I’m hoping somebody may have some input on healing of fractures, the process and how worried I should be!
3 weeks ago, I fractured my 5th metatarsal when rolling my ankle. It was classified an avulsion fracture, not Jones, and xray looked pretty minor. I was put in a cast and advised that I could bear weight as comfortable and not to worry - that these always heal.
Yesterday I went for follow-up and got some new xrays. The doctor saw no sign of healing (not surprising this early) but noted that the fracture is “drifting”. I was put in a non-weight bearing cast for 3 more weeks. Most concerning to me was the mention that if not healed next time I’ll be looking at surgery.
I’m wondering if I shouldn’t have been bearing weight to start with, if anything I have done/not done could be impacting it (coming to mind is my diet… I’ve tried to eat a bit light since I’m not able to exercise at all. Still plenty of calcium and protein though and I eat when I’m hungry!). And mostly I’m worried if this is indicative that it may not heal from here. The doctor said it’s more likely than not that it’ll heal, but didn’t seem to want to give any more of a guarantee than that. Is it common for bones to “drift” further apart in the healing process? Will my body still get the memo to heal this now that it’s 3 weeks later?
For the record, I almost always rec percutaneous cannulated screw fixation for 5th met avulsion fractures in runners/athletes since in my experience these are notoriously slow healers because of traction from the peroneus brevis tendon that inserts on that avulsed peice (although they generally do eventually - but then you lost a season/lots of fitness). The normal/stock rec is generally a CAM boot or cast though (which I just did yesterday with a patient since not active).
Haven’t taken nsaids since the day of the fracture, because I read that they can impede bone healing.
I have been limiting caloric intake a little bit, but not a ton, and have remained cognizant of protein and calcium. I just bought some calcium supplements yesterday. Should up my calories some? Not like I’m starving myself just cutting back a tiny bit since I am not working out.
If you’re not losing weight, I would think it unlikely that it’s nutrition. A little vitamin D might be a good idea.
Rod Roof’s post was very interesting.
Yes, there is evidence that NSAIDS can cause non-union.
The advice you were given is absolutely correct for an avulsion fracture and it wouldn’t be expected to show X-ray signs of healing at 3wks. The trouble is I disagree with the diagnosis - you do have a Jones fracture - the key is that the fracture line extends to the articulation with the fourth metatarsal and not the cuboid. Fractures in this region are a completely different story. They have a high rate of non union and require and long period of complete non weight bearing immobilization (or early screw fixation). Many of them still fail and require fixation and bone grafting. It is not too late to still try to avoid surgery but you should be completely non weight bearing and one could argue that, if it appears unstable already, that going straight for surgery might be the best option.
I hope that helps
Looking closely, I’d still call this the more common avulsion fx vs. a true Jone’s fx (usually about an inch from the styloid). The MO view makes it look worse than the AP view (weight bearing lateral would be nice) and in my mind, it is semantics anyway since I’d recommend intramedulary screw fixation anyway in his particular case (Wright Charlotte Carolina for example) http://www.ncbi.nlm.nih.gov/pubmed/19138486
Something else you can do that won’t affect anything else is to try taking a strontium supplement (make sure you take it a couple hours apart from anything containing calcium). Unfortunately, strontium ranelate (better bioavailability) is not available in the US (available in rest of world though as a prescription drug) but you can get strontium citrate from places like Doctor’s Best. It is traditionally used in cases of osteoporosis (e.g. post-menopausal women) but there are a few studies (just search pubmed for the primary papers) that indicates it may quicken fracture healing time.
I took it for a fractured tibia (medial malleolus), a result from a football/soccer tackle, and was told by the doc that it would be 3-4 months before I could start running again (probably very conservative). By week 4 I was running in straight lines normally and played a bit of footy and by 6 weeks I was back playing football properly and running as norma, and have experienced no issues with the ankle since then. Of course I can’t know if it was because of the strontium or me being a quick healer (was back playing competitive 11v11 football at 5 months after ACL reconstruction (and racing by 10 weeks…fly by night du, 2011, AG placed (i.e. didn’t hobble around)). However, it can’t hurt and strontium is found naturally in your body anyway. There is loads of stuff on the web that you can read about more on it to make your own decision.
An avulsion fx runs perpendicular to the bone? First year med student here just trying to learn. I thought it would be more oblique, with a smaller piece of bone proximal to the fracture.
An avulsion fx runs perpendicular to the bone? First year med student here just trying to learn. I thought it would be more oblique, with a smaller piece of bone proximal to the fracture.
1st year med student? LOL! Just regurgitate biochem Or, back at your cadaver …
An “avulsion fracture” is a generic phrase and varies depending on what bone you are talking about (shoulder, wrist, ankle, 5th met, etc.)
5th met fractures are generally 1 of 4 types: midshaft/spiral, stress fracture, Jone’s, or avulsion. Avulsion is the most common since it usually occurs with an inversion ankle sprain (a very common injury). The story behind a “Jone’s fracture” is that Jones (who, oddly enough was a physician himself), fell/twisted his ankle square dancing and suffered the injury. It occurs at the metaphyseal/diaphyseal junction where there is relative avascularity in the 5th met. This, coupled with traction of the peroneus brevis tendon, tends to cause a very slow healing fx or non union (other fx can do this, like a scaphoid fx in the wrist as well). There are very subtle findings separating the two and it can be a bit gray, but it is important since treatment paradigms differ (but not for athletes in my book).
It is only the same for younger/active people/athletes for a larger avulsion fx vs. a Jone’s fx. Other patients (or very small avulsion pieces, I generally rec CAM boot or cast).
Couple of reasons: first, there is that “gray” zone between a large avulsion fracture and a Jone’s fx with the different treatment recs. Second, few athletes want to remain NWB or in a cast (no running, swimming, even spinning difficult for 6 weeks plus and often with early percutaneous cannulated screw fixation, they can be at least back in the pool at 10 days (no cast needed after ORIF), spinning in a couple of weeks, and a better change for union much sooner. Surgery is via a minimally invasive percutaneous approach, minimizing risk. Since so many of these larger avulsion fractures go on to delayed healing (i.e. 6-12 weeks +) and THEN they can go on to ORIF surg (another 6 weeks min), I feel they are better served with early ORIF.
Metaphyseal, not true jones, not in watershed zone, non articular. 3 weeks has just resorbed. It will heal, just relax. X-rays lays lag the clinical course. Stress riser at the distal end of the screw.
I’m really happy that I went with the screw and got this fixed - I’m just shy of 3 years post injury (2.5 post fixation) and I’ve had nary a problem.
If I ever suffer an injury similar to this again, I wouldn’t even waste my time with a conservative approach. Put a screw in it, and let me get going again. Chances are the conservative approach will end in surgery anyways - and you’ll just have wasted 6 to 12 weeks waiting, rather than having it fixed, recovering from the procedure and getting on your way.
Than again, I am the guy that ran for ~2 months on this injury being undiagnosed - and then continued to run on it again for another 2 months after diagnosis
Here’s my experience with an Avulsion fx of the 5th metatarsal (nearly 12 months post fx now)…
First of all, I’m sorry this happened to you. It’s a tough injury but I can say from experience it will heal. There’s no one better to know than Dr. Rodney Roof (rroof) for this injury. He’s the best. I did the same thing you did, rolled my foot and broke the bone. I didn’t have surgery. My fx looked similar to yours. My surgeon said he’d love to do surgery and collect some cash but it would be questionable at best to cut me open without giving it a chance to heal. He guaranteed me it would heal and would heal in the normal time frame of 10-12 weeks. I’m glad I was patient…well, I wasn’t all that patient. Whether I had surgery or not I was going to miss out on my “A” race and there were no other races to enter for the year.
I iced every day until the swelling was gone. I supplemented with a calcium drink which went down easy - no idea if it did any good. I used a bone stimulator (my insurance covered it) - again, no idea if it helped.
Fitness comes back fast…a lot faster than you think. I was swimming with pull buoy @ 3-4 weeks post fx, riding stationary bike @ 6 weeks, walking @ 9 weeks and running again @ 12 weeks. Heading to IMCDA in 3 weeks. My swim is the same, bike is the same and run is faster than before the fx. I have phantom pain from time to time around the fx area - even 12 months post. It comes and goes. Doesn’t limit me at all.
For the record, I almost always rec percutaneous cannulated screw fixation for 5th met avulsion fractures in runners/athletes since in my experience these are notoriously slow healers because of traction from the peroneus brevis tendon that inserts on that avulsed peice (although they generally do eventually - but then you lost a season/lots of fitness). The normal/stock rec is generally a CAM boot or cast though (which I just did yesterday with a patient since not active).
Why not go for the EXOGEN Ultrasound Bone Healing System immediately following a non-displaced 5th met avulsion fracture? Don’t wait 3 months for the “non-union” news, just simulate healing right away? This way you might (1) heal correctly and (2) avoid surgery altogether.
Had the same injury years ago. Rolled my foot playing basketball. Your doctor handled it very different than mine. My doc’s fist words were, “very bad spot for a fracture, not a ton of blood flow in that area, you walk on the outside of your feet and always put pressure on that spot, no weight at all for 6 weeks unless you want me to insert a screw”. I went back after 6 weeks of no weight at all on the foot and it was showing some signs of healing and my doc said I will give you two more weeks before we put in a screw. That area just does not heal well. After two more weeks, (8 total now), he took off the cast and about 75% of the fracture was healed. I was allowed to put weight on it but no biking or running. After 12 weeks, fracture was healed and I started back slowly. I would tell you I still felt some soreness at that spot for about two more months when building back up.
For the record, I almost always rec percutaneous cannulated screw fixation for 5th met avulsion fractures in runners/athletes since in my experience these are notoriously slow healers because of traction from the peroneus brevis tendon that inserts on that avulsed peice (although they generally do eventually - but then you lost a season/lots of fitness). The normal/stock rec is generally a CAM boot or cast though (which I just did yesterday with a patient since not active).
Why not go for the EXOGEN Ultrasound Bone Healing System immediately following a non-displaced 5th met avulsion fracture? Don’t wait 3 months for the “non-union” news, just simulate healing right away? This way you might (1) heal correctly and (2) avoid surgery altogether.
Why not? Because most insurance payors won’t cover unless it is a non-union since most fractures heal within 12 weeks (so can’t blame them). You can certainly pay out of pocket, but at $4K, most do not. Occasionally, an insurance company will cover for fresh fracture that are known slow healers (i.e. Anthem regionally here), but not always. Certainly wouldn’t hurt to check since no down side at all.
Or, back at your cadaver …
