Jones type fifth metatarsal fracture fixation in athletes: A review and current concept

Table 1 Summary of fifth metatarsal fractures

Class	Description
Zone 1	(1) Proximal tubercle avulsion; (2) Long plantar ligament leads to a lateral band of the plantar fascia or the peroneus Brevis's contraction; (3) May extend into the Cubo-metatarsal joint; and (4) Nonunion is uncommon
Zone 2 (Jones fracture)	(1) Metaphyseal-diaphyseal junction; (2) Involves the fourth and fifth metatarsal articulation; (3) Vascular watershed area; (4) Acute injury; and (5) Increased risk of nonunion
Zone 3	(1) Proximal diaphyseal fracture; (2) Distal to the fourth and fifth metatarsal articulation; (3) Stress fracture in athletes; (4) Associated with cavovarus foot deformities. or sensory neuropathies; and (5) Increased risk of nonunion

Table 2 Stewart classification of Jones fracture[16]

Stewart classification
Type 1	Extra-articular fracture between the metatarsal base and diaphysis
Type 2	Intra-articular fracture of the metatarsal base
Type 3	Avulsion fracture
Type 4	Comminuted fractures with intra-articular extension
Type 5	Partial avulsion of the metatarsal base with or without a fracture

Table 3 Postoperative rehabilitation protocol for athletes

Phases of postoperative rehabilitation for fifth metatarsal Jones fractures
Phase I	After surgery, the patient can toe-touch using weight-bearing medical aids, such as walking boots or crutches. Discontinuation of use of these aids depends on how fast an individual heals or when they can tolerate body weight. Patients are required to use bone simulators at least twice a day and perform four-way ankle-resisted exercises two times a day. These exercises include plantar flexion, dorsiflexion, inversion, and eversion[18]
Phase II	In this phase, the patient can tolerate his or her full weight and can now use a walking boot. Bone simulators and ankle exercises are limited to twice a day. Furthermore, the patient participates in training using underwater treadmills with sessions lasting approximately 20 min at a speed of between 2.5 and 3.0 mph. These parameters are adjusted per the ability of the patient to tolerate an increase. "By the end of Phase II rehabilitation, the patient should be able to do interval training for 20 min in waist-deep water. An example of an interval training protocol is as follows: 60 seconds at a 5-6 mph pace followed by a 90-s run at 7-8 mph with jet resistance at approximately 45%-60% weight bearing"[19,38]
Phase III	At this stage, walking boots are replaced with cross-training shoes with rigid or orthotic inserts. Patients are gradually introduced to single-calf exercises in combination with dorsiflexion stretching and single-leg proprioception training. Progression to full weight bearing is continued and managed using limited change of direction and position exercises. For at least two times a day, the patient is involved in bone stimulation and resistance ankle routines
Phase IV	Patients can use professional sporting shoes such as cleats or boots with rigid or orthotic inserts. Full-weight running is combined with drill works that feature a position-specific change of direction. Single-leg plyometric exercises are included. Additionally, the athlete is required to continue using "bone stimulator, resisted ankle exercises, single-leg calf raises, dorsiflexion stretching exercises, and single-leg plyometric exercises"[19,38]. This phase aims to facilitate a limited return to regular training
Phase V	The patient can now participate in full training. The bone simulator is used twice a day combined with a regular training routine until the patient is fully recovered