Proximal fifth metatarsal fractures distal to the tuberosity, also known as Jones’ fractures, are troublesome fractures to manage with a high incidence of delayed union and nonunion.

We conducted a retrospective study of 32 patients with fractures of the fifth metatarsal distal to the tuberosity over a three year period. The aim was to assess healing with non-weight bearing and variations of weight bearing mobilization including minimal, partial and full weight bearing. This is one of the largest reported series of such fractures. These fractures were classified as acute fractures (14 fractures), fractures with features of delayed union (15 fractures) and fractures with features of nonunion (three fractures) at presentation according to the radiological classification used by Torg in 1984. These patients were treated in a plaster cast and mobilised either non-weight bearing or with variations of weight bearing. These patients were followed up for a mean of 16 months.

Our findings correspond with those observed by Torg and we describe a correlation between the radiological appearance of the fracture at presentation and the clinical course. Prevailing guidelines for the management of these fractures are ambiguous. A standardized classification is important because there is great variability in the types of fractures and appropriate treatment. It is important that radiological features are correlated with clinical features and appropriate treatment instituted. The treatment of choice for acute fractures is immobilization of the limb in a below-knee non-weight bearing plaster for 6 to 8 weeks. Fractures with delayed union may eventually heal if treated non-operatively, although this may take up to 20 weeks. An active athlete will benefit from early surgery. Fractures with symptomatic nonunion require surgery.

Introduction Exposure of the lesser metatarsophalangeal (MTP) joints is needed for many procedures e.g. forefoot arthroplasty and multiple Weil-type osteotomies. Traditionally collateral incisions and plantar incisions have been described. However exposure using these is often difficult and inadequate in the presence of rheumatoid arthritis (RA) and associated deformities. Transverse incisions offer excellent exposure, extensibilty, versatility and improved range of movements with decreased neurovascular compromise. Aesthetic wound healing is common. We describe our results following the use of a curved transverse incision for the Mann-Thompson type of arthroplasty and multiple Weil osteotomies. A single incision was used to expose all lesser MTP joints.

Method A total of 34 consecutive patients with either procedure were included, comprising 52 feet including 18 bilateral forefoot arthroplasty and 10 multiple Weil osteotomies. All patients were followed up for 12 months. A questionnaire was completed for each patient at conclusion of surgery, and then at 6 and 12 months. Ease of exposure, visualisation of target areas, wound healing, neurovascular complications and average range of movement were assessed. Four surgeons were involved in the study: one consultant, one NT middle grade, and two specialist registrars.

Results Three minor wound healing complications were noted, with no need for repeat surgery. No neurovascular complications were noted, cosmesis was good-to-excellent in all, a global range of movement of 30 degrees was achieved in 95%. Ease of exposure and visualisation of the target area was good-to-excellent in all patients. All surgeons reported satisfaction with the approach and rated it superior to the collateral and plantar incisions.

Conclusion We believe that this represents excellent results in this difficult group of patients. The curved transverse incision is a workhorse incision for the lesser MTP joints.