Working Diagnosis:
Diaphyseal stress fracture and subacute metaphyseal fractures bilaterally

Treatment:
He was kept in the walking boot during the day but allowed to practice and play as long as his pain did not progress. No plans for surgical correction of the non-union fractures.

Outcome:
At the end of the season he was pain free and he stopped using the walking boot.

Author's Comments:
Management of rare cases of combined diaphyseal stress fractures and Jones fractures, as in our case, provides a great challenge to the treating physician.

Controversies in diagnosing and classifying fractures of the proximal 5th metatarsal are common:
-Anatomic: Tuberosity vs Jones vs Diaphyseal stress fractures
-Radiographic appearance: Acute vs Delayed vs Nonunion fractures

There has been tremendous debate in the literature regarding whether to treat proximal fifth metatarsal fractures conservatively or surgically:
-Primary or delayed
-Whether the athlete should be treated more aggressively initially than the more sedentary person sustaining the same fracture.

If a surgical route was chosen, the controversy of whether the treatment should be:
-Closed or open
-Bone grafted or fixed with an intramedullary screw.

In our case, the transverse orientation of the bony defect at the 5th metatarsal based on his MRI is more in keeping with a subacute Jones fracture with incomplete osseous bridging.

Editor's Comments:
This case highlights the difficulties with diagnosing, classifying and treating 5th metatarsal fractures, the multiple imaging modalities that can help with diagnosis, and some of the controversies surrounding treatment options.

Roehrig, GJ, McFarland EG, Cosagea AJ et. al. Unusual Stress Fracture of the Fifth Metatarsal in a Basketball Player. Clin J Sport Med 2001;11(4):271-273.

References:
www.louortho.com/documents/quill_controv.pdf

www.podiatryinstitute.com/pdfs/Update_2006/2006_28.pdf

www.orthobullets.com/foot-and-ankle/7031/5th-metatarsal-base-fracture

www.podiatrytoday.com/current-concepts-in-treating-fifth-metatarsal-fractures

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