A 48 year old male patient sustained an acute ankle inversion injury. The patient presented with a painful foot at the emergency room. Physical examination revealed swelling and tenderness on palpation over the proximal 5th metatarsal, restriction in the range of motion and mild warmth.
Plain radiographs showed a fracture line at the proximal metaphysis of the 5th metatarsal bone (Fig. 1). Patient was treated with cast immobilization and weight-bearing restriction with crutches, to be applied for six weeks. Two weeks later, the patient removed the cast and ceased the weight-bearing restriction. A follow-up radiograph in the end of the 3d week was performed because of persistent pain and showed enlarged fracture line (Fig. 2). Relying on the clinical and radiographic findings, the clinicians suggested prolonged casting. On the 8th week after injury, the radiograph revealed severe disuse osteopenia and an MRI exam was requested to rull out Sudeck’s algodystrophy (Fig. 3). MR imaging showed bone marrow oedema at the fracture site, in keeping with a normal healing process (Fig. 4). No evidence of Sudeck’s algodystrophy or non-union was depicted. Due to lack of any significant clinical improvement, a CT exam was requested on the 10th week post-injury, to investigate for non-union or to show progression of healing in terms of periosteal or endosteal new bone formation (Fig. 5). On the 12th week after injury plain radiograph confirmed successful, continuing fracture healing (Fig.6). On the 15th week after injury, the patient reported slight improvement and persistent pain during motion and rarely at rest.
Fifth metatarsal fractures are the most common of the foot fractures and are frequently encountered in sports injuries and in accidents with motorcycles. Fractures within 1.5 cm of the proximal tuberosity (transverse fractures at the metaphyseal-diaphyseal zone), between the insertion of the peroneus brevis and tertius tendons, are defined as Jones’ fractures.
A combined clinical and radiological assessment is essential for the best treatment option. Non-displaced Jone’s fractures can be treated non-operatively with immobilization in a cast or below-the-knee boot with strict weight-bearing restriction for at least 6 to 8 weeks followed by 4 additional weeks of weight-bearing restriction. Surgical treatment is indicated when the fracture is displaced more than 3-4mm or when the angulation is more than 10º. For elite athletes, surgical correction with early internal fixation of all Jones-type fractures is preferred to ensure a short period of rehabilitation and prompt return to sports activity. The Jones fracture is characterized by a prolonged healing time (up to 14-16 weeks) and its high potentials for non-union. The reasons for the delayed union and the high rate of complications are related to limited blood supply of this anatomical area and the fact that the fifth metatarsal has the widest range of motion of all metatarsals. The Torg’s classification has been used for treatment planning in clinical practice: type I fractures are treated conservatively. Type II fractures can be treated conservatively or surgically, depending upon the patient’s activity level and demands. Type III fractures are prone to more complications and should be treated surgically. In all cases of nonunion or avascular necrosis or failed prolonged conservative treatment surgical fixation is mandatory.
Jone’s fracture
Based on the patient’s foot X-ray (partially visible: a transverse low-density line at the proximal fifth metatarsal), there is a horizontal or near-horizontal fracture line at the metaphyseal-diaphyseal junction of the proximal fifth metatarsal, showing disruption of the local trabeculae and soft tissue swelling nearby. The fracture line is clearly located approximately 1.5 cm distal to the tuberosity of the fifth metatarsal, suggesting a typical Jones fracture. There is no obvious displacement (or only minimal displacement), with local soft tissue swelling. The cortical integrity is compromised yet still retains partial support.
MRI sequences (if performed) may show abnormal signal around the fracture line, with local bone marrow edema signals and increased soft tissue edema signals. If a CT scan is performed, it can further delineate the fracture line orientation and fragment separation. In addition, the articular surfaces of the foot appear relatively preserved; no obvious secondary injury to other metatarsals or tarsal bones is noted.
Considering the patient’s age, injury mechanism (ankle inversion sprain), imaging findings (a transverse fracture line at the metaphyseal-diaphyseal junction of the proximal fifth metatarsal), and clinical symptoms (local swelling, pain, and restricted motion), the most consistent diagnosis is:
Jones Fracture of the Fifth Metatarsal
Due to the relatively poor blood supply and stress concentration in the area of a Jones fracture, healing often takes longer, and there is a higher risk of nonunion or delayed union. For further clarification of fracture grading or to monitor healing, MRI or CT scans may be used.
Rehabilitation should follow a gradual (FITT-VP) approach, transitioning from protection and immobilization to weight-bearing and functional training. A suggested plan is as follows:
Throughout rehabilitation, monitor pain and swelling in the fifth metatarsal area. If persistent or worsening pain, redness, or swelling occurs, seek medical attention. For patients with fragile bones or other comorbidities, exercise intensity and range of motion should be carefully controlled, and nutritional support, physical therapy, or medications may be necessary to ensure safety and efficacy.
Disclaimer: This report is for reference only and cannot replace in-person medical consultation or a professional physician’s diagnosis and treatment advice. Specific treatment plans should be determined by the treating physician based on the patient’s actual condition.
Jone’s fracture
