Dancer’s Fractures or Jones Fracture Treatments and Causes
In 1902 Sir Robert Jones described a foot fracture he suffered while dancing. The transverse fracture occurred at the proximal end of the fifth metatarsal, approximately 15 to 20 mm from its base. A dancer’s fracture occurs when the foot is forcefully inverted and plantar flexed while the peroneus brevis muscle forcefully contracts to stabilize the foot. This mechanism of traction from the peroneus brevis tendon or lateral cord of the plantar aponeurosis strongly pulls on its attachment site on the fifth metatarsal. Dancer’s fractures can occur with chronic repetitive overuse or acute trauma.
Now the terms Jones’ fractures and Dancer’s fracture are used to describe two different types of fractures on the 5th metatarsal. A Jones’ fracture occurs where the base meets the shaft of the 5th metatarsal. A Dancer’s fracture is an avulsion of the tip of the 5th metatarsal base. The terms Dancer’s fracture and Jones’ fracture are often both used to describe fractures of the 5th metatarsal. Dancer avulsion fractures and Jones’ fractures can be caused by very similar activities and hurt within an inch of each other. Both can occur with acute or chronic repetitive activities
For the rest of this article we will be discussing Dancer’s fracture or avulsions of the 5th metatarsal. A future article will discuss Jones’ fractures in greater detail.
Symptoms of Dancer’s Fractures
Patients experience severe pain and tenderness at the fracture site along the fifth metatarsal, which is located on the lateral aspect or outside of the foot. People commonly describe this area as the outside and middle part of their foot. It is very common with awkward inversion ankle sprains. Doctors and physicians can occasionally miss the dancer’s fracture initially because of their focus on the damaged tendons and ankle ligaments around the ankle mortise joint, which occurs during an inversion sprain. The increased swelling combined with the patient’s focus on the tibiotalar joint pulls attention away from the fifth metatarsal. Additionally, many people do not perceive much pain at the metatarsal until a few days after the inversion sprain.
When an inversion sprain and dancer’s fracture occurs at the same time, patients tend to feel more the discomfort along the lateral ligaments (anterior talofibular and calcaneofibular ligaments) of the ankle. In these cases, the Dancer’s fracture is seen on follow-up x-rays or when the tenderness along the fifth metatarsal becomes more pronounced while that anterior talofibular and calcaneofibular ligaments improve with therapy.
Complication of Dancer’s Fractures
A dancer’s fracture has a tendency to heal poorly because of poor blood supply and its tendency not to fuse back to the fifth metatarsal, also called a nonunion. The further the fracture occurs from the base of the fifth metatarsal, the slower it is to heal and the more likely for the nonunion to occur. Early diagnosis and evaluation allows for proper diagnosis and treatment of these fifth metatarsal fractures.
Additional injuries associated with the foot are crush injuries, bedroom fractures, chip fractures, hallux rigidus, sesamoid fractures, joint capsule sprains, and sesamoiditis. Mechanisms of injury are commonly different for each of the fractures, however foot and ankle fractures happen with many types of inversion sprains because of the body weight’s force across the foot. Inversion sprains and fractures are commonly associated with basketball, football, soccer, dancing, tennis, and any sport with a tendency to step on another foot or land awkwardly on the ground.
Diagnosis of Fifth Metatarsal Fractures
X-rays or MRIs are utilized to evaluate bone, muscle, tendon, and ligament damage in the ankle and foot. An MRI can better evaluate the muscle and tendon insertion of the peroneus brevis tendon and its correlation to pain on the outside of the foot. An X-ray or MRI can also help differentiate between subtle fractures or tendinopathy. A developmental apophysis (fifth metatarsal tuberosity) is common and normally seen along the fifth metatarsal in growing children and adolescents. Visually, the distinguishing characteristics are the absence of sclerosis along the fractured edges that would be seen in an acute fracture. More importantly, the orientation of the transverse line is seen in a Dancer’s fracture from pulling of the peroneus brevis insertion on the proximal end. Apophysis’ run parallel to the fifth metatarsal instead of transverse. Diagnostic x-rays may require anterior, posterior, oblique, and lateral views of the foot in full flexion.
Treatment of Dancer’s Fractures
In all fractures, the goals are to have the bone and fracture site heal quickly and without complications. As previously mentioned, dancer’s fractures have a tendency for the ends not to unite, also called a nonunion. Nonunion fractures are common in the foot and the wrist, where the scaphoid bone also has a tendency for nonunion fractures.
When the fracture occurs in the proximal zone of the fifth metatarsal, it is more likely to heal correctly and with less risk of nonunion. These fractures can be treated with early immobilization of the foot and limited activity. Fractures that occur further from the proximal end are more likely to experience delayed or nonunion, and these fractures should be treated more aggressively with rest and immobilization. Fractures further from the proximal end are also more likely to require internal screws to fix the two ends of bone close together to increase healing and union.
Internal fixation is seldom required when the fracture occurs in the proximal (zone I and II). Athletes may consider internal fixation with screws because of their increased likelihood of activity causing nonunion or future complications associated with nonunion. Conservative and non-operative treatment is an acceptable option for non-athletes. With nonsurgical management a cast, splint, or walking boot is worn for 4 to 8 weeks, and is usually enough treatment to produce successful healing in 75% of patients.
NSAIDS (non-steroidal anti-inflammatory drugs) or prescription pain medication may be given to reduce pain and inflammation during healing. Rehabilitation or physical therapy can begin once the cast is removed by your foot and ankle surgeon. Sports medicine or physical medicine techniques involve slowly increasing pain-free range of motion. As the range of motion improves, light strengthening and endurance exercises are given. Many of the exercises will involve rubber bands, foam, wobble boards, rocker board’s, unstable surfaces, or vibration therapy. With improvement, weight-bearing exercises increase to challenge the foot’s full range of motion. Agility, jumping, speed, and sports-specific training can be increased over time and with the appropriate progression of treatment.
Depending on the level of activity of the patient, some people can resume normal day-to-day activities within a couple weeks. More athletic individuals may require several additional weeks of therapy and treatment to increase muscle strength and endurance. Younger people heal faster and better from all bone fractures and injuries; older individuals may take a little more time. If there is a delay in healing, a bone stimulator may be prescribed by your podiatrist. With appropriate evaluation and treatment, dancer’s fractures can heal correctly without long term residual limitation.
Links to other toe and foot injuries
Sesamoiditis – is a condition that causes pain underneath the big toe. The sesamoid bones lie in the tendons underneath the big toe and can be very painful.
Sand toe is an injury to the joint capsule of the big toe. The toe can be forcefully plantar flexed and sprained. Any injury to the joint capsule is painful and takes a long time to heal.