SLR - May 2015 - Archibald J. Loch

Likelihood of Surgery in Isolated Pediatric Fifth Metatarsal Fractures
Reference: Mahan ST, Hoellwarth JS, Spencer SA, Kramer DE, Hedequist DJ, Kasser JR.  Likelihood of Surgery in Isolated Pediatric Fifth Metatarsal Fractures. J Pediatr Orthop. 2015 Apr-May; 35(3):296–302.

Scientific Literature Review

Reviewed By: Archibald J. Loch, DPM
Residency Program: Massachusetts General Hospital, Boston, MA

Podiatric Relevance: Fifth metatarsal fractures are commonly encountered in the podiatric practice. This often brings about the question of conservative versus surgical intervention to better treat these injuries. In adults 5th metatarsal fractures are well studied due to the difficulty associated with healing fractures in the region of the proximal metaphyseal-diaphyseal junction. Fractures of the fifth metatarsal in children are not as well studied; this study sought to identify the fracture location that will more likely require surgical intervention.

Methods: A retrospective chart review was performed on patients under the age of 18 who were treated for an isolated fifth metatarsal fracture, from 2003 through 2010 at Boston Children’s Hospital. Patient demographics, treatment, and complications were noted. Radiographs were reviewed for location of fracture and fracture displacement. Patient’s fracture characteristics were then compared measured and classified using the Herrera-Soto et al’s classification.

Results: A total of 238 fractures were included, average patient age of 12.8 years (range, 2-18) and 55.9 percent were sustained by males. Of the 238 fractures, 15 (6.3 percent) were treated surgically with the average age of this group at 15.1 years. Majority of surgical indications were failure to heal in a timely manner or refracture and all patients underwent a trial of non-operative treatment. Jones criteria for fracture location were predictive of needing surgery (P<0.01) but confusing in the clinic setting. Fractures that occurred between 20 and 40mm (or 25 to 50 percent of overall metatarsal length) from the proximal tip went on to surgery in 18.8 percent (6/32) of the time, whereas those that occurred between <20mm had surgery in 4.9 percent (9/184). This was a statistically significant correlation (P=0.0157).

Conclusions: Fifth metatarsal fractures are common, but need for surgical treatment is fairly uncommon. Anatomically a region of this bone is known to have difficult time healing; as such it can be hard to identify potentially problematic fractures. According to the study, a simple ruler measurement from the proximal tip of the fifth metatarsal to the fracture to help determine this problematic group and found a significant difference in those patients with a fracture of <20mm compared with those 20 to 40mm from the tip. This can help guide treatment and counsel patients. This study serves to illustrate that across a large population and multiple providers most of these fractures in children should be managed conservatively initially.

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