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Fractures of Proximal Portion of Fifth Metatarsal Bone: Anatomic and Imaging Evidence of a Pathogenesis of Avulsion of the Plantar Aponeurosis and the Short Peroneal Muscle Tendon¹

¹ From the Department of Radiology, School of Medicine, University of California, San Diego Medical Center, Calif (D.J.T., S.J.T., Y.K., D.R.); Department of Radiology, Veterans Administration San Diego Medical Center, Calif (D.J.T., S.J.T., Y.K., D.R.); and Department of Orthopedic Surgery, Scripps Clinic Medical Group, San Diego, Calif (M.J.B.). From the 2001 RSNA scientific assembly. Received March 18, 2002; revision requested April 30; revision received June 17; accepted July 1. Supported by Veterans Administration grant SA-360 and A. S. Onassis Public Benefit Foundation educational grant U-033. Address correspondence to D.J.T., 13 Papadopoulos St, Ioannina 45444, Greece (e-mail: rjtheodorou@hotmail.com).

View larger version (25K): [in a new window]   Figure 1a. (a) Drawing shows the major structures attaching to the proximal portion of the fifth metatarsal bone (MT5). CU = cuboid bone, PAL = lateral component of the plantar aponeurosis, PB = peroneus brevis tendon (ie, short peroneal muscle [SPM] tendon), PT = peroneus tertius tendon (ie, third peroneal muscle [TPM] tendon). (b) Drawing shows the fracture zones at the proximal portion of the fifth metatarsal bone. 1 = zone of tuberosity avulsion fracture, 2 = zone of Jones fracture, 3 = zone of diaphyseal stress fracture. (Drawings courtesy of S.J.T.)

View larger version (22K): [in a new window]   Figure 1b. (a) Drawing shows the major structures attaching to the proximal portion of the fifth metatarsal bone (MT5). CU = cuboid bone, PAL = lateral component of the plantar aponeurosis, PB = peroneus brevis tendon (ie, short peroneal muscle [SPM] tendon), PT = peroneus tertius tendon (ie, third peroneal muscle [TPM] tendon). (b) Drawing shows the fracture zones at the proximal portion of the fifth metatarsal bone. 1 = zone of tuberosity avulsion fracture, 2 = zone of Jones fracture, 3 = zone of diaphyseal stress fracture. (Drawings courtesy of S.J.T.)

View larger version (111K): [in a new window]   Figure 2a. Pathologic specimens from same cadaver show normal anatomy of the lateral supporting structures of the proximal portion of the fifth metatarsal bone (MT5) from the lateral aspect of the foot. PB = peroneus brevis tendon (ie, SPM tendon). (a) Dissection of cadaveric specimen reveals the major supporting structures attaching to the base of the fifth metatarsal bone. Surgical scissors are inserted under the SPM tendon, close to the insertion of this tendon into the metatarsal bone. The entire course of the PAL and the broad site of attachment of this structure to the base of the fifth metatarsal bone are seen. (b) Gross cadaveric specimen demonstrates the bare proximal portion of the fifth metatarsal bone. Surgical clamps tighten the broad fibrous band (b) formed by fibers converging from the PAL and the SPM tendon. (c) Dissection of cadaveric specimen reveals the tendinous and ligamentous structures inserting into the proximal portion of the fifth metatarsal bone. The dark area marked by the arrow indicates tuberosity, and the thick black line around the area is the site of attachment of the PAL. The anterior frenular ligament (f) extending from the long peroneal muscle tendon (PL) to the base of the fifth metatarsal bone is seen between hemostats. The SPM tendon has been reflected over the long peroneal muscle tendon.

View larger version (111K): [in a new window]   Figure 2b. Pathologic specimens from same cadaver show normal anatomy of the lateral supporting structures of the proximal portion of the fifth metatarsal bone (MT5) from the lateral aspect of the foot. PB = peroneus brevis tendon (ie, SPM tendon). (a) Dissection of cadaveric specimen reveals the major supporting structures attaching to the base of the fifth metatarsal bone. Surgical scissors are inserted under the SPM tendon, close to the insertion of this tendon into the metatarsal bone. The entire course of the PAL and the broad site of attachment of this structure to the base of the fifth metatarsal bone are seen. (b) Gross cadaveric specimen demonstrates the bare proximal portion of the fifth metatarsal bone. Surgical clamps tighten the broad fibrous band (b) formed by fibers converging from the PAL and the SPM tendon. (c) Dissection of cadaveric specimen reveals the tendinous and ligamentous structures inserting into the proximal portion of the fifth metatarsal bone. The dark area marked by the arrow indicates tuberosity, and the thick black line around the area is the site of attachment of the PAL. The anterior frenular ligament (f) extending from the long peroneal muscle tendon (PL) to the base of the fifth metatarsal bone is seen between hemostats. The SPM tendon has been reflected over the long peroneal muscle tendon.

View larger version (100K): [in a new window]   Figure 2c. Pathologic specimens from same cadaver show normal anatomy of the lateral supporting structures of the proximal portion of the fifth metatarsal bone (MT5) from the lateral aspect of the foot. PB = peroneus brevis tendon (ie, SPM tendon). (a) Dissection of cadaveric specimen reveals the major supporting structures attaching to the base of the fifth metatarsal bone. Surgical scissors are inserted under the SPM tendon, close to the insertion of this tendon into the metatarsal bone. The entire course of the PAL and the broad site of attachment of this structure to the base of the fifth metatarsal bone are seen. (b) Gross cadaveric specimen demonstrates the bare proximal portion of the fifth metatarsal bone. Surgical clamps tighten the broad fibrous band (b) formed by fibers converging from the PAL and the SPM tendon. (c) Dissection of cadaveric specimen reveals the tendinous and ligamentous structures inserting into the proximal portion of the fifth metatarsal bone. The dark area marked by the arrow indicates tuberosity, and the thick black line around the area is the site of attachment of the PAL. The anterior frenular ligament (f) extending from the long peroneal muscle tendon (PL) to the base of the fifth metatarsal bone is seen between hemostats. The SPM tendon has been reflected over the long peroneal muscle tendon.

View larger version (130K): [in a new window]   Figure 3a. Supporting structures of the proximal portion of the fifth metatarsal bone (MT5) in a cadaveric foot, with MR imaging-anatomic correlation. (a) Coronal T1-weighted MR image (600/22) obtained at the level of the base of the fifth metatarsal bone shows the SPM tendon (curved arrow) inserting into the dorsal surface of the base of the fifth metatarsal bone and the PAL (open arrow) inserting into the plantar surface of the bone. (b) Coronal anatomic slice approximately 3 mm posterior to the imaging section in a shows the SPM tendon (curved arrow) and the PAL (open arrow) inserting into the proximal portion of the fifth metatarsal bone.

View larger version (158K): [in a new window]   Figure 3b. Supporting structures of the proximal portion of the fifth metatarsal bone (MT5) in a cadaveric foot, with MR imaging-anatomic correlation. (a) Coronal T1-weighted MR image (600/22) obtained at the level of the base of the fifth metatarsal bone shows the SPM tendon (curved arrow) inserting into the dorsal surface of the base of the fifth metatarsal bone and the PAL (open arrow) inserting into the plantar surface of the bone. (b) Coronal anatomic slice approximately 3 mm posterior to the imaging section in a shows the SPM tendon (curved arrow) and the PAL (open arrow) inserting into the proximal portion of the fifth metatarsal bone.

View larger version (127K): [in a new window]   Figure 4a. Supporting structures of the proximal portion of the fifth metatarsal bone (MT5) in a cadaveric foot, with MR imaging-anatomic correlation. LP = LPL, PB = peroneus brevis tendon (ie, SPM tendon). (a) Sagittal T1-weighted MR image (600/22) of the lateral aspect of the foot shows the sites of insertion of the SPM tendon, PAL, and LPL into the proximal portion of the fifth metatarsal bone. (b) Sagittal anatomic slice shows the SPM tendon, PAL, and LPL inserting into the proximal portion of the fifth metatarsal bone. The tendon of the abductor muscle of the little toe (arrow) is seen coursing distally between the SPM tendon and the PAL.

View larger version (120K): [in a new window]   Figure 4b. Supporting structures of the proximal portion of the fifth metatarsal bone (MT5) in a cadaveric foot, with MR imaging-anatomic correlation. LP = LPL, PB = peroneus brevis tendon (ie, SPM tendon). (a) Sagittal T1-weighted MR image (600/22) of the lateral aspect of the foot shows the sites of insertion of the SPM tendon, PAL, and LPL into the proximal portion of the fifth metatarsal bone. (b) Sagittal anatomic slice shows the SPM tendon, PAL, and LPL inserting into the proximal portion of the fifth metatarsal bone. The tendon of the abductor muscle of the little toe (arrow) is seen coursing distally between the SPM tendon and the PAL.

View larger version (109K): [in a new window]   Figure 5a. Transverse T1-weighted MR images (600/22) of a fifth metatarsal bone specimen show the sites of attachment of (a) the SPM tendon (arrow) and (b) the PAL (arrow). The image in a was obtained at a level 6 mm superior to b.

View larger version (100K): [in a new window]   Figure 5b. Transverse T1-weighted MR images (600/22) of a fifth metatarsal bone specimen show the sites of attachment of (a) the SPM tendon (arrow) and (b) the PAL (arrow). The image in a was obtained at a level 6 mm superior to b.

View larger version (55K): [in a new window]   Figure 6a. Images obtained in a 54-year-old man with an acute fracture of the tip of the tuberosity (ie, most proximal portion of the fifth metatarsal bone). (a) Anteroposterior radiograph of the foot shows a bone chip (thin straight arrow) at the site of attachment of the PAL. Note the concomitant fracture (curved arrow) of the lateral aspect of the cuboid bone, as well as the diaphyseal spiral fracture (thick straight arrow) of the distal portion of the fifth metatarsal bone. (b) Transverse CT image of the foot shows the tiny bone fragment (small arrow) at the tip of the tuberosity and the fibers of the PAL (large arrow) attached to the tip of the tuberosity.

View larger version (68K): [in a new window]   Figure 6b. Images obtained in a 54-year-old man with an acute fracture of the tip of the tuberosity (ie, most proximal portion of the fifth metatarsal bone). (a) Anteroposterior radiograph of the foot shows a bone chip (thin straight arrow) at the site of attachment of the PAL. Note the concomitant fracture (curved arrow) of the lateral aspect of the cuboid bone, as well as the diaphyseal spiral fracture (thick straight arrow) of the distal portion of the fifth metatarsal bone. (b) Transverse CT image of the foot shows the tiny bone fragment (small arrow) at the tip of the tuberosity and the fibers of the PAL (large arrow) attached to the tip of the tuberosity.

View larger version (158K): [in a new window]   Figure 7a. Images obtained in a 42-year-old man with an acute fracture of the tuberosity of the fifth metatarsal bone. (a) Lateral radiograph of the foot shows the fracture (arrow) traversing the proximal portion of the fifth metatarsal bone. (b) Transverse T1-weighted spin-echo MR image (366/14) shows the fracture (large arrow) and the PAL (small arrows) attached to the avulsed fragment. (c) Transverse T1-weighted spin-echo MR image (366/14) obtained at a level approximately 16 mm superior to b shows the fracture (large arrow) and the SPM tendon (small arrows) inserting into the lateral aspect of the tuberosity.

View larger version (157K): [in a new window]   Figure 7b. Images obtained in a 42-year-old man with an acute fracture of the tuberosity of the fifth metatarsal bone. (a) Lateral radiograph of the foot shows the fracture (arrow) traversing the proximal portion of the fifth metatarsal bone. (b) Transverse T1-weighted spin-echo MR image (366/14) shows the fracture (large arrow) and the PAL (small arrows) attached to the avulsed fragment. (c) Transverse T1-weighted spin-echo MR image (366/14) obtained at a level approximately 16 mm superior to b shows the fracture (large arrow) and the SPM tendon (small arrows) inserting into the lateral aspect of the tuberosity.

View larger version (146K): [in a new window]   Figure 7c. Images obtained in a 42-year-old man with an acute fracture of the tuberosity of the fifth metatarsal bone. (a) Lateral radiograph of the foot shows the fracture (arrow) traversing the proximal portion of the fifth metatarsal bone. (b) Transverse T1-weighted spin-echo MR image (366/14) shows the fracture (large arrow) and the PAL (small arrows) attached to the avulsed fragment. (c) Transverse T1-weighted spin-echo MR image (366/14) obtained at a level approximately 16 mm superior to b shows the fracture (large arrow) and the SPM tendon (small arrows) inserting into the lateral aspect of the tuberosity.

View larger version (64K): [in a new window]   Figure 8a. Images obtained in a 57-year-old man with an acute Jones fracture. (a) Anteroposterior radiograph of the foot shows a fracture (arrow) anterior to the tuberosity of the fifth metatarsal bone. (b) Transverse CT image of the plantar aspect of the foot shows the fracture (large arrow) of the proximal diaphysis of the fifth metatarsal bone. The PAL (small arrow) is seen inserting into the proximal portion of the fifth metatarsal bone. (c) Transverse CT image of the foot obtained approximately 2 mm superior to b shows the fracture (large arrow) and the SPM tendon (small arrow) attached to the lateral side of the fragment.

View larger version (77K): [in a new window]   Figure 8b. Images obtained in a 57-year-old man with an acute Jones fracture. (a) Anteroposterior radiograph of the foot shows a fracture (arrow) anterior to the tuberosity of the fifth metatarsal bone. (b) Transverse CT image of the plantar aspect of the foot shows the fracture (large arrow) of the proximal diaphysis of the fifth metatarsal bone. The PAL (small arrow) is seen inserting into the proximal portion of the fifth metatarsal bone. (c) Transverse CT image of the foot obtained approximately 2 mm superior to b shows the fracture (large arrow) and the SPM tendon (small arrow) attached to the lateral side of the fragment.

View larger version (79K): [in a new window]   Figure 8c. Images obtained in a 57-year-old man with an acute Jones fracture. (a) Anteroposterior radiograph of the foot shows a fracture (arrow) anterior to the tuberosity of the fifth metatarsal bone. (b) Transverse CT image of the plantar aspect of the foot shows the fracture (large arrow) of the proximal diaphysis of the fifth metatarsal bone. The PAL (small arrow) is seen inserting into the proximal portion of the fifth metatarsal bone. (c) Transverse CT image of the foot obtained approximately 2 mm superior to b shows the fracture (large arrow) and the SPM tendon (small arrow) attached to the lateral side of the fragment.