Anatomical Features of Proximal Fifth Metatarsal Fracture: A Radiographic Study

doi:10.21203/rs.3.rs-2069626/v1

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Anatomical Features of Proximal Fifth Metatarsal Fracture: A Radiographic Study

https://doi.org/10.21203/rs.3.rs-2069626/v1

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Background

The existing study is not in-depth enough to address the high risk of fifth metatarsal proximal fracture nonunion. The purpose of this study was to investigate basic anatomical structure characteristics of the fifth metatarsal and to provide a clinical anatomical basis for the prevention and treatment of basal fractures of the fifth metatarsal.

Methods

Medical records were obtained and retrospectively reviewed to determine the differences in foot type and metatarsal morphology between fractured and non-fractured participants. Some related indicators of the fifth metatarsal were measured and analyzed anatomical data for clinical support.

Results

Seventy normal metatarsals and one hundred and twenty-three patients were included in the analysis. In comparison between normal and proximal fractures of the fifth metatarsal, we found that there was a significant difference in the lateral separation angle on the foot oblique radiographs (P < 0.05). In addition, in fractures, there was no difference between different injured areas. All lengths except the length of interface between fifth metatarsal and fourth metatarsal had statistical difference between men and women in gender (P < 0.05), and there were statistical differences in the contact length of joint surface between fifth metatarsal and dice (P < 0.05), the length of interface between fifth metatarsal and fourth metatarsal (P < 0.05), the width of the fifth metatarsal (P < 0.05) and the fifth metatarsophalangeal angle (P < 0.05) on the measurement side.

Conclusion

In the prevention of proximal fifth metatarsal fractures, special attention should be paid to the prevention of left foot and the recovery of lateral separation angle. In addition, due to differences in length, auxiliary supports and screws should be used longer in males than in females during treatment.

Fifth metatarsal

Base fracture

Foot characteristics

Anatomy

The proximal fracture of the fifth metatarsal is a fracture that occurs in the coarseness, base and proximal shaft of fifth metatarsal, sometimes involving the articular surface between the fourth and fifth metatarsals. In recent years, these injuries have been steadily increasing. The incidence of delayed union, nonunion, and refracture of fractures is increased due to the special anatomical structure and blood supply features.^{1, 8, 23} Otherwise, the number of delayed unions and nonunions caused by inappropriate treatment has also grown.^{12, 14, 16, 21}

So far, there are few studies on the incidence of proximal fractures of the fifth metatarsal, and the incidence of fractures is not clear enough.^{7, 10, 17, 27} All cases in this article are classified. We will also describe the incidence of different zones of proximal fifth metatarsal fractures to provide some data. And the fifth metatarsal proximal fractures are more commonly studied in athletes, ^{5, 18, 20} so this paper focuses on non-athletes to help ordinary people recover foot function as soon as possible. With the gathering and analysis of foot-related data, the occurrence of fifth metatarsal base fractures in patients is further minimized or treated in this article.

Medical data from January 2015 to October 2021 were obtained and retrospectively examined after approval by the institutional review board.

In this study, data analysis and data collection were performed on 123 patients with fifth metatarsal base fracture, and 70 adults with normal fifth metatarsal structure were compared to analyze the characteristics of patients with fifth metatarsal basal fracture ( Fig. 1 ). Normal fifth metatarsal inclusion criteria were adults with mature bone development and a fifth metatarsal with intact structure and tolerated imaging examiners. The researchers collected patients with fifth metatarsal basement fractures and excluded those with other fracture diseases and severe osteoporosis. Information about their gender, age, measurement side (right, left, or bilateral) was collected. All the data involved in the study was shown in Table 1.

Table 1

Comparison of measurements between the fractured and normal fifth metatarsal
	Fractured (N = 123)	Normal (N = 70)	P value
Median age, range(years)	51.00(60.00–39.00)	45.50(54.25-33.00)	/
Male, number (%)	61(49.59%)	39(55.71%)	0.455^a
Left, number (%)	70(56.91%)	35(50.00%)	0.371^a
ab(mm)	7.59 ± 0.59	7.55 ± 0.61	0.540^b
bc(mm)	0.74 ± 0.18	0.70 ± 0.22	0.280^b
cd(mm)	1.57 ± 0.27	1.59 ± 0.21	0.372^b
de(mm)	1.27 ± 0.26	1.24 ± 0.22	0.364^b
df(mm)	2.20 ± 0.28	2.20 ± 0.21	0.890^b
dg(mm)	1.85 ± 0.28	1.80 ± 0.19	0.162^b
∠α(°)	5.09 ± 4.24	4.94 ± 4.69	0.591^b
∠β(°)	3.61 ± 2.52	3.50 ± 2.31	0.898^b
∠γ(°)	68.43 ± 13.12	68.60 ± 11.82	0.867^b
∠δ(°)	16.19 ± 7.23	16.35 ± 6.36	0.965^b
∠ε(°)	2.44 ± 1.53	2.90 ± 1.49	0.035^{b *}
∠ζ(°)	144.25 ± 15.39	140.60 ± 23.67	0.365^b
∠η(°)	15.87 ± 3.52	16.69 ± 4.15	0.279^b
^a Chi-square test ^b Mann-Whitney U Test ^*P value < 0.05

Relevant points of the main fifth metatarsal for each group are as follows: a: the fifth metatarsal head's midpoint; b: the lowest point at the fifth metatarsal base; c: the fifth plantar cuboid articular surface's lowest point; d: the lowest point of the articular surfaces of the fourth and fifth metatarsals; e: the highest point of the articular surfaces of the fourth and fifth metatarsals.

On oblique radiograph, relevant length measurements include: ab: maximum length of fifth metatarsal; bc: the length of non-contact between the basal plane of the fifth metatarsal and the articular plane of the dice; cd: contact length of joint surface between fifth metatarsal and dice; de: length of interface between fifth metatarsal and fourth metatarsal; df: the width of the fifth metatarsal. From the lowest point of the interface between the fifth metatarsal and the fourth metatarsal, perpendicular to the central axis of the fifth metatarsal, intersect with the lateral bone of the fifth metatarsal to obtain the length; dg: the height of the fifth metatarsal. From the lowest point of the contact surface between the fifth metatarsal and the fourth metatarsal, make a vertical line to the lateral bone surface of the fifth metatarsal, intersect with the lateral bone of the fifth metatarsal to get the length.

On anteroposterior or oblique radiograph, related angle measurements include: ∠α: the second-fifth intermetarsal angle (IMA2-5); ∠β: the fourth-fifth intermetarsal angle (IMA4-5); ∠γ: the angle between the fifth metatarsal's articular surface as well as the dice and fifth metatarsal’s lateral surface; ∠δ: the fifth metatarsophalangeal angle (MTP-5); ∠ε: the lateral separation angle; ∠ζ: the lateral longitudinal arch angle; ∠η: the angle of the fifth metatarsal to the ground.

SPSS23.0 software was used to perform statistical analysis on all the data. Among the 123 cases collected, the number of three different zones was 80 ( 65.04% ), 49 ( 39.84% ) and 5 ( 4.07% ), respectively ( Fig. 2 ). Median age of patients was 51.00(60.00–39.00) years, 50.41% were female, and the left side was fractured in 56.91% of patients. Chi-square test was used for gender and measurement side.

Other data were tested by Mann-Whitney U Test and concluded as follows. Firstly, we detected whether there was a statistical difference between the normal fifth metatarsal and the affected fifth metatarsal. There were differences in the lateral separation angle (P = 0.035) between the two groups. See Table 1 for more information.

Secondly, we focused on the patients and compared the data of affected side, gender and division. It is thus concluded, there was no difference in the data of different regions. There were differences in ab (P < 0.001)、bc (P < 0.001)、cd (P < 0.001)、df (P < 0.001) and dg (P < 0.001) between men and women in gender, and there were statistical differences in cd (P < 0.001)、de (P = 0.008)、df (P = 0.010) and the fifth metatarsophalangeal angle (P = 0.025) in the measurement side. The overview of participants is shown in Table 2, 3, 4.

Table 2

Imaging analysis of proximal fifth metatarsal fracture in sexuality
	Male (N = 61)	Female (N = 62)	P value
ab(mm)	7.85 ± 0.54	7.34 ± 0.53	0.000^*
bc(mm)	0.79 ± 0.18	0.68 ± 0.17	0.000^*
cd(mm)	1.63 ± 0.21	1.51 ± 0.31	0.000^*
de(mm)	1.31 ± 0.27	1.23 ± 0.24	0.059
df(mm)	2.31 ± 0.29	2.10 ± 0.24	0.000^*
dg(mm)	1.94 ± 0.31	1.76 ± 0.21	0.000^*
∠α(°)	4.62 ± 3.90	5.56 ± 4.54	0.406
∠β(°)	3.33 ± 2.60	3.88 ± 2.42	0.051
∠γ(°)	67.22 ± 13.08	69.61 ± 13.16	0.193
∠δ(°)	15.99 ± 6.84	16.38 ± 7.65	0.532
∠ε(°)	2.31 ± 1.53	2.58 ± 1.53	0.245
∠ζ(°)	144.14 ± 16.34	144.36 ± 14.54	0.519
∠η(°)	16.58 ± 3.84	15.18 ± 3.05	0.122
^*P value < 0.05

Table 3

Imaging analysis of proximal fifth metatarsal fracture in fractured side
	Right (N = 53)	Left (N = 70)	P value
ab(mm)	7.60 ± 0.56	7.58 ± 0.62	0.986
bc(mm)	0.75 ± 0.18	0.72 ± 0.18	0.358
cd(mm)	1.48 ± 0.23	1.64 ± 0.23	0.000^*
de(mm)	1.33 ± 0.29	1.23 ± 0.23	0.008^*
df(mm)	2.14 ± 0.28	2.24 ± 0.28	0.010^*
dg(mm)	1.82 ± 0.30	1.88 ± 0.26	0.304
∠α(°)	4.59 ± 4.17	5.48 ± 4.29	0.064
∠β(°)	3.45 ± 2.28	3.73 ± 2.69	0.654
∠γ(°)	68.57 ± 13.93	68.32 ± 12.58	0.859
∠δ(°)	15.03 ± 6.63	17.07 ± 7.58	0.025^*
∠ε(°)	2.34 ± 1.44	2.52 ± 1.60	0.824
∠ζ(°)	143.91 ± 15.25	144.51 ± 15.60	0.934
∠η(°)	15.65 ± 3.57	16.04 ± 3.50	0.584
^*P value < 0.05

Table 4

Imaging analysis of proximal fifth metatarsal fracture in the partition
	Zone 1 (N = 80)	Zone 2 (N = 49)	Zone 3 (N = 5)	P value
ab(mm)	7.67 ± 0.58	7.54 ± 0.63	7.13 ± 0.53	0.085
bc(mm)	0.74 ± 0.18	0.74 ± 0.19	0.68 ± 0.11	0.631
cd(mm)	1.58 ± 0.29	1.57 ± 0.23	1.50 ± 0.12	0.762
de(mm)	1.28 ± 0.24	1.23 ± 0.21	1.63 ± 0.59	0.252
df(mm)	2.20 ± 0.32	2.24 ± 0.25	2.08 ± 0.19	0.438
dg(mm)	1.86 ± 0.27	1.87 ± 0.28	1.56 ± 0.46	0.314
∠α(°)	4.94 ± 4.17	5.46 ± 4.25	4.00 ± 2.64	0.720
∠β(°)	3.53 ± 2.63	3.73 ± 2.31	4.08 ± 1.85	0.524
∠γ(°)	66.73 ± 13.33	70.11 ± 13.51	71.84 ± 5.73	0.338
∠δ(°)	15.63 ± 6.21	17.47 ± 8.49	19.78 ± 8.73	0.224
∠ε(°)	2.42 ± 1.55	2.45 ± 1.49	2.72 ± 1.24	0.832
∠ζ(°)	143.57 ± 18.80	145.66 ± 4.76	146.92 ± 3.54	0.827
∠η(°)	15.61 ± 3.72	16.75 ± 3.02	15.68 ± 4.10	0.102
^*P value < 0.05

The metatarsal fracture is one of the most common injuries in the foot, with about 70% affecting the fifth metatarsal and 80% occurring near the base.²² The fifth metatarsal is located in the most lateral part of the foot, which is an essential part of the lateral longitudinal arch and transverse arch of the foot.^{12, 13}It plays a fundamental role in foot stress conduction, weightbearing buffer and maintenance of lateral balance. The fifth metatarsal extends laterally and protrudes, forming joints with the dice and the base of the fourth metatarsal, respectively. The stability of these joints is provided by ligaments of the joint capsule, dorsal and plantar wedge transverse ligaments, and the lateral band of plantar fascia.^{13, 15} When the fifth metatarsal is subjected to external force, it is easy to cause a fracture at the base. Combined with the fifth metatarsal proximal lateral more vulnerable to external injuries, increased the risk of an injury and even a fracture. Most studies on the fracture of the fifth metatarsal base believe that it is strongly correlated with the acute injury of the tendon.^{25, 28} In addition, the blood supply at the bottom of the fifth metatarsal base, mainly relying on nourishing blood vessels, is more likely to lead to delayed healing of the bottom fracture of the fifth metatarsal.^{8, 23}Otherwise, the fifth tarsometatarsal joint is a composite activity of the sagittal and horizontal plane. The complexity of movement also increases the difficulty of treatment.

Since the first description of Jones fractures in 1902,⁶the classification system for the proximal part of the fifth metatarsal fracture has been developing.^{3, 4, 10, 24, 26} We used the Lawrence and Botte's classification to possibly avoid any differences in the description of these fractures. At this time, the common method for the classification of fractures at the proximal of the fifth metatarsal is to divide the fracture types into three categories. At present, Lawrence and Botte's classification and Torg's classification are widely used in clinical practice.^{10, 26} Under this system, the classification of proximal fifth metatarsal fractures according to Lawrence differentiates 3 fracture types: tuberosity avulsion fractures (zone 1), Jones’ fractures (zone 2) and proximal diaphyseal fractures (zone 3).

In this study, from the analysis of imaging bone structure, this paper studies whether there are some special angle values and length values that have potential effects on this fracture. In view of these recent studies and our own work, we believe that patients with fractures of the fifth metatarsal base may have different medial deviation angles. The risk of an increase in the length and diameter of the fifth MT remains controversial. In order to further separate the risk factors of this fracture, further research is needed to observe the larger group of patients and the normal fifth metatarsal morphology so as to draw a general rule. According to our research results, we infer that there are differences in the length of the fifth metatarsal between the gender. The length of male fifth metatarsal is generally longer than that of female, so we suggest that the length of male brace or surgical screw should be appropriately increased in the treatment. On different sides, some lengths may be meaningful. In addition, we found that the fifth metatarsophalangeal joint angle of the affected side was also different. In the measurement of the angle related to the fifth metatarsal, we found that the angle of female was generally larger than that of male. Although there was no statistical difference on some evaluation criterions, in order to better restore the anatomy of the fifth metatarsal, it was recommended to conduct individualized treatment between implant angle and support design.

The treatment of fifth metatarsal fractures is developing and some clinical and theoretical studies are being applied to non-surgical or surgical treatment. In any case, when deciding on treatment, special attention should be paid to adults with surgical and non-surgical treatments based on patient preferences. The choice of treatment varies according to anatomic region, patient history and imaging findings. The recommended treatment for nondisplaced zone 1 fracture is to use walking plaster, air boots or weightbearing protective compression package until discomfort is reduced.⁹ If displacement exceeds 2 mm or angle deviation exceeds 30 %, these fractures should be treated surgically.^{19, 20, 29} The treatment of zone 2 and zone 3 fractures is more complex because they are considered to prolong healing time and nonunion. It is suggested that surgical intervention should be carried out for the active population with symptomatic bone nonunion in zones 2 and 3.²

Some scholars observed the consensus of morphological factors, and it is important to carry out further research on this work.^{1, 8, 11}In conclusion, the lateral deviation angle of the fifth metatarsal should be further studied. In the patients, we suggest that men and women should be treated differently because the length of men is longer than that of women and most of them have statistical differences. In addition, although there is no statistical difference in most angles, we find that the angle of women is generally larger than that of men. Attention should be paid to surgical treatment and brace treatment. The final results will support taking positive action to help reduce the risk of fractures to guide further fracture healing and treatment. With the deepening of imaging research and anatomical research, it is bound to be more widely used in the treatment of the fifth metatarsal base fracture, and constantly improve and perfect the known technical defects and surgical adverse reactions.

The main limitation of this study lies in its descriptive design. Nevertheless, we can still understand some anatomical data of the fifth metatarsal and analyze the characteristics. Otherwise, one limitation of current research is that all the subjects are nonathletes. In this area of anatomy, the collection of cases is limited because the investigation is confined to a hospital and old participants may affect final outcomes. In addition, there are inconsistencies in the distinction between the chronicity of fractures and the mechanisms of stress fractures and acute trauma. Therefore, this paper does not study the trauma mechanism.

Ethics approval and consent to participate

The study was approved by the local ethics committee. Ethical opinion number: YJ-KY2021072.

Consent for publication

Not applicable.

Availability of data and materials

The datasets used and analyzed during the current study are available from the first author on a reasonable request and upon completing a data sharing agreement. The data are not publicly available due to inclusion of unique health information from participants in a specific and limited region that could compromise participant confidentiality.

Competing interests

No conflicts interest existed in the submission of this manuscript, and the manuscript was approved by all authors for publication.

Funding

National Natural Science Foundation of China (Youth Science Foundation Project), Project Number: 82004458; Traditional Chinese Medicine Research Project of Sichuan Traditional Chinese Medicine Administration, Project Number:2020JC0138; Central Funds Guiding the Local Science and Technology Development General Program of Sichuan Provincial Science and Technology Department, project number: 2021ZYD0078; Science and Technology Plan Project of Office of Science and Technology and Talent Work of Luzhou, project number: 2020-ZRK-60; Scientific Research Project of Southwest Medical University, project number: 2020TYZD002; Funded project of PingKai Medical Technology Co.,Ltd., project number: YK2020A01. The content is the responsibility of the authors and does not necessarily represent the official views of the funding institutions.

Authors' Contributions

Ming-hui Li planned and wrote the study. Xu Chen took a lead in manuscript writing. Lei Huang and Gui-xuan You conceived and carried out the statistical analysis. Xiao-gao Tang, Bing-kun Li, and Xin Zhou pushed the manuscript development. Ming-hui Li, Xu Chen, Lei Huang and Gui-xuan You are the co-first authors. All authors reviewed the manuscript.

Corresponding author: Correspondence to Lei Zhang and Ding-xuan Wang.

Acknowledgements

Not applicable.

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Anatomical Features of Proximal Fifth Metatarsal Fracture: A Radiographic Study

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