Jones Fracture

Definition & Historical Note

Anatomy & Zone Classification (Lawrence & Botte / Botte Classification)

Radiograph - Jones Fracture

Why Jones Fractures Are Prone to Nonunion

• Long, narrow, straight fifth metatarsal with an adducted forefoot
• Metatarsus adductus with a curved fifth metatarsal and prominent base
• Cavus foot deformity (mechanical disadvantage for healing)
• Hypovitaminosis D

Diagnosis

• Plain radiographs are usually adequate (AP, oblique, lateral foot views)
• CT scan is considered for more detailed assessment in high-performance athletes
• Must be distinguished from Zone I avulsion fracture (pseudo-Jones) and Zone III stress fracture - the distinction drives management

Torg Classification (for Zone III stress fractures)

Treatment

Zone I (Pseudo-Jones / Tuberosity Avulsion)

• Walking boot, cast boot, or post-op shoe based on symptom level
• Weight bearing as tolerated
• Average healing: ~44 days (range up to 65 days)
• Nonunions rarely painful; if so, can excise the fragment
• ORIF only for displaced intraarticular fractures in young, highly active individuals

Zone II (True Jones Fracture)

• Non-weight-bearing short leg cast for 6-8 weeks
• 15-25% risk of nonunion with conservative management
• Recent data shows CAM boot with weight bearing as tolerated may achieve equivalent union to surgical treatment
• Up to 25% of patients treated non-operatively ultimately require surgical intervention; one study showed a 44% failure rate with cast alone

• Intramedullary screw fixation is the preferred technique
• Minimum screw diameter: 4.5 mm (not recommended to go smaller); mean is ~5 mm; use the largest screw to fill the canal to minimize refracture risk
• The AP radiograph determines screw diameter; lateral radiograph determines screw length
• Return to full activity before radiographic union is a predictor of operative failure
• Failure/refracture rates after surgery: 0-40% (most series <5%); nearly all athletes return to sport

• Acute fractures in competitive or elite athletes
• Zone II/III fractures not healing clinically at 8-12 weeks
• Patients whose occupational demands do not permit prolonged non-weight-bearing
• Recurrent fracture after prior non-operative treatment
• Metatarsus adductus or cavus foot (consider operative given mechanical disadvantage)

Zone III (Diaphyseal Stress Fracture)

• Mostly in athletes (repetitive microtrauma)
• Treatment follows the same principles as Zone II
• One study suggests no distinction needs to be made between Zone II and Zone III in terms of management and outcomes

Key Pitfalls

• Do not confuse Zone I (pseudo-Jones, avulsion) with the true Zone II Jones fracture - they have very different management and prognosis
• In children aged 10-13, a painful secondary ossification center on oblique view = Iselin disease, not a fracture
• Active adolescents with shaft Jones fractures: fixation is increasingly favored to allow faster return to activities and prevent refracture

Recent Evidence

SICK Scapula Syndrome

The Acronym

Definition & Context

• An underlying cause of shoulder pain and dysfunction, OR
• An accompanying result of existing shoulder pathology

Pathomechanics

Normal Scapular Function

• Positioning the glenoid for optimal glenohumeral joint reaction force (compressive, not shear)
• Providing a stable base for rotator cuff force generation
• Elevating and rotating to maintain subacromial clearance during arm elevation
• Acting as a force transfer link in the kinetic chain

• Upward rotation / protraction: Serratus anterior, upper trapezius
• Retraction / external rotation / posterior tilt: Middle and lower trapezius, rhomboids
• Elevation: Upper trapezius, levator scapulae
• Resistance to medial rotation: Rhomboids, levator scapulae

How SICK Scapula Develops

1. Pectoralis minor tightness - pulls the coracoid process anteroinferiorly, causing:
   • Anterior tilt of the scapula
   • Internal rotation of the scapula
   • Inferior displacement ("drooped" scapula)
2. Serratus anterior weakness/fatigue - impairs upward rotation, allowing medial border to "wing"
3. Lower trapezius inhibition - reduces posterior tilt and external rotation

• Decreased subacromial space (protracted scapula narrows the subacromial outlet) - contributes to impingement
• Coracoid pain from pectoralis minor tension and mechanical loading
• Reduced rotator cuff efficiency (suboptimal glenoid orientation)
• Increased risk of SLAP tears, labral pathology, and AC joint injury

Clinical Presentation

• Shoulder pain (often anterior - coracoid region, subcoracoid impingement)
• Subacromial/superior shoulder pain with overhead activity
• Generalized aching around the periscapular musculature
• Sense of shoulder fatigue, "heaviness," or instability
• Often bilateral but asymmetric

• The involved scapula appears "dropped" / inferiorly displaced compared to the contralateral side
• Inferior medial border prominence (winging)
• Coracoid process is prominent and tender to palpation
• Visible asymmetry of scapular resting position

Clinical Assessment

Static Linear Measurements (with arms at side)

1. Infera - vertical height difference of the superomedial angle of the inferior scapula between sides (cm)
2. Lateral displacement - horizontal distance of the superomedial scapular angle from midline, compared between sides (cm)
3. Abduction - angular difference of the medial scapular border from a midsagittal plumb line between sides (degrees)

Scapular Retraction Test (SRT) - Key Diagnostic Maneuver

1. Perform Jobe's "empty can" test (shoulder 90° abduction in scapular plane, maximal internal rotation, resisted elevation) - record pain (0-10) and strength
2. Manually reposition the scapula into retraction and posterior tilt (correct the dyskinesis)
3. Repeat the empty can test
4. Positive SRT = ≥2-point decrease in pain OR significant increase in strength with scapular correction - implies scapular malalignment is contributing to symptoms

Dynamic Assessment

• Arm elevation (look for premature elevation, asymmetric rhythm, winging)
• Lowering phase (eccentric control - often where dyskinesis is most apparent)
• Throwing or sport-specific movements

Associated Conditions

• Subacromial impingement syndrome
• SLAP tears (superior labrum anterior-posterior)
• Rotator cuff pathology (tendinopathy, partial tears)
• Glenohumeral internal rotation deficit (GIRD)
• AC joint pathology - notably, type III AC dislocations are associated with scapular dyskinesis and SICK scapula
• Shoulder instability (anterior)
• Biceps tendinopathy (coracoid/subcoracoid impingement on the biceps tendon)

Management

Phase 1 - Addressing Flexibility Deficits

• Pectoralis minor stretching (cornerstone - releases the primary driver of scapular anterior tilt/protraction)
• Posterior capsule stretching (for associated GIRD)
• Thoracic spine mobility work (thoracic kyphosis contributes to scapular protraction)

Phase 2 - Scapular Stabilizer Strengthening

• Lower trapezius activation (prone Y-raises, prone rows with external rotation)
• Serratus anterior strengthening (wall push-ups with plus, serratus punches, bear crawl variations)
• Middle trapezius (prone T-raises, seated rows)
• Rhomboids with caution - over-strengthening rhomboids without lower trap/serratus balance can worsen anterior tilt

Phase 3 - Rotator Cuff & Kinetic Chain Integration

• Rotator cuff strengthening in the newly corrected scapular position
• Kinetic chain exercises (hip, core, lumbopelvic) to restore proximal power transfer
• Sport-specific movement re-patterning (throwing mechanics, stroke mechanics, etc.)

Scapular Retraction Taping / Bracing

• Can provide short-term symptom relief and proprioceptive re-education
• Helps athletes "feel" the correct scapular position during early rehab

Biofeedback

• Visual biofeedback has shown immediate benefit for altering scapular muscle activation and motion
• Long-term transferability to functional tasks remains under investigation

Operative Treatment

• Surgery is rarely indicated for SICK scapula itself
• Indicated for specific underlying pathology not responding to conservative care (e.g., SLAP repair, labral reconstruction, AC joint surgery)
• Arthroscopic pectoralis minor release has been described for refractory cases where pectoralis minor tightness is the dominant driver
• Following AC joint surgery: structured rehab addressing SICK scapula improves outcomes - one study showed 18/23 patients with type III AC dislocation and scapular dyskinesis had resolved dyskinesis at 12 months after rehabilitation

Key Points Summary

• SICK = Scapular malposition, Inferior medial border prominence, Coracoid pain & malposition, dysKinesis
• Predominantly an overuse fatigue syndrome in overhead/throwing athletes
• Core mechanism: pectoralis minor tightness + serratus anterior / lower trapezius weakness
• The "dropped scapula" on the affected side is the hallmark clinical sign
• Scapular Retraction Test (SRT) is the key clinical test
• Management is primarily rehabilitation - pec minor stretching + scapular stabilizer strengthening
• Coexists with many other shoulder conditions (SLAP, impingement, instability) - address the whole picture