Lecture 16 parekh jones

Jones Fractures

Selene G. Parekh, MD, MBAAssociate Professor

North Carolina Orthopaedic ClinicDepartment of Orthopaedic Surgery

Adjunct Faculty Fuqua Business SchoolDuke University

Durham, NC919.471.9622

www.seleneparekhmd.com@seleneparekhmd

http://www.seleneparekhmd.com/

5th Metatarsal Fractures

• Consider in Zones

Jones fx

Diaphysealfx

Jones Fracture

• Fracture of the metaphyseal-diaphyseal junction• Must enter the 4/5 intermetatarsal articulation

Mechanism of Injury

• Vertical and mediolateral forces concentrated over the 5th MT

• Forced adduction• Can result in a fracture between shaft and

immobile base

• Greater propensity • Forefoot supination• Knee/ankle/hindfoot varus

Anatomy

• Peroneus brevis

• Peroneus tertius

• Abductor digiti minimi

• Lateral band of plantar fascia

• Plantar and dorsal interosseous

• Flexor digiti minimi brevis

Vascular Water-Shed

•Periosteal plexus

•Nutrient artery•Enters medial aspect of 5th MT at junction of proximal and middle third of bone

•Metaphyseal and diaphyseal vessels

Jones Fracture: Non-Op

• Indications• Elderly• Non-athletic• Low-demand

• Protocol• NWB cast 4-8 weeks

• 100 Fractures of 5th MT: Naval base• 72% union (avg. time 21.2 wks)Clapper, ClinOrth 1995

Jones Fracture: Non-Op

• Protocol• Orthotic

• No data

Jones Fracture: Operative

• Indications• Athlete

• Acute/stress fx• Active adult• Nonunion• Refracture• Cavovarus = lateral overload


• Operative goals• Expedite healing• Quicker recovery; easier rehab• Decrease nonunion rate• Decrease refracture risk


• Operative options• K-wiring and cast• Tension band wiring• IM curettage and casting• Mini-fragment screws• Low profile plates• IM screw fixation

• Open• Percutaneous


•Screw Fixation• Screw choices

• 4.5 mm malleolar (Synthes)• 5.0 mm cannulated (ACE/DePuy) • 6.5 mm short thread (Synthes)


•Nonunion after percutaneous screw fixation are all with Cannulated Screws or Small Screws


• Percutaneous Screw Fixation• Solid screw

• Large fragment screws

• Dedicated system• Cannulated bone preparation• Solid screw fixation

Jones Fracture: Set-up

• Supine

• Ankle block

• Mini C-arm• Flex knee and place foot on base

Jones Fracture: Approach

• Incision through skin only• 1 fingerbreadth proximal to base of 5th MT• Parallel to peroneals

• Mosquito through wound to base of 5th MT


• Solid screw into a curved bone


• Guide pin• Entry site extremely important• Start “high and inside”• Central in the canal on AP and lat views

Jones Fracture: Technique

• Entry drill• Tap to the correct screw diameter

• 4.5, 5.5, 6.5mm• Feel the 5th MT head torsional forces


• Measure length• Remove pin and drill guide• Place solid screw

• Chose the largest solid screw that comfortably” fits the canal

• Do not attempt to place down the entire MT

Insert Screw “High and Inside”

HIGH & INSIDE


• Failure to start “high and inside”• Prominent screw head• Perforation of medial cortexstress riser


• Avoid the headless tapered screw• Difficult to remove

• Avoid plate• Prominent• If removed refracture

Jones Fracture

• Postop management• NWB x 2 weeks• WBAT in boot x 4 weeks• Physical therapy

Jones Fracture

• Begin running in modified shoewear at 6-8 weeks if clinically nontender

Jones Fracture

• Follow radiographs• Healing may not be evident for 12 weeks

12 wks p.o.

Jones Fracture

• Leave screw forever!

Pitfalls of IM Screw

• Infection• Delayed wound healing• Distal perforation (stress riser)• Sural neuritis/neuroma• Peroneal tendinitis• Persistent nonunion

Jones Fracture Nonunion

• Hardware fatigue a sign of trouble


• Cavovarus?• Adequate fixation?


• If uncertain obtain CT


• Open Surgical technique• Remove hardware• Open bone graft

• Iliac crest vs. allograft vs. substitutes vs. BMP• Re-fixation with largest screw


• Dwyer for varus

RE ECT

the ankle

the foot

Lecture 16 parekh jones

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