Jones Fracture ORIF and recovery opinions

[CBOW078]

35yo Male, active/healthy, fractured while playing soccer

29SEP - Fracture
04OCT - ORIF Performed
07NOV - Post op follow up

Opinions and thoughts on recovery?

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[AttackNME]

How's his pain? Is he WB or PWB yet?

 

[CBOW078]

NWB during recovery for four weeks. Patient claimed zero pain during follow up. He claims that he walked on his heel and swam for two weeks. Recommended additional 4 weeks of NWB.

 

[Creflo]

Agree with 4 more weeks nwb, stress importance to patient. Run vitamin D, pth, 24 hour urine calcium. Get the vitamin D up above 40 or 50. Don't assume that young healthy guy has high vitamin D level. CT scan now and later to assess healing progress. Bone stim can't hurt.

 

[dtrack22]

I get that its a little distal but I think it's fair to call this a Jones fx. Before I give my two cents I'd like some of the other folks to answer some questions I have. Mostly to get others' thoughts about this injury and when/why they fix it in general.

-What is the non union rate of a fracture like this?
-In your mind, what is the point of throwing a screw across these fractures?
-Do you believe the screw is providing significant or stable compression across the fracture site?
-What force caused the fracture that you are trying to oppose?
-How often is gap widening of a fracture seen at 4-6 weeks in a fracture that is healing without complications?
-If you threw this screw and then have this person NWB for 8 weeks, does that change your mind about fixing it in the first place?

 

[ExperiencedDPM]

Agreed with prior comments. Why wasn’t this patient simply immobilized prior to intervening surgically. I’ve performed many of these ORIFs percutaneously, but with the films I see, this patient wouldn’t have gone to the OR until immobilization was first attempted.

 

[I post PRN]

I get that its a little distal but I think it's fair to call this a Jones fx. Before I give my two cents I'd like some of the other folks to answer some questions I have. Mostly to get others' thoughts about this injury and when/why they fix it in general.

-What is the non union rate of a fracture like this?
-In your mind, what is the point of throwing a screw across these fractures?
-Do you believe the screw is providing significant or stable compression across the fracture site?
-What force caused the fracture that you are trying to oppose?
-How often is gap widening of a fracture seen at 4-6 weeks in a fracture that is healing without complications?
-If you threw this screw and then have this person NWB for 8 weeks, does that change your mind about fixing it in the first place?

I agree, if you’re going to fix it, weight bear earlier. I’ll WBAT in a boot 4 weeks after fixing them. I fix just about every one of these too.

 

[janV88]

If pain and swelling is down that means it’s healing. Resorption 2-4 weeks after fracture is first signs of healing. Wbat in boot

 

[msuDPM]

Oof. Agree with some of previous comments. Not a Jones fx, non displaced. Personally I would put this patient in a low tide CAM, WBAT, f/u in 3 weeks for serial radiographs.

When I do fix these, typically 4 weeks nwb (to protect against screw breakage) and then weight bear in boot for 4-6 weeks. This is also typically after trial of conservative care with the exception of current athletes and gapping over 3-4 mm.

I'e only been in practice a little over a year and certainly don't have this whole thing mastered yet, but I've probably seen 30-40 jones/large avulsions type 5th met fx' s. I'e fixed 2 and put 2 into a bone stim before healing and they've all done pretty well.

 

[air bud]

Dtrack asks some great thoughtful questions.

I think calling this a Jones fracture is fine.

I don't see any reason to have surgically fixed this, at least right off the bat.

 

[air bud]

Agree with 4 more weeks nwb, stress importance to patient. Run vitamin D, pth, 24 hour urine calcium. Get the vitamin D up above 40 or 50. Don't assume that young healthy guy has high vitamin D level. CT scan now and later to assess healing progress. Bone stim can't hurt.

I think this is a lot of overkill. This is just costing the patient and the health system unnecessary money. I understand CYA. I put basically all fractures of any 5th met and all stress FX on 50k units VD3 a week for 6 weeks. But if clinically and radiographically healing those test are unnecessary

 

[AttackNME]

SAGE Journals: Your gateway to world-class journal research

This is why op fixed it. Even in stress fractures with no complete break, it is indicated for athletes with a desire for quicker return to activity

 

[hematosis]

I think this is a lot of overkill. This is just costing the patient and the health system unnecessary money. I understand CYA. I put basically all fractures of any 5th met and all stress FX on 50k units VD3 a week for 6 weeks. But if clinically and radiographically healing those test are unnecessary

Were not endocrinologist. its prob ok to order vit 3 and a CMP to check calcium levels but you prob shouldnt go ordering test you can't treat because now your responsible for it. PTH is overkill, ionized calcium is overkill and you shouldn't order that unless the serum calcium is off and your vit d is off.

You also shouldn't treat patients with that high dose of vit D. Thats for confirmed cases of vit D deficiency which primary care or endo should be treating. What if your patient has primary hyperparathyroidism and their vitamin d is low to protect them from absorbing excess calcium? not to mention other renal issues and things that can occur.


CT scan now and later? where do you practice at man? beverly hills?

My indications for fixing these type of fx are:
athletes
nonunions
refractures
cavovarus and lateral overload

 

[CBOW078]

I appreciate everyone's input here.

AttackNME is correct. This is a very active patient who wishes to return to sports. While that didn't make my decision to ORIF, the concerns were; poor blood flow to the Fx area, possible non-union and re-Fx; especially due to his level of activity.

The screw got such a good bite for compression, that the Fx is almost non-existent post op. I was dissapointed to see the Fx almost seems worse. Wondering if the patient's heel walking for 2wks and driving have cause enough micro-movement for the current X-ray outcomes. Patient is in a camboot but NWB.

 

[dtrack22]

Since nobody took the bait, I'll give some of my thoughts. Saying you wouldn't throw a screw in this but would in a true Jones fx is illogical. The only reason to put a IM screw in this or in a true Jones is for quicker return to weight bearing/activity, or you're treating an athlete that is going back to a very high level of competition (even if it doesn't need to be quickly). I'll give you certain structural abnormalities that increase risk of 5th met fx as well (cavus, met adductus, etc.). An IM screw is not providing significant compression across the fracture site which is fine because it isn't primarily a tensile force that you are trying to oppose. You are essentially beaming the 5th met to impart stability so that the patient can ambulate while this fracture takes its good sweet time to heal. If I'm putting a screw in this or a jones and having them NWB for 8 weeks, I would re-evaluate my reasoning for throwing it in the first place.

My threshold for throwing a screw in a true jones and this fracture is very low. I'm putting one in this guy, and I don't see any reason to believe this patient isn't healing normally. I believe Jones fx non unions are overblown, and I believe this guy would heal...with at least 8-12 weeks of strict NWB. However, I don't believe any patient I see will actually be NWB for 8-12 weeks (let alone 4). Compliance is a big issue in most of what we treat IMO. I don't think the patient would like that. I'm much more concerned with quicker return to function and return to a high activity level with a lower risk of re-injury. My decision to fix 5th mets has everything to do with that thought process and less to do with non union risks.

Why do so many people seem concerned with gap widening at 4 weeks? Up to 70% of fractures (that go on to on-time union) will demonstrate this at 4-6 weeks. Why the concern at this point in an asymptomatic patient?

 

[AttackNME]

I appreciate everyone's input here.

AttackNME is correct. This is a very active patient who wishes to return to sports. While that didn't make my decision to ORIF, the concerns were; poor blood flow to the Fx area, possible non-union and re-Fx; especially due to his level of activity.

The screw got such a good bite for compression, that the Fx is almost non-existent post op. I was dissapointed to see the Fx almost seems worse. Wondering if the patient's heel walking for 2wks and driving have cause enough micro-movement for the current X-ray outcomes. Patient is in a camboot but NWB.

If it isn’t very tender on palpation I would think of that more as bony resorption and normal bone healing. The fixation seems appropriate and isn’t loosening. I’d continue what ur doing, treat the pt not the X-rays

 

[prentice25]

In my experience with 5th met fx's, the patients tend to improve much quicker clinically than they do radiographically...

 

[CBOW078]

However, I don't believe any patient I see will actually be NWB for 8-12 weeks (let alone 4). Compliance is a big issue in most of what we treat IMO. I don't think the patient would like that. I'm much more concerned with quicker return to function and return to a high activity level with a lower risk of re-injury.

I would be naive to think this patient was strict NWB during recovery. My gut tells me that once we removed his dressings/stitches, he started his "own" WBAT, and did not disclose during our follow up. I was concerned with his return to activity and the prevention of a future fx due to his high level of activity; ORIF.

If it isn’t very tender on palpation I would think of that more as bony resorption and normal bone healing. The fixation seems appropriate and isn’t loosening. I’d continue what ur doing, treat the pt not the X-rays

Patient showed no signs of pain or discomfort during; palpation, rotation against 5th met, and had full range of motion in his ankle.

 

[AttackNME]

I would be naive to think this patient was strict NWB during recovery. My gut tells me that once we removed his dressings/stitches, he started his "own" WBAT, and did not disclose during our follow up. I was concerned with his return to activity and the prevention of a future fx due to his high level of activity; ORIF.


Patient showed no signs of pain or discomfort during; palpation, rotation against 5th met, and had full range of motion in his ankle.

Nice, yea I think he's doing fine, don't worry about the x-rays, at least for now hoping the next few xrays start filling in

 

[HaimFeldman]

First...this isn't a jones fracture. Second...Why did you even do surgery on this?

Also, did you clear the patient for WBAT in a regular shoe after 4 weeks? Seems a little aggressive but everyone has a different protocol in terms of when to begin weight bearing.

For isolated met fractures I typically keep patients non-weight bearing 4 weeks and then transition to WBAT in CAM boot if XRs demonstrate good radiographic signs of healing. One could argue a weight bearing cast as well.

If patient continues to have pain and you do not see radiographic signs of healing at that new area of diastasis my threshold for getting a bone stimulator is very low.

Before I saw the xrays, i assumed based on your comments this guy had attempted fixing an avulsion fracture.

It isn't a Jones fracture because it's a few mm distal. So what? Based on the Dameron-Lawrence-Bofte classifcation, or "Zone Classification," which is a far more useful guide than that stupid Stewart classification shoved down our throats in school, these types of fractures are treated exactly the same way as Jones fractures.

5th Metatarsal Base Fracture - Foot & Ankle - Orthobullets.com

CBOW078 did absolutely nothing wrong here.

There's nothing wrong with the decision to non-op the patient either, by the way. It boils down to the surgeon's discussion with the patient, the surgeon's comfort level, and the patient's choice. It was an active athlete, surgery gives him a chance to get back quicker but does come with risks. I don't know this CBO fellow, but I'm sure this discussion was had with the patient prior to surgery.

 

[I post PRN]

Since nobody took the bait, I'll give some of my thoughts. Saying you wouldn't throw a screw in this but would in a true Jones fx is illogical. The only reason to put a IM screw in this or in a true Jones is for quicker return to weight bearing/activity, or you're treating an athlete that is going back to a very high level of competition (even if it doesn't need to be quickly). I'll give you certain structural abnormalities that increase risk of 5th met fx as well (cavus, met adductus, etc.). An IM screw is not providing significant compression across the fracture site which is fine because it isn't primarily a tensile force that you are trying to oppose. You are essentially beaming the 5th met to impart stability so that the patient can ambulate while this fracture takes its good sweet time to heal. If I'm putting a screw in this or a jones and having them NWB for 8 weeks, I would re-evaluate my reasoning for throwing it in the first place.

My threshold for throwing a screw in a true jones and this fracture is very low. I'm putting one in this guy, and I don't see any reason to believe this patient isn't healing normally. I believe Jones fx non unions are overblown, and I believe this guy would heal...with at least 8-12 weeks of strict NWB. However, I don't believe any patient I see will actually be NWB for 8-12 weeks (let alone 4). Compliance is a big issue in most of what we treat IMO. I don't think the patient would like that. I'm much more concerned with quicker return to function and return to a high activity level with a lower risk of re-injury. My decision to fix 5th mets has everything to do with that thought process and less to do with non union risks.

Why do so many people seem concerned with gap widening at 4 weeks? Up to 70% of fractures (that go on to on-time union) will demonstrate this at 4-6 weeks. Why the concern at this point in an asymptomatic patient?

Nailed it on the head. Fix=faster recovery, even if they are a 50 year old fatty.

 

[I post PRN]

Before I saw the xrays, i assumed based on your comments this guy had attempted fixing an avulsion fracture.

It isn't a Jones fracture because it's a few mm distal. So what? Based on the Dameron-Lawrence-Bofte classifcation, or "Zone Classification," which is a far more useful guide than that stupid Stewart classification shoved down our throats in school, these types of fractures are treated exactly the same way as Jones fractures.

5th Metatarsal Base Fracture - Foot & Ankle - Orthobullets.com

CBOW078 did absolutely nothing wrong here.

There's nothing wrong with the decision to non-op the patient either, by the way. It boils down to the surgeon's discussion with the patient, the surgeon's comfort level, and the patient's choice. It was an active athlete, surgery gives him a chance to get back quicker but does come with risks. I don't know this CBO fellow, but I'm sure this discussion was had with the patient prior to surgery.

Agreed. I think the only way I would non op this patient is if they were paraplegic. This is a 9 minute surgery if you don’t suck. The benefits greatly outweigh the risks of surgery.