- Email: [email protected]
Functional outcome of fifth metatarsal fractures
G Model
JINJ-5779; No. of Pages 4 Injury, Int. J. Care Injured xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Functional outcome of fifth metatarsal fractures E. Bigsby a,*, R. Halliday a, R.G. Middleton a, R. Case b, W. Harries a a b
Trauma and Orthopaedic Department, Frenchay Hospital, Frenchay Park Road, Bristol BS16 1LE, UK Trauma and Orthopaedic Department, Weston General Hospital, Grange Road, Uphill BS23 4TQ, UK
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 8 June 2014
Introduction: Fifth metatarsal fractures are common and the outcome has been reported; however, prospective studies reporting the functional outcome using validated questionnaires are lacking in the literature. The aims of this study were to determine whether fifth metatarsal fractures remain symptomatic in the medium term and whether the fracture type influences outcome. Methods: Over the course of a year, 117 patients (62 avulsion fractures, 26 Jones fractures, 29 shaft fractures) were followed up (1 month, 4 months, 12 months), with functional outcome assessed using the Foot Function Index (FFI)- and Short Form 36 (SF36)-validated questionnaires. Results: The FFI reduced (function improved) over the course of the year from 22.0 (8.4–38.5) at 1 month to 0.0 (0.0–4.2) at 4 months, to 0.0 (0.0–1.3) at 1 year. There was no significant difference in the FFI scores with regard to gender or fracture type. Pain scores were also observed to decline over the year, with no significant differences between fracture types. However, while the severity of pain was low, the numbers of people reporting pain were relatively high. At 1 month, >80% of patients reported ongoing pain (83% avulsion, 88% Jones and 83% shaft), reducing to 38% at 4 months and 28% at 1 year. At final follow-up, 25% with an avulsion fracture, 28% with a Jones fracture and 33% with a shaft fracture reported pain. Conclusions: While 25–33% of patients continue to experience pain at 1 year, <10% experience any limitation of their activities. At the final follow-up at 1 year, there were no significant differences in functional outcome by fracture type, gender or patient age. Patients should be advised about the likelihood of ongoing low-level symptoms, even after a year from injury in this previously presumed innocuous injury. ß 2014 Published by Elsevier Ltd.
Keywords: Metatarsal Fracture Functional outcome Jones Avulsion Shaft
Introduction Fifth metatarsal fractures comprise >50% of foot fractures [1]. They are generally treated conservatively, although in athletes operative fixation has been recommended [2–5]. Fifth metatarsal fractures can be classified into avulsion, Jones [6], and shaft types. The majority of existing studies examining the outcome have been retrospective and focused on rates of non-union and re-fracture [7–10], with limited information on the functional outcome of patients. While many authors [3,11–13] have considered avulsiontype fractures to be unproblematic, others have reported ongoing symptoms [14,15]. Jones-type fractures have more widely been considered problematic [2,15–19], making them more often treated with operative fixation than other fifth metatarsal fracture types. The aims of this study were to determine whether fifth
* Corresponding author. E-mail address: [email protected] (E. Bigsby).
metatarsal fractures remain symptomatic in the medium term using a validated patient-reported functional outcome measure and to investigate whether the outcome is influenced by the fracture type. Material and methods All adults presenting to our level 1 trauma centre in the UK between 2009 and 2010 with an isolated fifth metatarsal fracture were invited to participate in the study. Patients were excluded if the injury was >2 weeks old, were unable to provide valid consent, had pre-existing foot pathology, had other injuries (including soft tissue injuries) to the same foot/ankle or if primary fixation was performed. The patients were treated according to the treating surgeon’s preferred practice and included plaster, Tubigrip bandage, and advice on supportive footwear. Patients were asked to complete a questionnaire at 1 month, 4 months and 1 year after injury. The questionnaires were given to the patient during their clinic
http://dx.doi.org/10.1016/j.injury.2014.06.010 0020–1383/ß 2014 Published by Elsevier Ltd.
Please cite this article in press as: Bigsby E, et al. Functional outcome of fifth metatarsal fractures. Injury (2014), http://dx.doi.org/ 10.1016/j.injury.2014.06.010
G Model
JINJ-5779; No. of Pages 4 E. Bigsby et al. / Injury, Int. J. Care Injured xxx (2014) xxx–xxx
2
appointment or posted to them. The validated questionnaires comprised the Foot Function Index (FFI) [20] and the Short Form 36 version 2 (SF36v2) [21]. The FFI comprises 23 questions where the patient places a mark on a line, which equates to a 0–9 scale. The FFI is subdivided into three sections: pain, disability and activity limitation. Each section is scored from 0 to 100 and these three sections can then be averaged to give the FFI (a higher score reflects a poorer function). The SF36v2 comprises 36 questions about general health and well-being and provides a summary of the mental component score (MCS) and the physical component score (PCS) on a scale of 0–100, with 50 being the norm, and higher scores reflecting a better selfperceived health. The fractures were classified according to anatomical position following that described by Lawrence and Botte [22] into (1) avulsion/tuberosity-type fracture, (2) Jones-type fracture (a transverse fracture at the junction of the proximal metaphyseal–diaphyseal junction without distal extension beyond the fourth to fifth intermetatarsal articulation) and (3) shaft-type fractures (fractures distal to the Jones type). The initial radiographs were evaluated by two of the authors and consensus reached on any differences. The study was endorsed by the local research ethics committee. Statistical analyses comprised descriptive statistics with medians and interquartile ranges given unless otherwise stated and was performed with Statistical Package for the Social Sciences (SPSS) version 19.0 (IBM Corporation, New York, NY, USA). The Shapiro– Wilk test was used to test for normality. Comparison between groups was carried out using the Mann–Whitney, Kruskal–Wallis and chi-squared tests. A p value of <0.05 was considered statistically significant. Results General A total of 123 patients entered the study, although six patients subsequently withdrew. One patient died during the study of unrelated causes, before completion of the 12-month follow-up; however, their data have been included and calculation of the return rate at final follow-up reflects the missing patient episode. Of the 117 remaining patients, 62 were avulsion fractures, 26 Jones fractures and 29 shaft fractures. The return rates with time post injury were as follows: 86% at 31 days, 71% at 119 days and 70% at 383 days. The median age of patients at injury was 48 years (29.9–64.0) for all fracture types (43 years for avulsion, 45 years for Jones and 54 years for shaft), with no significant difference between groups. The gender balance of patients was 1:1.58 (male:female) in the avulsion group, 1:0.63 (male:female) in the Jones group and 1:3.83 (male:female) in the shaft group. There were significantly (p = 0.04) more male patients in the Jones fracture group compared to the others.
General health The median PCS for all fracture types combined at 1 month was 36.5 (31.6–43.6) and the MCS was 53.2 (42.2–59.4). At 1 year, the PCS was 53.0 (45.9–56.0) and the MCS 57.2 (52.7–59.1). There was no significant difference between the individual fracture types at 1 month, 4 months or 1 year (Table 1). Overall foot function The median FFI of all metatarsal fracture types combined (Table 2) reduced from 22.0 (8.4–38.5) at 1 month to 0.0 (0.0–4.2) at 4 months, to 0.0 (0.0–1.3) at 1 year. There was no significant difference in the FFI scores depending on fracture type at any of the follow-up intervals. There was also no significant difference in the FFI scores with regard to gender. In order to investigate whether there were differences in the FFI in different age groups, we compared those aged 45 years and less to those over 45 years. There were no significant differences between the FFI scores at any of the time intervals. Pain The pain scores (scale of 0–100), regardless of fracture type, reduced from a median of 12.8 (2.5–30.5) at 1 month to 0.0 (0.0– 4.9) at 4 months and 0.0 (0.0–1.6) at 1 year. Similar patterns of reduction in pain scores were observed for individual fracture types with no significant differences between them at any of the time points investigated. While median pain scores are low, there are a substantial number of individuals reporting pain (Table 3). At 1 month, >80% of patients reported ongoing pain (83% avulsion, 88% Jones and 83% shaft), reducing to 38% at 4 months and 28% at 1 year. At final follow-up, 25% with an avulsion fracture, 28% with a Jones fracture and 33% with a shaft fracture reported pain. There were no significant differences in the proportions of patients reporting pain depending on the fracture type at any of the followup times. There were also no significant differences in the age of patients at 1 month or 1 year who reported pain, although there was a significant difference (p = 0.029) at 4 months follow-up, with those reporting pain being younger. There were no significant differences in the proportion of patients reporting pain compared to those in no pain in terms of gender, at all follow-up times. There was also no significant difference in pain severity at final follow-up in terms of fracture type, with all having a median score of 2 on a 0–9 scale with 9 being the worst. Functional limitation of activities In terms of limitation of activities, the majority (74%) reported some limitations 1 month after injury (Table 4), while even at 4 months post injury 24% of patients remained limited in their activities as a result of their injury. This was most pronounced in the shaft group where 39% had limitations of activities compared
Table 1 Median physical component scores (PCS) and mental component scores (MCS) of the SF36, with interquartile ranges in parentheses. The p values given represent Kruskal– Wallis testing between fracture types. Fracture type
All Avulsion Jones Shaft p value
1 month
4 months
1 year
PCS
MCS
PCS
MCS
PCS
MCS
36.5 (31.6–43.6) 35.2 (31.1–43.2) 38.1 (32.6–43.4) 36.3 (31.5–43.0) 0.917
53.2 (42.2–59.4) 51.7 (42.9–59.4) 56.0 (41.8–62.0) 49.5 (41.6–57.6) 0.295
49.9 (41.6–55.8) 51.4 (43.8–56.2) 48.9 (41.3–53.8) 48.0 (38.2–56.0) 0.545
56.9 (52.9–59.4) 56.2 (53.1–59.5) 58.5 (56.3–60.0) 55.9 (51.3–58.8) 0.171
53.0 (45.9–56.0) 53.3 (46.1–56.4) 50.2 (43.8–55.7) 52.4 (47.2–55.4) 0.884
57.2 (52.7–59.1) 57.2 (52.8–58.5) 57.8 (56.1–58.9) 56.3 (50.4–60.0) 0.577
Please cite this article in press as: Bigsby E, et al. Functional outcome of fifth metatarsal fractures. Injury (2014), http://dx.doi.org/ 10.1016/j.injury.2014.06.010
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JINJ-5779; No. of Pages 4 E. Bigsby et al. / Injury, Int. J. Care Injured xxx (2014) xxx–xxx Table 2 Median Foot Function Index scores, with interquartile range in parentheses.
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Table 4 Numbers of patients with limitation of activities, with percentages in parentheses.
Fracture type
1 month
4 months
1 year
Fracture type
1 month
4 months
1 year
All Avulsion Jones Shaft
22.0 20.6 22.3 23.7
0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00
All Avulsion Jones Shaft
75 39 17 19
20 9 2 9
6 4 0 2
(8.4–38.5) (8.1–34.1) (8.3–36.5) (8.6–48.6)
(0.00–4.2) (0.00–4.1) (0.00–1.5) (0.00–6.5)
(0.00–1.3) (0.00–1.6) (0.00–1.0) (0.00–0.5)
to only 21% for avulsion and 11% for Jones fractures. However, this difference was not significant (p = 0.075). At final follow-up, 9% of avulsion and 10% of shaft fracture patients had restricted their activities as a consequence of their injuries, while none of the patients with Jones fractures did. There were no significant differences in age or gender between those patients with limitation of ongoing activity and those without limitation. Discussion The purpose of our study was to report the functional outcome of fifth metatarsal fractures using a validated scoring system. While previous studies have provided an assessment of function, many used questionnaires that have not been validated [7,12,23], and as such their results have to be interpreted with caution. Wiener et al. [12] used their own modified foot score, while Grey et al. [23] used their own modification to The American Orthopaedic Foot and Ankle Society (AOFAS) midfoot score, and Chuckpaiwong et al. [7] reported more generally on return to activities. In the present study, an improvement in FFI scores were noted over the course of a year, with the median score dropping to 0 at 4 months and remaining at 0 at 1 year. However, while the median FFI was 0, there were considerable numbers of patients who remained symptomatic. In terms of pain, at final 1-year follow-up, 25% of avulsion, 28% of Jones and 33% of shaft fracture patients remained symptomatic, with a pain score of 2.0 (scale of 0–9). This is similar to Vorlat et al. [15] who reported a mean pain score of 2.1 (scale of 0– 10) at mean follow-up of 490 days. However, while they reported that patients older than 45 years experienced more problems with function than younger patients, we found no differences at any of the time intervals between the two age groups. Egol et al. [14], in a study of 49 patients with avulsion-type fractures, reported that 31% still required analgesia at 6 weeks and 20% by 12 weeks. Pain scores were only reported at the final follow-up of 1 year, with 10% of patients falling into the moderate-to-severe pain group with a mean score of 0.73 (on a 10-point scale). In terms of functional limitations, in the present study at final follow-up, 9% of the avulsion group and 10% of the shaft group had restricted their activities as a consequence of their injuries, while none of the patients in the Jones group did. It is difficult to directly compare the functional limitation from other studies due to the limited detail of previously published reports. However, in a study by Wiener et al. [12], where 89 patients with avulsion fractures were investigated, 20 (22%) of the 89 patients had ongoing symptoms at 12 weeks, which compares to 35% at 4 months in the current study. A retrospective study by Vorlat et al. [15] comprising
(74%) (74%) (68%) (79%)
(24%) (21%) (11%) (39%)
(7%) (9%) (0%) (10%)
38 patients (32 avulsion and 6 Jones types) reported a mean ankle score of 82.4 (range: 20–100) at a mean follow-up of 490 days (range: 102–940), with 10 of the patients (26%) reporting problems wearing shoes. Similarly, a prospective study of tuberosity fractures by Grey et al. [23] using their own modification of an already modified version of the AOFAS midfoot score showed a score of 90 (scale of 0–100, with 100 being the best) at 12 weeks. Compared to a study by Egol et al. [14] of 49 patients (50 fractures) with avulsion type using the validated Short Musculoskeletal Function Assessment (SMFA) questionnaire, this study reported an SMFA score of 2.7 at 1 year (scale 0–51, with 0 being the best function). These studies are comparable to our study, where the average FFI (on a scale of 0–100, with 0 being the best) was 22 at 1 month, and 0 at 4 months and 1 year. The limitations of this study may be considered to be the lack of radiological follow-up; however, it has been documented that the interpretation of radiological union on plain radiographs is poor [24–26] and it was the authors’ view that the functional outcome is of more relevance to the patient. We do accept that treatment both within a fracture group and between fracture groups was not standardised; however, this is often the reality of the way these injuries are managed, with both patients and treating surgeons preferring one treatment modality over another. Finally, while this study is one of the largest in the literature, there are relatively small numbers for the Jones and shaft fracture types. Further study in this area should focus on the longer-term outcome to determine if and when ongoing pain resolves. In addition, while the current study was unable to identify factors associated with a poorer outcome, a larger study may be able to determine these and hence lead to the possibility of treating the problematic group more aggressively. Conclusions This study of 117 patients is the largest prospective study of the functional outcome of conservatively managed fifth metatarsal fractures using a validated scoring system. While the majority of patients see a steady improvement in their pain and function following their injury, 25–33% of patients continue to experience pain at 1 year, although <10% experience any limitation of their activities; however, patients should be advised about this at the time of injury. At the final follow-up at 1 year, there were no significant differences in functional outcome by fracture type, gender or patient age. Conflict of interest Financial assistance was provided by the North Bristol Trust charitable funds and the British Orthopaedic Foot and Ankle Society.
Table 3 Numbers of patients with ongoing pain, with percentages in parentheses. Fracture type
1 month
4 months
1 year
All Avulsion Jones Shaft
86 44 22 20
32 15 8 9
23 11 5 7
Acknowledgements (84%) (83%) (88%) (83%)
(38%) (35%) (44%) (39%)
(28%) (25%) (28%) (33%)
We would like to thank the North Bristol Trust charitable funds and the British Orthopaedic Foot and Ankle Society for grants that made this project possible.
Please cite this article in press as: Bigsby E, et al. Functional outcome of fifth metatarsal fractures. Injury (2014), http://dx.doi.org/ 10.1016/j.injury.2014.06.010
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JINJ-5779; No. of Pages 4 E. Bigsby et al. / Injury, Int. J. Care Injured xxx (2014) xxx–xxx
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References [1] Hasselman CT, Vogt MT, Stone KL, Cauley JA, Conti SF. Foot and ankle fractures in elderly white women: incidence and risk factors. J Bone Joint Surg Am 2003;85(5):820–4. [2] Clapper MF, O’Brien TJ, Lyons PM. Fractures of the fifth metatarsal: analysis of a fracture registry. Clin Orthop Rel Res 1995;315:238–41. [3] Quill GE. Fractures of the proximal fifth metatarsal. Orthop Clin North Am 1995;26:353–61. [4] Ekstrand J, van Dijk CN. Fifth metatarsal fractures among male professional footballers: a potential career-ending disease. Br J Sports Med 2012. Online publication: doi: 10.1136/bjsports-2012-092096. [5] Kerkhoffs GM, Versteegh VE, Sierevelt IN, Kloen P, vanDijk CN. Treatment of proximal metatarsal V fractures in athletes and non-athletes. Br J Sports Med 2012;46:644–8. [6] Jones R. Fracture of the base of the fifth metatarsal bone by indirect violence. Ann Surg 1902;35:697–700. [7] Chuckpaiwong B, Queen RM, Easley ME, Nunley JA. Distinguishing Jones and proximal diaphyseal fractures of the fifth metatarsal. Clin Orthop Relat Res 2008;466:1966–70. [8] Josefsson PO, Karlsson M, Redlund-Johnell I, Wendeberg B. Closed treatment of Jones fracture: good results in 40 cases after 11–26 years. Acta Orthopaedica 1994;65(5):545–7. [9] Seitz WH, Grantham SA. The Jones’ fracture in the nonathlete. Foot Ankle 1985;6:97–100. [10] Herrera-Soto JA, Scherb M, Duffy MF, Albright JC. Fractures of the fifth metatarsal in children and adolescents. J Pediatr Orthop 2007;27(4):427–31. [11] Rosenberg GA, Sferra JJ. Treatment strategies for acute fractures and nonunions of the proximal fifth metatarsal. J Am Acad Orthopaedic Surg 2000;8(5.):332–8. [12] Wiener B, Linder J, Giattini J. Treatment of fractures of the fifth metatarsal: a prospective study. Foot Ankle Int 1997;18:267–9. [13] Kavanaugh JH, Brower TD, Mann RV. The Jones fracture revisited. JBJS Am 1978;60:776–82.
[14] Egol K, Walsh M, Rosenblatt K, Capla E, Koval KJ. Avulsion fractures of the fifth metatarsal base: a prospective outcome study. Foot Ankle Int 2007;28(5.): 581–3. [15] Vorlat P, Achtergael W, Haentjens P. Predictors of outcome of non-displaced fractures of the base of the fifth metatarsal. Int Orthopaedics 2007;31:5–10. [16] Early JS. Fractures and dislocations of the midfoot and forefoot. In: Bucholz RW, Keckman JD, Court-Brown CM, editors. Rockwood and Green’s fractures in adults. 6th ed., Lippincott: Williams & Wilkins; 2006. p. 2338–400. [17] Torg JS, Balduini FC, Zelko RR, Pavlov H, Peff TC, Das M. Fractures of the base of the fifth metatarsal distal to the tuberosity: classification and guidelines for non-surgical and surgical management. JBJS Am 1984;66:209–14. [18] Josefsson PO, Karlsson M, Redlund-Johnell I, Wendeberg B. Jones fracture: surgical versus nonsurgical treatment. Clin Orthopaedics Rel Res 1994;299: 252–5. [19] Zwitser EW, Breederveld RS. Fractures of the fifth metatarsal; diagnosis and treatment. Injury 2010;41(6):555–62. [20] Budiman-Mak E, Conrad KJ, Roach K. The foot function index: a measure of foot pain and disability. J Clin Epidemiol 1991;44(6):561–70. [21] Ware JE, Kosinski M, Bjorner JB, Turner-Bowker DM, Gandek B, Maruish ME. User’s Manual for the SF-36v2TM Health Survey. 2nd ed, Lincoln, RI: QualityMetric Incorporated; 2007. [22] Lawrence SJ, Botte MJ. Jones’ fractures and related fractures of the proximal fifth metatarsal. Foot Ankle 1993;14:358–65. [23] Gray AC, Rooney BP, Ingram R. A prospective comparison of two treatment options for tuberosity fractures of the proximal fifth metatarsal. The Foot 2008;18:156–8. [24] Van Kollenburg JAPAC, Ring D. Time to union as a measure of effectiveness. Harvard Orthopaedic J 2012;14:12–21. [25] Davis BJ, Roberts PJ, Moorcroft CI, Brown MF, Thomas PBM, Wade RH. Reliability of radiographs in defining union of internally fixed fractures. Injury 2004;35:557–61. [26] Bhandari M, Guyatt GH, Swiontkowski MF, Tornetta P, Sprague S, Schemitsch EH. A lack of consensus in the assessment of fracture healing among orthopaedic surgeons. J Orthopaedic Trauma 2002;16(8):562–6.
Please cite this article in press as: Bigsby E, et al. Functional outcome of fifth metatarsal fractures. Injury (2014), http://dx.doi.org/ 10.1016/j.injury.2014.06.010
JINJ-5779; No. of Pages 4 Injury, Int. J. Care Injured xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Functional outcome of fifth metatarsal fractures E. Bigsby a,*, R. Halliday a, R.G. Middleton a, R. Case b, W. Harries a a b
Trauma and Orthopaedic Department, Frenchay Hospital, Frenchay Park Road, Bristol BS16 1LE, UK Trauma and Orthopaedic Department, Weston General Hospital, Grange Road, Uphill BS23 4TQ, UK
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 8 June 2014
Introduction: Fifth metatarsal fractures are common and the outcome has been reported; however, prospective studies reporting the functional outcome using validated questionnaires are lacking in the literature. The aims of this study were to determine whether fifth metatarsal fractures remain symptomatic in the medium term and whether the fracture type influences outcome. Methods: Over the course of a year, 117 patients (62 avulsion fractures, 26 Jones fractures, 29 shaft fractures) were followed up (1 month, 4 months, 12 months), with functional outcome assessed using the Foot Function Index (FFI)- and Short Form 36 (SF36)-validated questionnaires. Results: The FFI reduced (function improved) over the course of the year from 22.0 (8.4–38.5) at 1 month to 0.0 (0.0–4.2) at 4 months, to 0.0 (0.0–1.3) at 1 year. There was no significant difference in the FFI scores with regard to gender or fracture type. Pain scores were also observed to decline over the year, with no significant differences between fracture types. However, while the severity of pain was low, the numbers of people reporting pain were relatively high. At 1 month, >80% of patients reported ongoing pain (83% avulsion, 88% Jones and 83% shaft), reducing to 38% at 4 months and 28% at 1 year. At final follow-up, 25% with an avulsion fracture, 28% with a Jones fracture and 33% with a shaft fracture reported pain. Conclusions: While 25–33% of patients continue to experience pain at 1 year, <10% experience any limitation of their activities. At the final follow-up at 1 year, there were no significant differences in functional outcome by fracture type, gender or patient age. Patients should be advised about the likelihood of ongoing low-level symptoms, even after a year from injury in this previously presumed innocuous injury. ß 2014 Published by Elsevier Ltd.
Keywords: Metatarsal Fracture Functional outcome Jones Avulsion Shaft
Introduction Fifth metatarsal fractures comprise >50% of foot fractures [1]. They are generally treated conservatively, although in athletes operative fixation has been recommended [2–5]. Fifth metatarsal fractures can be classified into avulsion, Jones [6], and shaft types. The majority of existing studies examining the outcome have been retrospective and focused on rates of non-union and re-fracture [7–10], with limited information on the functional outcome of patients. While many authors [3,11–13] have considered avulsiontype fractures to be unproblematic, others have reported ongoing symptoms [14,15]. Jones-type fractures have more widely been considered problematic [2,15–19], making them more often treated with operative fixation than other fifth metatarsal fracture types. The aims of this study were to determine whether fifth
* Corresponding author. E-mail address: [email protected] (E. Bigsby).
metatarsal fractures remain symptomatic in the medium term using a validated patient-reported functional outcome measure and to investigate whether the outcome is influenced by the fracture type. Material and methods All adults presenting to our level 1 trauma centre in the UK between 2009 and 2010 with an isolated fifth metatarsal fracture were invited to participate in the study. Patients were excluded if the injury was >2 weeks old, were unable to provide valid consent, had pre-existing foot pathology, had other injuries (including soft tissue injuries) to the same foot/ankle or if primary fixation was performed. The patients were treated according to the treating surgeon’s preferred practice and included plaster, Tubigrip bandage, and advice on supportive footwear. Patients were asked to complete a questionnaire at 1 month, 4 months and 1 year after injury. The questionnaires were given to the patient during their clinic
http://dx.doi.org/10.1016/j.injury.2014.06.010 0020–1383/ß 2014 Published by Elsevier Ltd.
Please cite this article in press as: Bigsby E, et al. Functional outcome of fifth metatarsal fractures. Injury (2014), http://dx.doi.org/ 10.1016/j.injury.2014.06.010
G Model
JINJ-5779; No. of Pages 4 E. Bigsby et al. / Injury, Int. J. Care Injured xxx (2014) xxx–xxx
2
appointment or posted to them. The validated questionnaires comprised the Foot Function Index (FFI) [20] and the Short Form 36 version 2 (SF36v2) [21]. The FFI comprises 23 questions where the patient places a mark on a line, which equates to a 0–9 scale. The FFI is subdivided into three sections: pain, disability and activity limitation. Each section is scored from 0 to 100 and these three sections can then be averaged to give the FFI (a higher score reflects a poorer function). The SF36v2 comprises 36 questions about general health and well-being and provides a summary of the mental component score (MCS) and the physical component score (PCS) on a scale of 0–100, with 50 being the norm, and higher scores reflecting a better selfperceived health. The fractures were classified according to anatomical position following that described by Lawrence and Botte [22] into (1) avulsion/tuberosity-type fracture, (2) Jones-type fracture (a transverse fracture at the junction of the proximal metaphyseal–diaphyseal junction without distal extension beyond the fourth to fifth intermetatarsal articulation) and (3) shaft-type fractures (fractures distal to the Jones type). The initial radiographs were evaluated by two of the authors and consensus reached on any differences. The study was endorsed by the local research ethics committee. Statistical analyses comprised descriptive statistics with medians and interquartile ranges given unless otherwise stated and was performed with Statistical Package for the Social Sciences (SPSS) version 19.0 (IBM Corporation, New York, NY, USA). The Shapiro– Wilk test was used to test for normality. Comparison between groups was carried out using the Mann–Whitney, Kruskal–Wallis and chi-squared tests. A p value of <0.05 was considered statistically significant. Results General A total of 123 patients entered the study, although six patients subsequently withdrew. One patient died during the study of unrelated causes, before completion of the 12-month follow-up; however, their data have been included and calculation of the return rate at final follow-up reflects the missing patient episode. Of the 117 remaining patients, 62 were avulsion fractures, 26 Jones fractures and 29 shaft fractures. The return rates with time post injury were as follows: 86% at 31 days, 71% at 119 days and 70% at 383 days. The median age of patients at injury was 48 years (29.9–64.0) for all fracture types (43 years for avulsion, 45 years for Jones and 54 years for shaft), with no significant difference between groups. The gender balance of patients was 1:1.58 (male:female) in the avulsion group, 1:0.63 (male:female) in the Jones group and 1:3.83 (male:female) in the shaft group. There were significantly (p = 0.04) more male patients in the Jones fracture group compared to the others.
General health The median PCS for all fracture types combined at 1 month was 36.5 (31.6–43.6) and the MCS was 53.2 (42.2–59.4). At 1 year, the PCS was 53.0 (45.9–56.0) and the MCS 57.2 (52.7–59.1). There was no significant difference between the individual fracture types at 1 month, 4 months or 1 year (Table 1). Overall foot function The median FFI of all metatarsal fracture types combined (Table 2) reduced from 22.0 (8.4–38.5) at 1 month to 0.0 (0.0–4.2) at 4 months, to 0.0 (0.0–1.3) at 1 year. There was no significant difference in the FFI scores depending on fracture type at any of the follow-up intervals. There was also no significant difference in the FFI scores with regard to gender. In order to investigate whether there were differences in the FFI in different age groups, we compared those aged 45 years and less to those over 45 years. There were no significant differences between the FFI scores at any of the time intervals. Pain The pain scores (scale of 0–100), regardless of fracture type, reduced from a median of 12.8 (2.5–30.5) at 1 month to 0.0 (0.0– 4.9) at 4 months and 0.0 (0.0–1.6) at 1 year. Similar patterns of reduction in pain scores were observed for individual fracture types with no significant differences between them at any of the time points investigated. While median pain scores are low, there are a substantial number of individuals reporting pain (Table 3). At 1 month, >80% of patients reported ongoing pain (83% avulsion, 88% Jones and 83% shaft), reducing to 38% at 4 months and 28% at 1 year. At final follow-up, 25% with an avulsion fracture, 28% with a Jones fracture and 33% with a shaft fracture reported pain. There were no significant differences in the proportions of patients reporting pain depending on the fracture type at any of the followup times. There were also no significant differences in the age of patients at 1 month or 1 year who reported pain, although there was a significant difference (p = 0.029) at 4 months follow-up, with those reporting pain being younger. There were no significant differences in the proportion of patients reporting pain compared to those in no pain in terms of gender, at all follow-up times. There was also no significant difference in pain severity at final follow-up in terms of fracture type, with all having a median score of 2 on a 0–9 scale with 9 being the worst. Functional limitation of activities In terms of limitation of activities, the majority (74%) reported some limitations 1 month after injury (Table 4), while even at 4 months post injury 24% of patients remained limited in their activities as a result of their injury. This was most pronounced in the shaft group where 39% had limitations of activities compared
Table 1 Median physical component scores (PCS) and mental component scores (MCS) of the SF36, with interquartile ranges in parentheses. The p values given represent Kruskal– Wallis testing between fracture types. Fracture type
All Avulsion Jones Shaft p value
1 month
4 months
1 year
PCS
MCS
PCS
MCS
PCS
MCS
36.5 (31.6–43.6) 35.2 (31.1–43.2) 38.1 (32.6–43.4) 36.3 (31.5–43.0) 0.917
53.2 (42.2–59.4) 51.7 (42.9–59.4) 56.0 (41.8–62.0) 49.5 (41.6–57.6) 0.295
49.9 (41.6–55.8) 51.4 (43.8–56.2) 48.9 (41.3–53.8) 48.0 (38.2–56.0) 0.545
56.9 (52.9–59.4) 56.2 (53.1–59.5) 58.5 (56.3–60.0) 55.9 (51.3–58.8) 0.171
53.0 (45.9–56.0) 53.3 (46.1–56.4) 50.2 (43.8–55.7) 52.4 (47.2–55.4) 0.884
57.2 (52.7–59.1) 57.2 (52.8–58.5) 57.8 (56.1–58.9) 56.3 (50.4–60.0) 0.577
Please cite this article in press as: Bigsby E, et al. Functional outcome of fifth metatarsal fractures. Injury (2014), http://dx.doi.org/ 10.1016/j.injury.2014.06.010
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JINJ-5779; No. of Pages 4 E. Bigsby et al. / Injury, Int. J. Care Injured xxx (2014) xxx–xxx Table 2 Median Foot Function Index scores, with interquartile range in parentheses.
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Table 4 Numbers of patients with limitation of activities, with percentages in parentheses.
Fracture type
1 month
4 months
1 year
Fracture type
1 month
4 months
1 year
All Avulsion Jones Shaft
22.0 20.6 22.3 23.7
0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00
All Avulsion Jones Shaft
75 39 17 19
20 9 2 9
6 4 0 2
(8.4–38.5) (8.1–34.1) (8.3–36.5) (8.6–48.6)
(0.00–4.2) (0.00–4.1) (0.00–1.5) (0.00–6.5)
(0.00–1.3) (0.00–1.6) (0.00–1.0) (0.00–0.5)
to only 21% for avulsion and 11% for Jones fractures. However, this difference was not significant (p = 0.075). At final follow-up, 9% of avulsion and 10% of shaft fracture patients had restricted their activities as a consequence of their injuries, while none of the patients with Jones fractures did. There were no significant differences in age or gender between those patients with limitation of ongoing activity and those without limitation. Discussion The purpose of our study was to report the functional outcome of fifth metatarsal fractures using a validated scoring system. While previous studies have provided an assessment of function, many used questionnaires that have not been validated [7,12,23], and as such their results have to be interpreted with caution. Wiener et al. [12] used their own modified foot score, while Grey et al. [23] used their own modification to The American Orthopaedic Foot and Ankle Society (AOFAS) midfoot score, and Chuckpaiwong et al. [7] reported more generally on return to activities. In the present study, an improvement in FFI scores were noted over the course of a year, with the median score dropping to 0 at 4 months and remaining at 0 at 1 year. However, while the median FFI was 0, there were considerable numbers of patients who remained symptomatic. In terms of pain, at final 1-year follow-up, 25% of avulsion, 28% of Jones and 33% of shaft fracture patients remained symptomatic, with a pain score of 2.0 (scale of 0–9). This is similar to Vorlat et al. [15] who reported a mean pain score of 2.1 (scale of 0– 10) at mean follow-up of 490 days. However, while they reported that patients older than 45 years experienced more problems with function than younger patients, we found no differences at any of the time intervals between the two age groups. Egol et al. [14], in a study of 49 patients with avulsion-type fractures, reported that 31% still required analgesia at 6 weeks and 20% by 12 weeks. Pain scores were only reported at the final follow-up of 1 year, with 10% of patients falling into the moderate-to-severe pain group with a mean score of 0.73 (on a 10-point scale). In terms of functional limitations, in the present study at final follow-up, 9% of the avulsion group and 10% of the shaft group had restricted their activities as a consequence of their injuries, while none of the patients in the Jones group did. It is difficult to directly compare the functional limitation from other studies due to the limited detail of previously published reports. However, in a study by Wiener et al. [12], where 89 patients with avulsion fractures were investigated, 20 (22%) of the 89 patients had ongoing symptoms at 12 weeks, which compares to 35% at 4 months in the current study. A retrospective study by Vorlat et al. [15] comprising
(74%) (74%) (68%) (79%)
(24%) (21%) (11%) (39%)
(7%) (9%) (0%) (10%)
38 patients (32 avulsion and 6 Jones types) reported a mean ankle score of 82.4 (range: 20–100) at a mean follow-up of 490 days (range: 102–940), with 10 of the patients (26%) reporting problems wearing shoes. Similarly, a prospective study of tuberosity fractures by Grey et al. [23] using their own modification of an already modified version of the AOFAS midfoot score showed a score of 90 (scale of 0–100, with 100 being the best) at 12 weeks. Compared to a study by Egol et al. [14] of 49 patients (50 fractures) with avulsion type using the validated Short Musculoskeletal Function Assessment (SMFA) questionnaire, this study reported an SMFA score of 2.7 at 1 year (scale 0–51, with 0 being the best function). These studies are comparable to our study, where the average FFI (on a scale of 0–100, with 0 being the best) was 22 at 1 month, and 0 at 4 months and 1 year. The limitations of this study may be considered to be the lack of radiological follow-up; however, it has been documented that the interpretation of radiological union on plain radiographs is poor [24–26] and it was the authors’ view that the functional outcome is of more relevance to the patient. We do accept that treatment both within a fracture group and between fracture groups was not standardised; however, this is often the reality of the way these injuries are managed, with both patients and treating surgeons preferring one treatment modality over another. Finally, while this study is one of the largest in the literature, there are relatively small numbers for the Jones and shaft fracture types. Further study in this area should focus on the longer-term outcome to determine if and when ongoing pain resolves. In addition, while the current study was unable to identify factors associated with a poorer outcome, a larger study may be able to determine these and hence lead to the possibility of treating the problematic group more aggressively. Conclusions This study of 117 patients is the largest prospective study of the functional outcome of conservatively managed fifth metatarsal fractures using a validated scoring system. While the majority of patients see a steady improvement in their pain and function following their injury, 25–33% of patients continue to experience pain at 1 year, although <10% experience any limitation of their activities; however, patients should be advised about this at the time of injury. At the final follow-up at 1 year, there were no significant differences in functional outcome by fracture type, gender or patient age. Conflict of interest Financial assistance was provided by the North Bristol Trust charitable funds and the British Orthopaedic Foot and Ankle Society.
Table 3 Numbers of patients with ongoing pain, with percentages in parentheses. Fracture type
1 month
4 months
1 year
All Avulsion Jones Shaft
86 44 22 20
32 15 8 9
23 11 5 7
Acknowledgements (84%) (83%) (88%) (83%)
(38%) (35%) (44%) (39%)
(28%) (25%) (28%) (33%)
We would like to thank the North Bristol Trust charitable funds and the British Orthopaedic Foot and Ankle Society for grants that made this project possible.
Please cite this article in press as: Bigsby E, et al. Functional outcome of fifth metatarsal fractures. Injury (2014), http://dx.doi.org/ 10.1016/j.injury.2014.06.010
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JINJ-5779; No. of Pages 4 E. Bigsby et al. / Injury, Int. J. Care Injured xxx (2014) xxx–xxx
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Please cite this article in press as: Bigsby E, et al. Functional outcome of fifth metatarsal fractures. Injury (2014), http://dx.doi.org/ 10.1016/j.injury.2014.06.010