SLR - November 2012 - Homan Badri(2)
Reference: Polzer H., Polzer S., Mutschler W., Prall W. Acute fractures to the proximal fifth metatarsal bone: Development of classification and treatment recommendations based on the current evidence, Injury. 43:1626-32, 2012.
Scientific Literature Review
Reviewed by: Homan Badri, DPM
Residency Program: Mount Auburn Hospital, Harvard Medical School, Cambridge, MA
Podiatric Relevance:
Conservative versus surgical management is an important decision that the podiatric surgeon must make for many different conditions involving the lower extremity. Meaningful classifications of fifth metatarsal fractures could provide surgeons with guidance regarding the best treatment recommendations.
Methods:
A systematic review was performed that evaluated all randomized controlled trials or prospective cohort studies that assessed acute fracture of the proximal fifth metatarsal. The authors classified these acute fifth metatarsals into three zones based on the Lawrence and Botte classification system. Key words included “metatarsal,” “fracture,” and “injury,” in Medline, Embase, and the Cochrane library databases.
Results:
A total of six studies met the inclusion criteria. Based on these studies, zone one injuries (“tuberosity avulsion fracture”) tended to heal well with functional treatment, even with comminution, displacement or articular involvement. Zone two injuries (“Jones fractures”) also treated with functional treatment generally presented with good results. Zone three injuries (past the metatarsal-diaphyseal junction) presented with higher treatment failure when treated non-operatively.
Conclusion:
This systematic review concludes that zone one and two injuries tended to have good outcomes with conservative management consisting of immobilization and non-weightbearing for approximately six to eight weeks. However, zone three injuries would benefit from early intra-medullary screw fixation in order to reduce overall recovery time. The authors also recommend that the Lawrence and Botte classification be reduced to two zones of injury rather than three zones as the anatomic distinction between the two fracture zones remains poorly defined based on available studies and there is little data to suggest delineation of zones one and two would result in changes of management. High quality prospective randomized trials with well-defined methods and outcome measures are required before valid and reliable conclusions can be made regarding surgical versus conservative management of acute fifth metatarsal fractures.