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Study Supports Changes to Treatment of Acute Proximal Fifth Metatarsal Fractures

Key findings

  • This literature review identified 32 papers (covering 1,239 fifth metatarsal fractures) that evaluated the outcome of both conservative and surgical treatment of different types of acute proximal fifth metatarsal fractures (zones 1-3).
  • For acute tuberosity (zone 1) avulsion fractures, union rates were found to be over 90% and essentially independent of treatment choice and degree of fracture displacement
  • For acute Jones (zone 2) fractures, both union rate (96.3% vs 77.4%) and time to union (9.4 weeks vs 11 weeks) were substantially better following surgical as compared to non-operative treatment
  • For acute zone 2 fractures, surgical intervention also resulted in lower rates of refracture (2.1% vs 2.4%)
  • Notably, only 10 proximal diaphyseal (zone 3) fractures were found to be reported in the literature

When deciding between conservative or surgical treatment of acute proximal fifth metatarsal fractures, the principal considerations remain anatomic location and degree of fracture displacement. These fractures have been subdivided into three zones (as published in Foot and Ankle International):

  • Tuberosity avulsion fractures (zone 1)
  • Jones fractures (zone 2)
  • Proximal diaphyseal fractures (zone 3)

By reviewing more than 100 years of medical literature, G. M. M. J. Kerkhofs, MD, PhD, department chair at the University of Amsterdam, and Christopher W. DiGiovanni, MD, chief of the Foot and Ankle Center at Massachusetts General Hospital, and colleagues found support for treating all zone 1 fractures conservatively and treating all zone 2 fractures surgically. They reported their findings in Knee Surgery, Sports Traumatology, Arthroscopy.

Study Design

Using four online databases, the researchers retrieved papers from the earliest record, June 1902, until January 2019 that reported conservative and/or surgical treatment of acute proximal fifth metatarsal fractures. Papers could be written in English, French, German or Dutch.

32 articles (1,239 fractures) were included in the final analysis: one randomized controlled trial, three prospective comparative studies, four prospective case series, five retrospective comparative studies and 19 retrospective case series.

Tuberosity Avulsion Fractures

711 zone 1 fractures were included from 19 articles, of which 75% were managed conservatively (50% nondisplaced, 15% displaced, 35% unrecorded). Of the 25% managed surgically, 93% were displaced and 7% were nondisplaced.

In pooled results, union rates were independent of both treatment choice and degree of displacement.

Jones Fractures

518 zone 2 fractures were included from 21 articles, of which 61% were treated conservatively and 39% were treated surgically. In pooled results, both union rates and time to union were better following surgical treatment.

Proximal Diaphyseal Fractures

10 zone 3 fractures were identified in a single case series. All patients were treated conservatively and no bone healing outcomes were reported.


  • Nondisplaced acute zone 1 fractures: Treat conservatively
  • Displaced acute zone 1 fractures: Conservative and surgical treatment demonstrated comparable union rates, although ideal management remains unclear due to the small number of cases identified
  • Acute zone 2 fractures: The literature supports surgery as the treatment of choice regardless of the degree of fracture displacement, although a lack of high-level evidence to support these findings still suggests that conservative treatment is justifiable. Surgeons should consider patient age, body mass index, employment status, patient expectations and preference
  • Acute zone 3 fractures: No recommendation can be made about optimal treatment because these fractures are rarely reported

Learn more about the Foot and Ankle Service at Mass General

Refer a patient to the Department of Orthopaedics at Mass General

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In this video, Christopher W. DiGiovanni, MD, chief of the Foot and Ankle Service at Massachusetts General Hospital, explains how researchers are working to increase the chance and speed of healing from fifth metatarsal injuries.