Jones Fractures

by Doug Bartels

THE PATIENTimage1-23 image2-25

A 24-year-old male presents to the emergency department one hour after suffering a forefoot adduction ankle injury while playing flag football.  The lateral side of his right foot is painful and he is having a hard time walking due to the pain.  On exam, the base of his 5th metatarsal is very tender to palpation and there is associated swelling and ecchymosis.  X-ray of the foot are ordered.  What do you see?

THE FRACTURE

The x-rays show a fracture through the proximal portion of the 5th metatarsal which is commonly referred to as a Jones’ fracture.  The most widely accepted definition of a Jones’ fracture as described by Torg et al. is a fracture of the proximal part of the diaphysis distal to the tuberosity of the 5th metatarsal.  Why do we care?  What makes this fracture unique, compared to all other metatarsal fractures, is that it exists in a vascular watershed region.  Because of this, fractures at this site are at increased risk of delayed union or complete non-union.

HOW DO WE HANDLE THESE FRACTURES?

This is the million dollar question.  Both conservative and surgical options for management of Jones’ fractures exist.  Leaving Jones’ fracture to heal on their own has been shown to result in suboptimal outcomes including non-union and increased time to bone union; however, surgical intervention has proven to have issues as well with a far from perfect track record for healing.  So which is better?

SYSTEMATIC REVIEW

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WHAT DO THESE RESULTS MEAN?

This systematic review found that surgical intervention of Jones’ fractures leads to lower non-union rates, faster time to union, and faster return to sports and activity when compared to patients managed conservatively.  So, take a knife to everyone?  It is still important to analyze each patient on a case-by-case basis to determine if comorbidities or additional patient factors would make surgical intervention a suboptimal choice.

THANK YOU

Student Presentations • November 2015

Here are three presentations, two using Prezi and one using Emaze. All three require Flash.


Living with intractable epilepsy made easier

Epilepsy is a disease that not only affects the individual suffering from it, but it can also be a source of significant stress and anxiety for the family or caregivers. Treatment resistant epilepsy is an especially difficult diagnosis: typically, even though your child is taking a combination of anti-epileptic drugs (AEDs), she/he is likely to suffer a “breakthrough” seizure once in a while. In some individuals, the seizure activity may manifest few times during the day, while in others it may be much less frequent. Every patient and their caregiver should have an action plan, outlining the actions to be taken when the individual manifest a cluster of seizure activity or has prolonged seizures, lasting more than 5 minutes (from the concern for status epilepticus). The action plan should be carefully reviewed and discussed with the physician, as to answer any questions that you may have. It is important that you feel confident and know what actions to perform when your child is actively seizing.

An important part of each action plan is the “emergency” medications.

Sample Action Plan (source: Epilepsy Foundation)

Often, parents or caregivers are instructed to administer rectal diazepam when they notice a cluster of seizure activity occurring or prolonged seizure that does not resolve in 5 minutes. Rectal diazepam is safe and relatively easy to administer in a non-hospital setting. However, its administration is often times “socially unacceptable.” It also requires removal of clothing and proper positioning, which may be difficult to do when the person affected by epilepsy is an adolescent/adult and is violently convulsing. A recent meta-analysis of the available literature of randomized controlled studies, revealed that use of buccal midazolam (which can be administered either via oral mucosa or via intranasal route), is even slightly more effective than the traditional rectal diazepam and has a similar safety profile.1 It makes it a desirable option for many families who struggle with the administration of rectal formulations of the medication. If you or the people involved with the care of someone who suffers from epilepsy have found it difficult to administer rectal diazepam, it is certainly worth discussing other options that may be available with the physician who is taking care of your child.

To view a short a short video demonstrating the administration of buccal midazolam, please click below:  https://www.youtube.com/watch?v=8bINlAxRDa8

Sources:

  1. My Seizure Plan. Accessed online
  2. Adminstration of Buccal Midazolam. Accessed online 
  3. Brigo et al. Nonintravenous midazolam versus intravenous or rectal diazepam for the treatment of early status epilepticus: A systematic review with meta-analysis. Epilepsy & Behavior. 49 (2015) 325–336. PMID: 25817929.

Presenting in the ER

“…no matter how much compassion and warmth I may have with my patients, my superiors grade me more on how polished I am, how well crafted my presentation is.”

– Fourth-year medical student

As unfair as it may be, your clinical grade in most of your rotations will be based on how well you present your patients. It’s very unlikely that we watch you do your physical exam or observe your interaction with the patient. It all comes down to that short performance. So why not be great at that game?

Cricothyrotomy Video

Ruben Strayer of EMUpdates posted a great video on how to do a cricothyrotomy. The only things that I would change are

  1. I would likely be swearing a lot more out of sheer panic
  2. I’d have everything ready (syringe and bougie)
  3. I’d pass the bougie in before removing the scalpel, just paranoid of losing that entrance
  4. I would also have a change of underwear or two ready

Great video of a procedure we do not do often. The more we see it, the less freaked out we’ll be by it.

He actually has another video of the same. How many cameras does this guy have in the resusc bay?