SLR - March 2018 - Vincent H. Mandas

Comparative Study of Surgical and Conservative Treatments for Fifth Metatarsal Base Avulsion Fractures (Type I) in Young Adults or Athletes

Reference: Wu GB, Li B, Yang YF. Comparative Study of Surgical and Conservative Treatments for Fifth Metatarsal Base Avulsion Fractures (Type I) in Young Adults or Athletes. J Orthop Surg (Hong Kong). 2017 Dec 11;26(1)

Scientific Literature Review

Reviewed By: Vincent H. Mandas, DPM
Residency Program: Grant Medical Center, Columbus, Ohio

Podiatric Relevance:
Fifth metatarsal fractures are one of the most commonly seen injuries by podiatrists. The anatomic properties of the fifth metatarsal and its associated soft-tissue attachments play a key role in weight distribution during ambulation. Therefore, it is not uncommon to see fifth metatarsal base fracture in active patients presenting with simple injuries. The management of fifth metatarsal base fractures, specifically avulsion fractures, continues to be a controversial topic regarding conservative versus operative treatment. There are studies in the literature with documented results supporting conservative treatment; however, some studies argue that conservative treatment alone may produce unfavorable, long-term outcomes. The authors of the current study investigate the therapeutic effects of a minimally invasive surgical technique in treating patients presenting with displaced (2–3 mm) tuberosity avulsion fractures of the fifth metatarsal base. The purpose of this study is to evaluate patient outcomes following operative treatment by comparing nonoperative treatment outcomes.

Methods: A total of 46 young adults or athletes who presented with a displaced fifth metatarsal base avulsion fracture within two weeks of injury were included in this study. Exclusion criteria included presence of open fracture, multiple metatarsal fractures, pathologic or osteoporotic fractures, or previous surgical intervention on the affected foot or ankle. Five patients were lost to follow-up. The remaining 41 patients were allocated to the operative group (n=21) and nonoperative group (n=20) by computer randomization. The operative group underwent closed reduction with percutaneous screw fixation, and the nonoperative group underwent immobilization with plaster casting. The authors then recorded and analyzed the results of specific outcome measures after treatment to compare between the two groups. Outcomes were primarily measured by assessing radiographic union, time to full weightbearing, time to return to work and functional outcomes evaluated by AOFAS and VAS-FA scoring systems.

Results: All 41 patients had a minimum follow-up of 12 months. There was no significant difference in age or gender between the two groups (P>0.05). Radiographs confirmed primary union in all but three patients who went on to malunion. All three malunions were seen in the nonoperative group, and two of these patients had frequent mild to moderate plantar pain. The AOFAS and VAS-FA scores at six and 12 months, respectively, were significantly better in the operative group (P<0.05). However, there was no significant difference seen in AOFAS scores at six months after treatment (P>0.05). On average, patients in the operative group were full weightbearing and returned to work significantly earlier than the nonoperative group (P<0.05).  

Conclusions: The authors of the current study suggest that operative treatment is necessary for young patients or athletes with displaced fifth metatarsal base avulsion fractures. However, one of the duties of a podiatric surgeon is to educate patients about their injury and present different treatment options as there is no guarantee with any treatment approach. Research, such as this, aids the podiatric surgeon in giving patients realistic postoperative expectations.

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