Jones fracture

1. Definition

A Jones fracture is a transverse fracture of the proximal diaphysis of the fifth metatarsal bone, located 1.5 to 3 cm distal to the tuberosity (styloid process). It occurs at the metaphyseal-diaphyseal junction, an area with relatively poor blood supply, which predisposes it to delayed healing or nonunion.

2. Cause and Etiology

The primary cause of a Jones fracture is indirect force, typically due to:

Inversion and plantarflexion of the foot (e.g., while jumping or twisting).
Repetitive stress or chronic overuse, especially in athletes.
Acute trauma (e.g., landing awkwardly from a jump or rolling the ankle).

Etiologic factors include:

Biomechanical imbalances (e.g., cavovarus foot deformity).
Poor footwear or playing surfaces.
High-impact sports (e.g., basketball, football, soccer, track and field).

3. Pathophysiology

The Jones fracture occurs in a watershed area of blood supply at the junction of the metaphysis and diaphysis of the fifth metatarsal.
This region receives a dual blood supply, but neither is robust, making it prone to delayed union or nonunion.
The injury is usually caused by tensile stress and bending forces applied during sudden inversion or twisting motions.

Vascular Supply Note:

Proximal tuberosity (avulsion fracture): supplied by metaphyseal arteries.
Jones fracture region: located between the metaphyseal and nutrient artery zones, making healing more tenuous.

4. Epidemiology

Common in athletes and individuals involved in repetitive impact activities.
More frequent in males than females, likely due to higher participation in high-impact sports.
Peak incidence occurs in late teens to early 30s.
Also seen in military recruits and ballet dancers.

5. Clinical Presentation

Symptoms:

Acute pain is localized to the lateral border of the foot, especially over the fifth metatarsal shaft.
Swelling and tenderness at the base of the fifth metatarsal.
Difficulty or inability to bear weight.
Bruising may be present.
In chronic or stress-type Jones fractures, pain is insidious and worsens with activity.

Examination:

Focal tenderness 1.5–3 cm distal to the tuberosity of the fifth metatarsal.
Pain is reproduced by resisted eversion or passive inversion.
Gait may be antalgic or non-weight-bearing.

6. Imaging Features

Plain Radiographs (AP, lateral, and oblique views):

Transverse fracture line at the metaphyseal-diaphyseal junction.
Located approximately 1.5 to 3 cm distal to the base of the fifth metatarsal.
No involvement of the articular surface of the cuboid (differentiates from avulsion fractures).

Differential Diagnosis:

Avulsion fracture (pseudo-Jones fracture): more proximal, involves the styloid.
Stress fracture: often more distal, with periosteal reaction and sclerosis.

MRI:

Helpful in stress-type Jones fractures, especially if the X-ray is negative.
Shows bone marrow edema and fracture line.

CT Scan(3D):

Useful for evaluating nonunion or preoperative planning.

7. Treatment

Nonoperative Management (for nondisplaced fractures in non-athletes):

Non-weight-bearing cast or boot for 6–8 weeks.
Gradual return to weight-bearing after signs of healing.
Requires frequent radiographic monitoring due to the high risk of delayed union.

Surgical Management (indications):

Displaced fractures, nonunions, athletes, or delayed unions.
Intramedullary screw fixation (common technique).
Tension band wiring or plate fixation in some cases.
Bone grafting in cases of chronic nonunion.

8. Healing and Prognosis

Healing Time:

Nonoperative: typically 8–12 weeks or longer.
Surgical: ~6–8 weeks for return to play in athletes, though full healing can take longer.

Complications:

Delayed union or nonunion (up to 30% nonoperatively).
Refracture, especially if return to sport is too early.
Infection, hardware failure, or nerve irritation post-surgery.

Prognosis:

Generally good with proper management.
Surgical fixation allows faster recovery and higher union rates, especially in active individuals.

Summary Table: Jones Fracture Overview

Feature	Description
Location	Proximal 5th metatarsal, ~1.5–3 cm distal to tuberosity
Mechanism	Inversion injury or repetitive stress
Symptoms	Lateral foot pain, swelling, difficulty walking
Imaging	X-ray (diagnostic), MRI (stress fractures), CT (nonunion)
Treatment	Conservative (casting), Surgical (IM screw fixation)
Complications	Nonunion, refracture, delayed union
Prognosis	Good with treatment, better outcomes in surgery for active individuals

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Case study: A 46-Year-Old Woman with Bilateral Foot Pain After a Fall
Acute Jones Fracture

History and Imaging Findings

A 46-year-old woman presented with persistent pain in both feet following a fall.
Radiographic examination was performed.

Quiz 1:

What is the most significant abnormal finding?
(1) Calcaneal stress fracture
(2) Charcot joint
(3) Colles fracture
(4) Jones fracture
Which of the above is most closely associated with a decrease in Bohler’s angle?
(1) Calcaneal stress fracture
(2) Charcot joint
(3) Colles fracture
(4) Jones fracture
Where is this fracture located?
(1) Metaphyseal-diaphyseal junction
(2) Diaphysis
(3) Metaphysis
(4) Epiphysis
What is the final key characteristic of this eponymous fracture?
(1) Extension into the tarso-metatarsal articulation
(2) Extension into the metatarsal-metatarsal articulation
(3) Transverse trajectory
(4) Significant displacement

Follow-up CT Scan
A CT scan of the lower extremity was performed to evaluate for possible narrowing of Bohler’s angle.

Böhler’s Angle is measured on a lateral X-ray and represents the angle formed between two lines drawn across specific landmarks of the calcaneus:

The first line connects the highest point of the calcaneal tuberosity to the highest point of the posterior facet.
The second line extends from the highest point of the posterior facet to the anterior process of the calcaneus.

The angle formed between these two lines is referred to as Böhler’s angle.

📏 Normal Range:
Böhler’s angle typically falls within the normal range of 20° to 40°.
An angle less than 20° is suggestive of a calcaneal fracture.

🩺 Clinical Significance:
A decreased Böhler’s angle indicates depression or collapse of the calcaneus, which helps assess the severity of the fracture.
Restoring this angle postoperatively is one of the primary goals of treatment.

Three axial and coronal cross-sectional images of the left lower extremity CT scan are displayed in the bone window.

No evidence of a calcaneal stress fracture is seen, but the Jones fracture is again identified.

A Jones fracture is a fracture that occurs at the base of the fifth metatarsal of the foot, typically involving the bone located on the outer side of the foot.
This type of fracture commonly occurs during sports activities and is usually caused by twisting forces or excessive pressure applied to the foot.

Findings and Diagnosis

Imaging Findings:
Radiographs and CT scans reveal an acute, non-displaced transverse fracture at the base of the fifth metatarsal, extending into the articulation between the fourth and fifth metatarsals.
Narrowing of Böhler’s angle is noted.
An acute dorsal avulsion fracture of the navicular bone is also present.
Soft tissue swelling is observed along the dorsum and lateral aspect of the foot.

Differential Diagnosis:

Proximal fifth metatarsal fracture (Zone 1 or Zone 3)
Acute Jones fracture (Zone 2)
Calcaneal stress fracture
Accessory bone (os peroneum)

Os Peroneum

Definition:
The os peroneum is a sesamoid bone located within the peroneus longus tendon, typically situated along the lateral aspect of the foot. It is closely associated with the peroneal tendons and plays an important role in foot function.

Function:
The os peroneum contributes to tendon stability and assists in the movement and biomechanics of the foot.

Associated Conditions:

Pain and Inflammation:
The os peroneum can become a source of pain, which may be related to pathologic conditions such as bursitis or tenosynovitis.

Diagnosis:
Acute Jones Fracture (Zone 2)

Discussion

Jones Fracture

Proximal fractures of the fifth metatarsal are classified into three zones: Zone 1, Zone 2, and Zone 3.
A Jones fracture is defined as a fracture of the proximal fifth metatarsal that extends into the articulation between the fourth and fifth metatarsals, corresponding to Zone 2. This type of fracture has a high risk of nonunion.

Pathophysiology

Jones fractures are thought to occur due to a significant adduction force on the forefoot when the ankle is in plantar flexion.
Strong soft tissue attachments to the fifth metatarsal restrict mobility and can lead to displacement or dislocation during injury.

Epidemiology

Fractures of the fifth metatarsal account for approximately 68% of all metatarsal fractures.
Among proximal fifth metatarsal fractures:

Zone 1 fractures account for 93%
Zone 2 (Jones) fractures account for 4%
Zone 3 fractures account for 3%

Clinical Presentation

Patients typically present with lateral foot pain, soft tissue swelling, and difficulty bearing weight, usually following trauma or ankle injury.

Management

Non-displaced fractures of the fifth metatarsal are generally managed non-operatively.
Due to the high risk of nonunion, Jones fractures should be treated with non–non-weight-bearing immobilization using a cast for 6 to 8 weeks.

Reference

(1) Bowes J, Buckley R. Fifth metatarsal fractures and current treatment. World J Orthop. 2016;7(12):793-800.

(2) Chuckpaiwong B, Queen RM, Easley ME, Nunley JA. Distinguishing Jones and proximal diaphyseal fractures of the fifth metatarsal. Clin Orthop Relat Res. 2008;466(8):1966-1970.

(3) Metzl JA, Bowers MW, Anderson RB. Fifth metatarsal Jones fractures: Diagnosis and treatment. J Am Acad Orthop Surg. 2022;30(4):e470-e479.

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