Fifth Metatarsal Pathology

Radiographic findings may include:

  • a linear or curvilinear decreased density dividing a bone into two or more segments
  • ill-defined increased density
  • ossicle adjacent to 5th metatarsal tuberosity
  • abnormal 4-5 intermetatarsal angle
  • abnormal lateral deviation angle

Differential Diagnosis:

  • metatarsal fracture
  • fifth metatarsal apophysis
  • persistent fifth metatarsal apophysis
  • os vesalianum
  • bunionette deformity

Podcasts

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Here are presentations of fifth metatarsal trauma and related variants (with *interpretations):

  • Case 1
  • *Case 1
  • Case 2
  • *Case 2
  • Case 3
  • *Case 3
  • Case 4
  • *Case 4
  • Case 5
  • *Case 5
  • Case 6
  • *Case 6
  • Case 7
  • *Case 7
  • *Case 8a
  • *Case 8b
  • *Case 8c
a Stewart 1 DP b Stewart 1 Medial oblique c Stewart 1 lateral
a Stewart 1 dp marked b Stewart 1 oblique marked c Stewart 1 lateral marked

Dorsoplantar (a), medial oblique (b), and lateral (c) views.
a), b), and c): An ill-defined decreased density runs through the proximal metadiaphysis from anterior-inferior-lateral to posterior-superior-medial (arrows). There is obvious discontinuity of the proximal metadiaphysis inferolaterally that separates the base from the diaphysis. The distal segment is angulated superomedially.
Diagnosis: Proximal diametaphyseal fracture with some distraction and angulation, 5th metatarsal (Stewart type 1, aka Jones fracture).

a Stewart 2 DP b Stewart 2 medial oblique c Stewart 2 lateral
a Stewart 2 DP marked b Stewart 2 medial oblique marked c Stewart 2 lateral marked

Dorsoplantar (a), medial oblique (b), and lateral (c) views.
a), b), and c): An obliquely-oriented curvilinear decreased density runs through the tuberosity from anterior-inferior-lateral (white arrow) to posterior-superior-medial and disrupts the articular surface for the cuboid(black arrow).
Diagnosis: Intra-articular tuberosity fracture with no gross angulation or distplacement, 5th metatarsal (Stewart type 2).

a Stewart 3 DP b Stewart 3 medial oblique c Stewart 3 lateral
a Stewart 3 DP marked b Stewart 3 medial oblique marked c Stewart 3 lateral marked

Dorsoplantar (a), medial oblique (b), and lateral (c) views.
a), b), and c): A curvilinear decreased density runs across the tip of the tuberosity, separating it from the base. It does not enter the joint.
Diagnosis: Tuberosity avulsion fracture, 5th metatarsal (Stewart type 3).

a Stewart 4 DP b Stewart 4 medial obliqu c Stewart 4 lateral
a Stewart 4 medial oblique b Stewart 4 medial oblique marked c Stewart 4 lateral marked

Dorsoplantar (a), medial oblique (b), and lateral (c) views.
a) There is discontinuity along the lateral aspect of the 5th metatarsal base. There may be slight medial displacement of the diaphyseal segment.
b) Two lines of decreased density cross the tuberosity; the more proximal line disrupts the articular surface for the cuboid. The distal line separates the tip of the tuberosity from the remainder of the tubersosity.
c) Ill-defined decreased densities form a letter "V"; the distal "arm" runs across the tip of the tuberosity, and the proximal decreased density runs across the base from inferoposterior to superoanterior.
Diagnosis: Comminuted base/tuberosity fracture, 5th metatarsal (Stewart type 4).

a Stewart 5 DP b Stewart 5 medial oblique c Stewart 5 lateral
a Stewart 5 DP marked b Stewart 5 medial oblique marked c Stewart 5 lateral marked

Dorsoplantar (a), medial oblique (b), and lateral (c) views.
a), b), and c): Physes (growth plates) are stil open and visible. The 5th metatarsal apophysis appears normal proximally (A); however, an ill-defined area of decreased density (arrows) surrounds the distal half of the apophysis which is separated from the proximal portion.
Diagnosis: Apophyseal fracture, 5th metatarsal tuberosity (Stewart type 5).

a normal apophysis b apophysis trauma

 

a normal apophysis marked b apophysis trauma marked

Dorsoplantar (a) and medial oblique (b) views (different patients).
a) Apophysis (arrows) is sclerotic and divided (arrowhead) into two segments.
b) Decreased density involves the entire apophysis, which appears divided into multiple segments (arrows) and is abnormally distracted (line) from the tuberosity/base.
Diagnosis: a) Iselen's disease (normal variant in this case); b) Apophyseal trauma, 5th metatarsal tuberosity (Stewart type 5).

a persistent 5th met apophysis b os vesalianum
a persistent 5th met apophysis marked b os vesalianum marked

Medial oblique (a) and dorsoplantar (b) views (different patients).
a) The apophysis (PA) remains separate and unattached to the tuberosity.
b) A small ossicle (V) is seen adacent to the tip of the tuberosity; the adjacent tuberosity is flat and there are small spurs at its margins (arrows).
Diagnosis: a) Persistent 5th metatarsal apophysis; b) Os vesalianum versus nonunion avusion fracture, 5th metatarsal tuberosity.

a normal 5th met b 5th met IM angle increased c 5th met bowed

Dorsoplantar views (different patients).
a) Normal 5th metatarsal.
b) Tailor's bunion secondary to increased 5th intermetatarsal angle (Fallat type 3).
c) Tailor's bunion secondary to abnormal bowing of 5th metatarsal (Fallat type 2).

a 5th IM angle b 5th IM angle 2

Dorsoplantar views (same patient). 4th-5th intermetatarsal angle.
a) Method 1 (5th metatarsal axis).
b) Method 2 (medial border of 5th metatarsal shaft).

a lateral deviation normal b lateral deviation abnormal

Dorsoplantar views (different patients).
a) Normal lateral deviation angle.
b) Abnormal lateral deviation angle.

Should a radiographic study be ordered for suspicion of fifth metatarsal fracture?

Definitely yes.

What are the best views to order?

At a minimum order DP, medial oblique, and lateral views.

Other information

5th metatarsal stress fractures are very uncommon.

It may be dfficult to determine if the base/tuberosity is comminuted.

References:

  1. Christman RA: Foot and Ankle Radiology, 2nd edition, Lippincott Williams & Wilkins, 2015.