From Jones to avulsion: rethinking the fifth metatarsal base

PURPOSE OF REVIEW: Fifth metatarsal fractures are the most common metatarsal injury in the pediatric population; however, their management is frequently extrapolated from adult protocols. This review explores the emergence of pediatric-specific classification systems and evolving evidence on surgical versus conservative treatment in skeletally immature patients. RECENT FINDINGS: Anatomical and developmental differences critically distinguish pediatric fractures from adult fractures. Recent pediatric classifications, including those by Herrera-Soto and Lee, improve upon the widely used Dameron/Lawrence-Botte system by recognizing the apophysis as a distinct entity and offering better prognostic correlation. Zone 1 avulsion fractures achieve near-universal healing with conservative management. Emerging evidence supports surgical fixation with intramedullary screws for Zone 2 (Jones) fractures in adolescent athletes, whereas prepubertal patients respond well to conservative treatment. Nutritional factors, particularly vitamin D deficiency and inadequate calcium intake, are increasingly being recognized as modifiable risk factors for stress fractures and delayed union. SUMMARY: The management of fifth metatarsal fractures should be individualized according to the fracture zone, skeletal maturity, and activity level. Pediatric-specific classifications offer improved diagnostic accuracy. Nutritional optimization should be integrated into comprehensive management protocols, and further pediatric-focused clinical trials are needed.