instruct the patient to gradually increase weight-bearing as pain allows, using the walking boot for support, and to seek earlier reassessment if symptoms worsen, indicating potential complications.
From the Research
Initial Outpatient Primary Care Management
The initial outpatient primary care management of an acute nondisplaced fracture of the proximal fifth metatarsal in a 68-year-old male involves:
- Characterizing the fracture and identifying any conditions that require emergent referral, such as neurovascular compromise and open fractures 2
- Evaluating the Lisfranc ligament if the midfoot is injured, as injuries to this ligament require referral or specific treatment based on severity 2
- Providing a soft dressing for avulsion fractures of the proximal fifth metatarsal tuberosity 2, 3
- Individualizing treatment for proximal fifth metatarsal fractures that are distal to the tuberosity based on the characteristics of the fracture and patient preference 2
Treatment Options
Treatment options for nondisplaced fractures of the proximal fifth metatarsal include:
- A soft dressing followed by a firm, supportive shoe and progressive weight bearing 2
- Non-weight-bearing cast immobilization for 6 to 8 weeks for true Jones fractures 3
- Symptomatic care in a hard-soled shoe for tuberosity avulsion fractures 3
- Intramedullary screw fixation for high-performance athletes with acute Jones fractures or for nonacute diaphyseal stress fractures and Jones fractures that develop into delayed unions and nonunions 3, 4
Important Considerations
Important considerations in the management of proximal fifth metatarsal fractures include:
- Distinguishing between fractures of the tuberosity and those distal to the tuberosity, as the latter have a poorer prognosis 2, 5
- Evaluating the patient's activity level and Torg classification to determine the indication for surgical treatment of Jones' fractures 6
- Recognizing that Jones fractures can have a prolonged healing time and non-union, and may require operative fixation 6, 4