Lecture 16 parekh jones
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Plus de Selene G. Parekh, MD, MBA
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Lecture 16 parekh jones
- 1. Jones Fractures Selene G. Parekh, MD, MBA Associate Professor North Carolina Orthopaedic Clinic Department of Orthopaedic Surgery Adjunct Faculty Fuqua Business School Duke University Durham, NC 919.471.9622 www.seleneparekhmd.com @seleneparekhmd
- 2. 5th Metatarsal Fractures • Consider in Zones Jones fx Diaphyseal fx
- 3. Jones Fracture • Fracture of the metaphyseal-diaphyseal junction • Must enter the 4/5 intermetatarsal articulation
- 4. Mechanism of Injury • Vertical and mediolateral forces concentrated over the 5th MT • Forced adduction • Can result in a fracture between shaft and immobile base • Greater propensity • Forefoot supination • Knee/ankle/hindfoot varus
- 5. Anatomy • Peroneus brevis • Peroneus tertius • Abductor digiti minimi • Lateral band of plantar fascia • Plantar and dorsal interosseous • Flexor digiti minimi brevis
- 6. Vascular Water-Shed •Periosteal plexus •Nutrient artery •Enters medial aspect of 5th MT at junction of proximal and middle third of bone •Metaphyseal and diaphyseal vessels
- 7. Jones Fracture: Non-Op • Indications • Elderly • Non-athletic • Low-demand • Protocol • NWB cast 4-8 weeks • 100 Fractures of 5th MT: Naval base • 72% union (avg. time 21.2 wks)Clapper, ClinOrth 1995
- 8. Jones Fracture: Non-Op • Protocol • Orthotic • No data
- 9. Jones Fracture: Operative • Indications • Athlete • Acute/stress fx • Active adult • Nonunion • Refracture • Cavovarus = lateral overload
- 10. Jones Fracture: Operative • Operative goals • Expedite healing • Quicker recovery; easier rehab • Decrease nonunion rate • Decrease refracture risk
- 11. Jones Fracture: Operative • Operative options • K-wiring and cast • Tension band wiring • IM curettage and casting • Mini-fragment screws • Low profile plates • IM screw fixation • Open • Percutaneous
- 12. Jones Fracture: Operative •Screw Fixation • Screw choices • 4.5 mm malleolar (Synthes) • 5.0 mm cannulated (ACE/DePuy) • 6.5 mm short thread (Synthes)
- 13. Jones Fracture: Operative •Nonunion after percutaneous screw fixation are all with Cannulated Screws or Small Screws
- 14. Jones Fracture: Operative • Percutaneous Screw Fixation • Solid screw • Large fragment screws • Dedicated system • Cannulated bone preparation • Solid screw fixation
- 15. Jones Fracture: Set-up • Supine • Ankle block • Mini C-arm • Flex knee and place foot on base
- 16. Jones Fracture: Approach • Incision through skin only • 1 fingerbreadth proximal to base of 5th MT • Parallel to peroneals • Mosquito through wound to base of 5th MT
- 17. Jones Fracture: Approach • Solid screw into a curved bone
- 18. Jones Fracture: Approach • Guide pin • Entry site extremely important • Start “high and inside” • Central in the canal on AP and lat views
- 19. Jones Fracture: Technique • Entry drill • Tap to the correct screw diameter • 4.5, 5.5, 6.5mm • Feel the 5th MT head torsional forces
- 20. Jones Fracture: Technique • Measure length • Remove pin and drill guide • Place solid screw • Chose the largest solid screw that comfortably” fits the canal • Do not attempt to place down the entire MT
- 21. Insert Screw “High and Inside” HIGH & INSIDE
- 22. Jones Fracture: Technique • Failure to start “high and inside” • Prominent screw head • Perforation of medial cortexstress riser
- 23. Jones Fracture: Technique • Avoid the headless tapered screw • Difficult to remove • Avoid plate • Prominent • If removed refracture
- 24. Jones Fracture • Postop management • NWB x 2 weeks • WBAT in boot x 4 weeks • Physical therapy
- 25. Jones Fracture • Begin running in modified shoewear at 6-8 weeks if clinically nontender
- 26. Jones Fracture • Follow radiographs • Healing may not be evident for 12 weeks 12 wks p.o.
- 27. Jones Fracture • Leave screw forever!
- 28. Pitfalls of IM Screw • Infection • Delayed wound healing • Distal perforation (stress riser) • Sural neuritis/neuroma • Peroneal tendinitis • Persistent nonunion
- 29. Jones Fracture Nonunion • Hardware fatigue a sign of trouble
- 30. Jones Fracture Nonunion • Cavovarus? • Adequate fixation?
- 31. Jones Fracture Nonunion • If uncertain obtain CT
- 32. Jones Fracture Nonunion • Open Surgical technique • Remove hardware • Open bone graft • Iliac crest vs. allograft vs. substitutes vs. BMP • Re-fixation with largest screw
- 33. Jones Fracture Nonunion • Dwyer for varus