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5th MT Avulsion Fracture – Shoe or Cast?

January 29, 2021

Editor’s note: This post was modified 31 January 2021. There was confusion (mostly with me – Clay Smith, who edited this post) about the definition of a dancer’s fracture. See comments. This article was about 5th MT base avulsion fractures.

Written by Aaron Lacy

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In patients with 5th metatarsal base avulsion fractures, pain at 6 months after treatment with a hard-soled shoe and weight bearing as tolerated was non-inferior to a short-leg cast. Patients treated with hard-soled shoe also had reduced time to return to pre-injury activity.

Why does this matter?
The 5th metatarsal base avulsion fracture is a common foot injury. Optimizing treatment for these common injuries should be patient and outcome centered. If we can increase function while injured, and reduce time to recovery, that would be an optimal treatment plan.

These hard-soled shoes were made for walkin’…
78 patients (aged 18-65) with 5th metatarsal zone 1 tuberosity avulsion, comminuted, or displaced fractures were placed in a short leg posterior splint after initial ED or outpatient clinic visit. At a 1-week follow up appointment, participants were prospectively randomized to either treatment with a hard-soled shoe or short leg cast, with both groups having weight bearing as tolerated restriction. Primary outcome was mean difference in the 100-mm Visual Analogue Score (a validated pain score) at 6 months after the fracture. The absolute difference comparing the hard-soled shoe group to the short leg cast was -1.3 mm (95% CI -4.3 to 1.8mm, 8.6 ± 7.0 mm vs 9.8 ± 7.3 mm). A secondary outcome, return to pre-injury activity (days), was significantly reduced in the hard-soled shoe group (37.2 ± 14.4 vs 43.0 ± 11.1, p = 0.04). Patient satisfaction was similar between groups.

While several key types of patients were excluded (i.e. obesity, diabetes, concurrent lower-extremity injury, open or pathologic fractures), this opens the door for future studies for possible immediate treatment with hard-soled shoe. This would be faster for providers and, most importantly, seems to be more patient centered. Our orthopedic group recommends immediate use of a walking boot for these fractures, which is nice.

Hard-Soled Shoe Versus Short Leg Cast for a Fifth Metatarsal Base Avulsion Fracture: A Multicenter, Noninferiority, Randomized Controlled Trial. J Bone Joint Surg Am. 2020 Dec 2. doi: 10.2106/JBJS.20.00777. Online ahead of print.

3 thoughts on “5th MT Avulsion Fracture – Shoe or Cast?

  • We’ve been doing this for as long as I can remember. Only reason I ever do a splint/cast for these is if the patient is uncomfortable enough to need immobilization and can’t afford an air boot (about $100, fibreglass/plaster is free for them).

  • Minor point: I sent this to my sports medicine wife who pointed out that a 5th MT avulsion fracture at the base is different than a Dancer’s fracture:
    "A true dancer’s fracture occurs mostly in the middle portion of the long metatarsal bone and is oriented diagonally along the shaft. The fracture line may even spiral and rotate throughout the bone."

    • I should have just stuck with the description and not used a nickname. I was always taught that a zone 1, 5th MT base avulsion fracture was called a dancer’s fracture, and a zone 2 was a Jones fracture. Now I see that the nomenclature varies. Radiopaedia calls it a dancer fracture or pseudo-Jones. Several other sites call the avulsion a pseudo-Jones. And I see many sources that indicate a "dancer’s fracture" involves the diaphysis, often in a spiral-type injury. So, I will amend the post and remove "dancer." I will also remove any reference to Dasher, Prancer, Vixen, Comet, Cupid, Donner, Blitzen, or Rudolph. It is too confusing to use a nickname. Thanks for clarifying!

What are your thoughts?