A 29-year-old man presents to urgent care on a Saturday with pain in his left foot after playing tennis. A series of x-rays is ordered.
Review the images below and consider what your diagnosis and next steps would be. Resolution of the case is described on the following page.
Differential Diagnosis
- Midfoot sprain
- Avulsion fracture of the base of the 5th metatarsal
- Jones fracture (proximal 5th metatarsal fracture extending into the intermetatarsal joint)
- Os peroneum (ossicles in the peroneus longus)
Diagnosis
The correct diagnosis is an avulsion fracture of the base of the 5th metatarsal. The x-ray shows transverse lucency at the base of 5th metatarsal, not involving the diaphysis. The Lawrence-Botte classification is a commonly used nomenclature for proximal 5th metatarsal fractures, which are categorized into zones. Zone 1 includes a tuberosity (styloid process) avulsion fracture. Zone 2 includes a Jones fracture. Zone 3 includes a diaphyseal stress fracture.
What to Look For
- Pain located on the lateral midfoot at the 5th metatarsal tuberosity
- Does not always result from major trauma or injury and can happen with repetitive exercise
Pearls for Urgent Care Management
- Treatment may include protected weight bearing in a stiff soled shoe, boot, or cast
- Besides rest, anti-inflammatory medications can be used for pain management
- Surgical intervention may be needed, which includes intramedullary screw fixation
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