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Intramedullary Screw Fixation for Chronic Proximal Fourth Metatarsal Stress Fractures: A New Technique for the Fourth Metatarsal “Jones”

In athletes, conservative treatment of proximal fourth metatarsal stress fractures can result in deconditioning, delayed return to sport, disability, and recurrence of the fracture. Although nonoperative care has been advocated for such an injury, internal fixation can provide more rapid and reliable healing in athletes. However, until now, bone grafting with or without dorsal plate fixation was the only surgical option. We have developed a means of inserting a 4.5-mm cannulated intramedullary screw as a safe approach that can promote complete healing and timely return to sport. This fixation shows healing similar to intramedullary screw fixation of the fifth metatarsal Jones fracture. We term this the “fourth metatarsal ‘Jones’ fracture” and treat it in a similar manner as the fifth. The senior author has treated 8 athletes surgically with this approach for chronic nonunion of fourth metatarsal stress fractures. Clinical and radiographic assessments up to 10 years after surgery show 100% healing without fourth tarsometatarsal joint degeneration. Subjective reporting indicates 100% healing in as little as 6 weeks. No postoperative complications (screw failure, persistent sclerosis, refractures, or arthritis at the tarsometatarsal joint) have occurred. This technique results in reliable, effective, fast healing of chronic fourth metatarsal stress fracture sites in competitive athletes. However, the technique is technically demanding.