Good morning, everyone. Thanks for the opportunity, and we'll go ahead and get started. All right, so I have no disclosures. So fifth metatarsal fracture is kind of what we're talking about here. I know we're going to focus in on Jones fractures, but the fifth metatarsal is most commonly fractured. Metatarsal fractures account, in terms of foot, 68% of fractures, and the fifth metatarsal being also very high and important. We talk about these in zones, zone one, two, and three, as kind of shown there. And the importance of that is because the blood supply to the fifth metatarsal in this watershed area is highlighted in the gray, light gray there. And when it breaks, you can lose some of that blood supply, which affects the amount that it can heal and how quickly it heals, which is why this is talked about a lot, and we want to focus in on understanding where these fractures are. I think this is a nice, another picture of kind of what those fractures are and where they are located. And the biggest thing, the red area for the Jones fracture, it's kind of right where, if it intersects with that joint there between the fourth and fifth, it's kind of where that Jones fracture, how you can define that well. And why is that important? It's because we treat them a little bit differently. So the main thing you look at is kind of the weight-bearing differences here. And although it seems really nice and easy on this picture, it's not always easy to tell which one, which zone you're in. So another way to think about it is just that, you know, if it's distal tuberosity, those are important ones and you're going to treat it a little differently. So if you're looking at that. But we frequently, I frequently get asked which zone it is and what it is. And so I thought I'd take a second here to go through a couple of examples and have each of us kind of think about which zone and what type of fracture it is, really. So now if you think of the first one here, you know, kind of seeing where this fracture is going into, it's going right into that intrametatarsal joint. So this would be a zone two injury. This one is a little bit more proximal to that. It doesn't quite go into the joint, so kind of a zone one. Here a little more distal, so zone three. Here again, it's more subtle, but it's proximal, it's kind of twisted, turned on us a little bit, but it's proximal. It's more of a zone one. Again, zone three, a little more obvious here, a little distal. This one's even more subtle, it's more proximal of a tuberosity, zone one. Looks like it might just, this looks more like a stress type reaction, you can see that beaking there a little bit, but this is potentially zone three, zone two. You can see maybe it extends a little bit into that joint, hard to tell for sure. This one, again, starts out distal, but comes in angled into that joint. This one more proximal, zone one, again, turned us and displaced slightly. This one is a zone two, zone three, you can have an argument of which one it is. This one really subtle, but more proximal, zone one. This is a more clear zone two, and then a lot of these examples are a little more obvious, but this one, I think, kind of highlights, it's not always clear, so if you're not sure, it's always good to get other's opinions, and I think you've asked around the room how you would treat this, it would be different, it's just kind of like, is this a zone one, is it slightly going to zone two, and so it's not always clear. How do these happen? So typically, acutely, with this indirect kind of inversion force, so same as like your standard ankle sprain, so it's always important to make sure you're palpating the fifth metatarsal whenever you have an ankle sprain, because there's similar mechanisms. They can also be from overuse injuries, so some of those examples are kind of stress injuries that's happened over time, so there's repetitive pivoting, weight bearing, which is obviously very common in football. The peroneus brevis attaches right to that tuberosity, and so you can have that pull off, which is a lot of those tuberosity injuries, so if you have a really eccentric force with that inversion, they're trying to protect themselves, they might pull off that tuberosity. So key ones, it tends to people who have a lot of cutting and turning, so your receivers, your corners, your running backs, overuse, defensive linemen, particularly their defensive ends are kind of angulating when they're trying to get around the corner, and tight ends. So in the sideline, what are you going to do? So make sure you're doing your Ottawa ankle rolls anytime you have someone coming in with ankle pain over to the tents, and as you can see, the fifth metatarsal is one of those key areas that you want to make sure you palpate, so you don't want to make sure you miss these, because they can present very much like an ankle sprain, so make sure you palpate that if you're having a lot of pain, if they're not able to weight bear, then it may be indicated for an x-ray, either the same day or the next day, or whenever, as quick as you can get it to make sure, before they can go back. So other things to evaluate, so not necessarily acutely, but maybe in a training room, you want to make sure you palpate the fifth metatarsal, you want to look for calluses, are they overloading that side, are they demonstrating that, and evaluate their alignment, and that's also really important, I think it's overlooked a lot, so I think the best way to look at it, if you look at image B there, coming from behind, having them stay facing away from you, you see that left foot is more neutral, and the right side is more varus alignment, which can overload that lateral side, and so if you look at the bottom images there, the kind of pictures of the red, you know, when you have a little bit of that cavus foot, you can overload that lateral side, which can predispose you to injuries on the lateral side, so important to include that as part of your workout. Evaluate their shoes or their cleats, sometimes you can see that they're wearing a lot more than that lateral side, and maybe that's a subtle indication that their alignment needs to be adjusted with some shoe adjustments. Home and block testing is described as well, and it kind of helps find where that varus is coming from, is it coming from the forefoot, from the hind foot, and the reason why this is important is because it guides what kind of orthotic you might want to do, or what kind of shoe wear you might want to modify to help prevent these, or if they've occurred, prevent them from reoccurring. Just as a different example, you might have a recess for that first ray if they have a forefoot driven, or more of a posting in the posterior part of it if it's in the hind foot, so important to include this as part of your assessment, especially if you're going to adjust their shoe wear and their cleats. So what's the initial workup if they have an acute injury you're worried about, it's radiographs. I think, as you can see, probably the oblique radiograph is probably going to be a key one. It's going to be the one that gives you the most profile of that fifth metatarsal and allow you to really assess that fracture lines. But in these chronic scenarios where they're having pain along that fifth metatarsal, maybe not an acute event that they can remember, sometimes the x-rays are going to be negative, and that's where an MRI might be useful in terms of evaluating for a stress injury to that area to dictate your treatment. So what is treatment? Conservative management is an option, and it kind of varies based on your athletic level, the timing of the season, what are the patient and family goals, and conversations with them. But if you're going to do conservative, it's a boot, non-weight-bearing for up to six weeks. You want to get regular radiographs to make sure that this is healing. You can make sure you want to modify their shoe wear if you're going to get them back. What are the risks of non-operative treatment? So delayed union 66%, non-union 28%, refracture 33%. So pretty high, which is why we worry about these in terms of make sure we're defining which ones are joint fractures and which ones need surgery. So surgical treatment, high demand, high level athletes, we typically will recommend surgery. Surgery has relatively low risk. It's often a single screw, and so it's low risk, and potentially help them get back sooner. If you're looking for objective numbers, these are some that are in the literature, greater than four millimeters of displacement, more of angulation, which is where your lateral x-ray will kind of come into play in terms of plantar angulation. By that being said, the majority of young athletes will recommend surgery. And what is that surgery? So if you look at NFL players, 2009, 2015, 72 players came to the combine with Jones fractures history. All of them had intramedullary screws. So I think predominantly intramedullary screws are still the primary treatment of choice for these type of injuries. And I think, like I said, it's minimal surgery in terms of incision and mobility to the site and relatively effective. Plantar plating, as shown in the image on the right there, is an option. And it's described and has some potential advantages in terms of the forces, but mostly considered in revision settings. So where's some surgical pearls if you're going to go to surgery? They'll talk about the high inside. So the top left image, you're a little bit high. And then on the top right, you're kind of on the inside, making sure you're down that canal. And so getting that start point is critical in making sure you're, because that kind of dictates the whole procedure. And once you get that start site, the rest of it becomes pretty easy. When you use the largest and longest screw that you can, I think the most commonly that I see that they come back for failures is that the screw is too small. So make sure, longest and biggest you can get, typically a 4-5 to a 6-5 solid screw, making sure that you're a good fit. You do want to make sure you're not too, too long, because if you start getting into a natural curvature, you can increase the risk of a non-union. So you just want to make sure you optimize that length and width. Other things you can do to augment this. So we use this in our practice as well for these high-level athletes, bone marrow aspirate concentrate, demarolized bone matrix, bone simulators, and obviously supplements as well. And in this series, 100% return to play on the average of nine and a half weeks and relatively low re-operation rates. Plantar plating is an option as well. You do get some irritation potentially, and this is typically reserved for those difficult revision cases, especially if they've already used a really big screw and you may not necessarily get great purchase for a secondary screw. General rehab. So for the general population versus the high-level athlete in season, you know, you can do a little bit more to try to get those people back potentially for the same season. So you can see, we'll focus on high-level athletes here, so non-weight bearing for two weeks in a cam boot, start on that bone simulator and those supplements, get them moving at two weeks, getting ready to go radiographs. And once they have some bridging cows, you start getting them moving and progressing them. Okay. That can be as quick as four weeks. And sometimes we get players back as early as six weeks, if you're really in season high level. If you're, you know, more of a recreational youth athlete, you're going to be a little more cautious and they have a little more luxury of time. You're a little more cautious about six weeks before you really get them moving again. Complications. So refracture rate, you know, can be as high as a 30% of the high-level athlete's prominence. So cuboid impingement is a real thing. You want to make sure that you're really countersink that screw. As you can see this demonstrated here, if that screw has a little problem, they may bump right into that cuboid and cause some persistent pain. And then NFL players in a series, in a couple of papers and series that they have, refracture rates are relatively low, 7.5 to 12%. Maybe it's the patients themselves being high-level athletes and less symptomatic. Maybe it's the other augments that we tend to use. So again, the important thing is when you're getting them back, make sure you're assessing their alignment and adjusting their shoe wear appropriately and help protect that repair and prevent refractures. When they return to play, how do they do? So there's some mixed data. Some data shows that there's no difference between them in terms of number of starts and number of games they play. There's some others that show they might have a lower percentage of playing and snaps that they partake in and lower fantasy scores. So there's an interesting study by Spang et al. looking at CTs post-operatively and assessing those patients that do well or not well, and they found that the ones that don't have the complete healing tend to do worse and have less participation. So that may be obvious and it may be a reason to get CT scans and try to be cautious when you go back. But it's definitely in-season and high-level athletes that can be difficult to manage sometimes. So summary, joint fractures are common. Assess their alignment, check their focalis, check their shoe wear, and then make sure you make the appropriate modifications. Operator treatment for most athletes. That's going to be an instrument or a screw, using the largest possible that you can to fit in there. Revisions, most commonly is the largest screw, considering a plantar plating. High-level athletes, there's different augments you can use to try to stimulate and get them back sooner. Return to play, approximately eight weeks or 12 weeks. And then if possible, try to wait until they're fully healed. And then again, those modifications. Those are my references. Thanks. Thank you.

fifth metatarsal fractures

Jones fractures

fracture zones

fracture identification

treatment options