ORIGINAL ARTICLE
Fractures of the Fifth Metatarsal in Children
and Adolescents
Jose A. Herrera-Soto, MD, Michael Scherb, MD, Michael F. Duffy, MD, and Jay C. Albright, MD
Objective: Fractures of the fifth metatarsal are the most common
metatarsal fractures in children. Their treatment is based on the adult
literature. The purpose of our study was to identify the different
types of fifth metatarsal fractures, to determine the mean time to
healing, and to examine whether current adult recommendations can
be extrapolated to children and adolescents.
Methods: A total of 103 patients met the inclusion criteria. The
fractures were classified according to location. Type I represented an
apophyseal injury. Type II represented tubercle fractures with intra-
articular extension. Type III injuries represented Jones fracture.
Metatarsal neck and shaft fractures were included separately.
Results: Apophyseal fractures did well with a short-leg walking cast
for 3 to 6 weeks. Displaced intraarticular fractures had a significant
delay in healing versus nondisplaced ones. Jones fractures had
delays in healing if not treated surgically. Neck and shaft fractures
did well with casting.
Conclusions: Most fractures of the fifth metatarsal in the pediatric
population do well clinically after a course of walking cast, unless
the fracture is an intra-articular displaced fracture type or the fracture
occurs in the proximal diaphyseal area. Fixation of Jones fractures in
active adolescents should be considered to allow faster return to
regular activities and prevent refracture. We recommend nonY
weight bearing casts for all angulated or displaced intra-articular
injuries to avoid delays in healing and angulation. From our series, it
is evident that most pediatric fifth metatarsal fractures behave as
those found in adults and can be treated similarly.
Key Words: adolescent, children, fleck, intra-articular,
Jones fracture, metatarsal fractures
(J Pediatr Orthop 2007;27:427Y431)
A lthough fractures of the metatarsals represent less than
6% of all fractures in children,1 they are becoming more
common in children. Fractures of the fifth metatarsal are the
most common metatarsal fractures in children.2 Exposure to
high-demand sports and activities has made this fracture more
common. Nearly all of the literature on these metatarsal base
fractures is based on adult patients.3Y5 To the best of our
knowledge, there is only 1 study that does not have treatment
recommendations regarding the incidence of metatarsal
fractures in children .2 There are no reports in the literature
From Orlando Regional Medical Center and Arnold Palmer Hospital for
Children, Orlando, FL.
This study was conducted at the Nemours Children’s Hospital, Orlando, FL.
Reprints: Jose Antonio Herrera-Soto, MD, Department of Pediatric
Orthopaedics, 89 West Copeland St., Orlando, FL 32819. E-mail: jose.
herrera)orhs.org.
Copyright * 2007 by Lippincott Williams & Wilkins
J Pediatr Orthop & Volume 27, Number 4, June 2007
Copyright @ Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
on the management of these injuries in children. To this point,
the treatment of pediatric metatarsal fractures of the fifth toe
is based on the adult literature.
There are several types of metatarsal base fractures in
the adult population.4,6 The Jones fracture, which is described
as a fracture distal to the proximal diaphyseal junction, is the
most problematic of them.4 Healing of fractures in this
Bwatershed area[ can be delayed because of limited vascular
supply. In our practice, refracture at the proximal diaphyseal
region has been identified in young adolescents despite proper
care. We did not find any treatment recommendations for
such injury in children. Anecdotally, we have identified a
tendency of delayed healing and angulation with a walking
cast, especially in those fractures that are displaced. Pain in
the area may last several months.
The purpose of our study was to identify the different
types of fifth metatarsal fractures, to determine the mean time
to healing, and to examine whether current adult recommen-
dations can be extrapolated to children and adolescents.
METHODS
We identified 228 patients with metatarsal fractures on
our database from January 1999 to May 2005. Inclusion
criteria were met by any patient between the ages of 4 and 18
years with a fracture of the fifth metatarsal with or without
associated metatarsal fractures. All patients needed at least 1
follow-up visit to be part of the study. Exclusion criteria
included all other toe metatarsal fractures, inadequate follow-
up films, and open or associated soft tissue injuries.
A total of 103 patients (45% of all metatarsal
fractures) met the inclusion criteria. This group represents
our retrospective study cohort. The patient age, mechanism
of injury, and type and duration of treatment were obtained
from their medical records after institutional review board
approval. The type of casting (walking or nonwalking) was
noted. Any complications were also noted. Radiographic
examination included 3-view radiographs of the foot. The
fractures were classified according to location. Any fracture
displacement, angulation, and time to union were noted.
Fractures were classified as complete if the fracture line
included all cortices and as incomplete if not all cortices
were involved.
We classified the injuries into 5 types (Table 1). Type I
represents a fracture at the base of the fifth metatarsal
(tubercle), classified as Bfleck[ injuries (Fig. 1). In this group,
the fracture line or the symptoms were at the area of the
apophysis without intra-articular extension. The second
group (Type II) comprises tubercle fractures with intra-
articular extension (Fig. 2). These intra-articular fractures can
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TABLE 1. Types of Metatarsal Fractures

Percentage of Average No. Weeks
Type All Fractures Age to Healing
Fleck 28.6 13.1 4
Intra-articular 42.9 12.4 6
Jones 14.3 14.2 12
Diaphyseal 5.7 11.3 7
Neck 8.6 10.9 4

extend to the metatarsal-cuboid joint or into the fifth-and-

fourth metatarsal joint area. Type III injuries represented a
fracture at the proximal diaphyseal region (Jones fracture)
(Fig. 3). Metatarsal neck fractures (Fig. 4) and shaft fractures
were included separately.

RESULTS
A total of 103 patients with 105 fifth metatarsal
fractures were identified. There were 51 boys and 52 girls.
Two patients presented bilateral injuries at different times.
Thirty patients (28.6%) presented with an avulsion fracture of
the apophysis, 45 (42.8%) presented with fractures of the base
with intra-articular extension. Fifteen patients (14.2%)
presented with a proximal diaphyseal junction fracture. Six
fractures (5.7%) were in the midshaft region, and 9 (8.6%)
were at the neck area. FIGURE 2. Complete intra-articular fracture of the fifth
metatarsal.

Type I/Fleck Fractures

FIGURE 1. Displaced apophyseal fracture on a 14-year-old
after a twisting injury.
There were 30 apophyseal-type injuries with equal sex
distribution. The average age was 13.1 years (range, 8Y17
years). Most injuries were caused by twisting. The type of
treatment in all patients was a walking cast for 3 to 6 weeks,
depending on pain and swelling at the fracture site. There
were no complications. All but 2 patients (2 boys with
displaced apophyseal injuries) demonstrated radiographic
healing or no displacement after treatment. All patients,
including those with displaced fragments, presented resolu-
tion of symptoms at the latest follow-up.
Type II/Intraarticular Fractures
There were 45 intra-articular fractures in 44 patients.
There were 20 boys and 24 girls. The average age was 12.4
years (range, 9Y19 years). There was no difference in age
between boys and girls. The type of treatment was a
nonYweight bearing cast for 4 to 6 weeks in 6 patients and
short-leg walking cast for 4 to 6 weeks in the remaining
patients.
Thirty-three patients presented with nondisplaced intra-
articular fractures (gap, G2 mm). These included 31
nondisplaced fractures and 2 with a unicortical fracture
laterally. The mean healing time was 43 days. The healing
time for the nondisplaced group was 37 days (range, 20Y62
days). Three of the nondisplaced fractures demonstrated a
plantar-lateral wedge at the time of healing; and 3 other
fractures had some residual cortical breech at the latest visit
but were symptom free.

428 * 2007 Lippincott Williams & Wilkins

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J Pediatr Orthop & Volume 27, Number 4, June 2007 Fractures of the Fifth Metatarsal

FIGURE 3. Fifteen-year-old boy with

refracture of a Jones fracture after nonYweight
bearing cast treatment for 8 weeks. At the
latest follow-up after fixation, the patient
resumed sports without further sequelae.

There were 11 displaced or angulated injuries and 1
patient with medial rather than lateral comminution. The
average duration of treatment was 58 days (range, 21Y75
days) for these patients. The difference in healing time
between the displaced and the nondisplaced fractures was
statistically significant (P = 0.009). Patients treated with a
short-leg nonYweight bearing cast healed on average of 36
days after the beginning of treatment, whereas those in
walking casts healed at 44 days. There was no difference
in time to fracture healing noted with regard to age or sex (P =
0.3 and 0.48, respectively).
We had 11 patients (25%) with more than 8 weeks of
casting and persistence of symptoms. Seven (17%) of the 42
patients had fracture healing with residual wedging at the
plantar-lateral cortex. We had 5 patients without fully healed
fractures who were symptom free at their latest follow-up.

FIGURE 4. Angulated metatarsal neck fracture treated in a walking cast. No symptoms or sequelae was reported.

* 2007 Lippincott Williams & Wilkins 429

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Herrera-Soto et al
Type III/Jones Fractures
We identified 15 proximal diaphyseal injuries, 11 boys
and 4 girls. All of their injuries were caused by either a direct
hit or a twist. The average age was 14.2 years (range, 5Y17
years), and the average follow-up period was 15 weeks
(range, 4Y36 weeks). Treatment was a short-leg walking
cast for 4 weeks in 8 patients, nonYweight bearing cast for
4 to 6 weeks in 5, and immediate closed reduction and
internal fixation in 2. The average duration of treatment
from the day of injury to the day of fracture healing was
12.1 weeks (range, 4Y28 weeks). At their latest follow-up,
all of the patients demonstrated fracture healing and were
symptom free.
Three patients (age, 913 years) from the group with
nonYweight bearing cast for 6 weeks presented with
refractures within 3 to 10 weeks of cast removal. Their
casts were removed at 6 weeks and they were instructed to
begin moderate activities for 1 month. These 3 patients were
athletes. All refractures underwent intramedullary fixation
with a cannulated interfragmentary lag screw, and one of
them was supplementary with bone grafting as well (Fig. 3).
The patients who underwent either primary fixation or
fixation after a refracture (average age, 15.5 years) healed
at a mean of 6.7 weeks (range, 5Y11 weeks). The patient who
underwent additional bone grafting required the longest time
to healing. The remaining patients demonstrated cortical
healing by their sixth week after fixation. Patients older than
13 years with fractures that were treated by closed means and
were complete needed an average of 12.3 weeks to
demonstrate full cortical healing (range, 8Y17 weeks).
Two patients from the weight-bearing cast group and
one from the nonYweight bearing group required additional 4
to 8 weeks in a cast or a boot to achieve union. These 3
patients were older than 16 years. Three of the 9 patients in
the nonYweight bearing cast group required 14 weeks to
demonstrate full cortical healing and resolution of symptoms.
Two patients older than 16 years with unicortical injuries did
well with short-leg cast walker.
Diaphyseal Fractures
There were 6 diaphyseal-type injuries with equal sex
distribution. The average age at the time of injury was 11.3
years (range, 10Y12 years). The type of treatment was short-
leg nonwalking cast. The average duration of treatment was
49 days (range, 27Y93 days). There were no complications.
All patients with radiographs demonstrated full healing and
were symptom free. The duration of follow-up was similar to
the duration of treatment because most patients were
discharged after demonstrating full cortical healing and
absence of symptoms.
Neck Fractures
There were 9 metatarsal neck fractures (Fig. 4). There
were 3 men and 6 women. The average age was 10.9 years
(range, 5Y14 years). The average time to fracture healing was
29 days (range, 25Y40 days). The average follow-up since the
day of injury was 45 days. The mechanism of injury was
caused by either a fall with a twisting moment or a direct hit.
The type of treatment was 3- to 4-week wearing of short-leg
430
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J Pediatr Orthop & Volume 27, Number 4, June 2007
walking cast. This treatment was performed on all but 1
patient with a minimally angulated fracture with associated
second to fourth metatarsal neck fractures. This patient was
placed in a nonYweight bearing cast for 4 weeks and healed
uneventfully. None of the patients required surgical inter-
vention. There were no complications. All patients demon-
strated no further displacement or angulation and were
symptom free at their latest visit.
DISCUSSION
Fractures of the fifth metatarsal are the most common
metatarsal fracture in children.2 We obtained similar
percentages of fifth metatarsal base fractures (45% of all
metatarsal fractures) in our patient population when com-
pared with those of Owen et al.2 They are usually caused by
direct trauma or repetitive stress or are associated with tarsal
injuries. The treatment should be tailored according to the
fracture type and the degree of displacement. Unfortunately,
there is no concise data in the literature regarding the proper
care of these injuries in children. There are several types of
fractures of the fifth metatarsal in the adult literature.4,5 We
have identified 3 types of metatarsal base fractures similar to
those in adults. A weakness of this study is that it is
retrospective, precluding the opportunity to examine vali-
dated functional outcomes after these injuries.
The first adult type is an avulsion injury to the tubercle,
where the lateral cord of the plantar aponeurosis inserts.
These are not intra-articular in character. The corresponding
fracture in children is a proper avulsion fracture or an
apophyseal stress injury at the base of the metatarsal. The
apophysis is not present before the age of 8 years and usually
fuses at the age of 12 years in girls and 15 years in boys.6
These findings were fairly consistent in our patient popula-
tion. Like their adult counterparts, these fractures were
treated with a short-leg walking cast for 3 to 6 weeks,
depending on symptoms and swelling. All patients with
avulsion fractures in our series responded well to this type of
treatment. Those with displaced avulsion injuries took longer
to ameliorate their pain but, at their latest follow-up, were
pain free, probably because of a fibrous union.
The type II injury (intra-articular) is a metaphyseal base
fracture that extends to the fifth metatarsal-cuboid joint or
into the fifth-and-fourth metatarsal joint area.6 This type of
fracture has not been described in children. In adults, this
fracture treatment is controversial. Some suggest to treat
these patients by using a walking cast, and others suggest to
treat them by using a nonYweight bearing cast for 6 to 8
weeks.7 All but 6 of our patients with intra-articular
involvement (13%) were treated by using weight-bearing
casts. Our patient population presented with 29% rate of
displacement when weight bearing was allowed. There was
evidence of a plantar-lateral wedge in these cases. This is
caused by the stresses at the fracture site, rather than at the
tarsometatarsal joint, that the bone is placed into during
ambulation. This wedging did not seem clinically significant
in the short run. Prolonged casting (98 weeks of wearing the
cast) was noted in 11 patients (25%). There was a significant
difference in the time to fracture healing between those with
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J Pediatr Orthop & Volume 27, Number 4, June 2007
displaced injuries and those without displacement. However,
age was not a factor in time to fracture healing.
The type III fracture at the proximal diaphyseal region
(Jones fracture) creates hesitancy regarding the best mode of
treatment. The juncture of the metadiaphyseal region is a
watershed area and has a tenuous blood supply. Thus, even in
children, injuries in this area are prone to delay in healing.
Jones fractures can be secondary to repetitive stress (stress
injury) or to acute trauma.3,7,8 Stress injuries show cortical
sclerosis and tend to have a poor vascular supply. In our
series, these patients were better treated with internal
fixation with or without bone grafting.3,8 The acute Jones
fractures can be treated by using either nonwalking cast for
6 weeks, followed by 2 weeks of progressive weight bearing,
or by means of reduction and internal fixation with or
without bone grafting.4,6,9 We identified several Jones
fractures treated conservatively that progressed to healing
but refractured shortly after resuming activities. In our
series, delayed healing and refracture was noted almost
exclusively in patients older than 13 years. Jones fractures
in children younger than 13 years may be treated with
nonwalking cast, whereas older patients may benefit from
surgical treatment.
Diaphyseal and neck fractures respond well to 3 to 4
weeks of wearing short-leg walking cast without any
complications. They were the least common in our patient
population. In our series, nondisplaced and minimally
displaced injuries did well in a short-leg walking cast.
None of the patients required surgical fixation. None of our
patients demonstrated delayed healing or further angulation/
displacement once in a cast. When the case involved
multiple toes with associated displacement and angulation,
toe traps with counterpressure at the ankle and a well-
molded cast at the metatarsal region usually controlled the
displacement. The only indications for surgery of diaphyseal
and neck fractures are those that are open and, potentially,
those with angulation. We cannot comment on the severity
of angulation that will require fixation or on the results of
surgery for these patients because we did not have to
perform any. We did not find any report on the indications of
surgical fixation in treatment of these fractures. One has to
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Fractures of the Fifth Metatarsal
consider also the age of the patient and the remodeling
potential of angulated injuries.
In conclusion, fractures of the fifth metatarsal are
becoming common in children and adolescents. It is our
opinion that most fractures of the fifth metatarsal in the
pediatric population do well clinically after a course of
walking cast, unless the fracture is an intra-articular fracture
type or the fracture occurs in the proximal diaphyseal area (ie,
Jones fracture). Fixation of Jones fractures in active
adolescents should be considered to allow faster return to
regular activities and to prevent refracture. Bone grafting may
not be needed in children with proximal diaphyseal fractures,
as opposed to the adult population. Displaced intra-articular
fractures and acute Jones fractures should be treated with a
nonYweight bearing cast to avoid delayed healing and future
displacement or angulation. We recommend nonYweight
bearing casts for all angulated and/or displaced intra-articular
injuries to avoid delays in healing. From our series, it is
evident that most pediatric fifth metatarsal fractures (regard-
less of age) behave as those found in adults and can be treated
similarly.
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