What is the recommended treatment for a patient with a Jones fracture of the 5th metatarsal?

Jones Fracture Treatment

For Jones fractures (zone 2 proximal fifth metatarsal fractures), surgical fixation with intramedullary screw is the preferred treatment due to superior union rates (89-100%) compared to conservative management (nonunion rates 15-30%), though conservative treatment with immediate weight-bearing in a walking boot remains a reasonable option for low-demand patients who wish to avoid surgery. 1, 2, 3

Treatment Decision Algorithm

Surgical Fixation (Preferred for Most Patients)

Primary indications:

• Athletes or high-demand patients wanting rapid return to activity 4
• Patients unwilling to accept 4-6 weeks non-weight-bearing 4
• Displaced fractures with minimal to moderate displacement 3
• Patients prioritizing faster radiographic union 1

Surgical technique:

• Intramedullary screw fixation (4.5-5.5mm full-core screw) using percutaneous approach 3
• High and inside starting point to avoid peroneus brevis insertion and sural nerve 3
• Achieves 100% union rate at mean 5.7 weeks 5
• Allows immediate weight-bearing in controlled ankle motion boot for 2 weeks, then transition to regular shoes 5
• Return to all activities at 6 weeks regardless of radiographic healing 5

Surgical outcomes:

• Union rates: 89-100% 3
• Mean time to radiographic union: 5.7 weeks 5
• Complication rate: 13% (primarily hardware removal, sural neuritis) 1

Conservative Management (Alternative for Select Patients)

Appropriate for:

• Low-demand patients who are risk-averse and prioritize avoiding surgery 1
• Patients willing to accept longer time to return to sports 1
• Minimally displaced acute fractures in adults 2

Conservative protocol:

• Weight-bearing as tolerated in walking boot (immediate weight-bearing) 2
• Alternative: Non-weight-bearing cast for 4-6 weeks followed by weight-bearing boot 1
• Mean follow-up demonstrates 66.7% radiographic union with immediate weight-bearing protocol 2
• Nonunion rate: 6.4% with weight-bearing protocol vs 37.5% with non-weight-bearing cast 2

Conservative outcomes:

• Better VAS scores at 2 weeks and FFI-RS scores at 12 weeks compared to surgery 1
• Longer time to return to sports compared to surgical treatment 1
• Risk of painful nonunion requiring delayed surgery: 6.4-15% 1, 2

Critical Anatomical Consideration

The zone 2 fracture location (junction of metaphysis and diaphysis at the fourth-fifth intermetatarsal articulation) has retrograde vascular supply creating a watershed region, explaining the high nonunion risk with conservative treatment. 2, 3

Postoperative Protocol (If Surgical)

• Weeks 0-2: Non-weight-bearing in soft wrap and postoperative boot 3
• Week 3: 25% weight-bearing 3
• Week 4: 50% weight-bearing 3
• Week 5: 75% weight-bearing 3
• Week 6: 100% weight-bearing, expect radiographic union 3
• Weeks 6-8: Increase walking and physical therapy 3
• Weeks 8-12: Begin pool/treadmill activity 3

Common Pitfalls to Avoid

Surgical technique errors:

• Avoid incision too close to proximal fifth metatarsal (causes soft-tissue tension); place 1-3cm proximal 3
• Must use high and inside starting point to protect peroneus brevis insertion and sural nerve 3
• Verify guidewire position on AP, lateral, and oblique views before drilling 3

Treatment selection errors:

• Do not use percutaneous screw fixation for comminuted fractures or proximal-split patterns (requires plate fixation or bone grafting) 3
• Do not recommend traditional non-weight-bearing cast protocol when immediate weight-bearing in boot shows equivalent or better outcomes 2

Patient counseling:

• Surgical patients achieve faster radiographic union but conservative patients report better early pain scores 1
• Both approaches achieve excellent AOFAS scores at final follow-up with no significant difference 1