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EVIDENCE-TO-PRACTICE REVIEW  

 

53 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                              Volume 5 – Issue 1 – April 2022 

 
 

Casting and Splinting Options for Pseudo-Jones Avulsion Fractures: 
An Evidence-to-Practice Review 
Amber M. Kingsley, SCAT, ATC; Aysha B. Reyes, SCAT, ATC; Zachary K. Winkelmann, PhD, SCAT, ATC 
University of South Carolina, Columbia, SC 

  

 
ABSTRACT 
Avulsion fractures of the fifth metatarsal bone occur when a 
portion of the bone is broken or pulled off the rest of the 
bone. These fractures are often seen in athletes, especially 
those of a young age. Avulsion fractures of the fifth 
metatarsal bone are commonly treated non-surgically with 
immobilization of the foot. There are several different 
options for immobilization of the foot with no clear result as 
to which immobilization method is the most effective. The 
purpose of this evidence-to-practice review was to 
summarize a systematic review on comparative outcomes 
of immobilization interventions on avulsion fractures of the 
fifth metatarsal. The authors included five studies in this 
review that compared two intervention methods including 
short leg casting and removable splinting of the foot. The 
authors reviewed foot function scores and non-union rates of 
the foot. It was found that both foot function scores and non-
union rates of the fifth metatarsal bone were better in the 
removable splinting intervention group. From the results of this 
evidence-to-practice review, we recommend the use of a 
removable splint for avulsion fractures of the fifth metatarsal 
bone.  
Key Phrases 
Patient education, healthcare information technology, 
preceptor training and development 
 
Correspondence 
Dr. Zachary Winkelmann, 1300 Wheat Street, Columbia, 
SC 29208. 
E-mail: winkelz@mailbox.sc.edu   
Twitter: @zachwinkelmann 
 
Full Citation 
Kingsley AM, Reyes AB, Winkelmann ZK. Casting and 
splinting options for pseudo-jones avulsion fractures: 
An evidence-to-practice review. Clin Pract Athl Train. 
2022;5(7): 53-57. 
https://doi.org/10.31622/2022/0005.01.8.  
 
Submitted: December 3, 2020 Accepted: September 3, 
2021. 
 
ORIGINAL REFERENCE 
Pituckanotai K, Arirachakaran A, Piyapittayanun P, 
Tuchinda H, Peradhammanon E, Kongtharvonskul J. 
Comparative Outcomes of Cast and Removable 
Support in Fracture Fifth Metatarsal Bone: 
Systematic Review and Meta-Analysis. J Foot Ankle 
Surg. 2018;57(5):982-986. doi: 
10.1053/j.jfas.2018.03.018 

 

SUMMARY 
 
CLINICAL PROBLEM AND QUESTION 
 
Fractures of the metatarsals are the most common 
fractures of the foot. Specifically, fractures of the 
fifth metatarsal account for approximately 50% 
of all metatarsal fractures,1 and a large majority 
of these occur in young, active individuals.2 A 
Jones fracture is defined as a transverse fracture 
of the proximal end of the fifth metatarsal bone 
in the foot,2 whereas a pseudo-Jones fracture is 
an avulsion fracture of the base of the fifth 
metatarsal.3 A pseudo-Jones fracture is also 
referred to as a Zone 1 fracture, and occurs when 
a portion of the bone is pulled off from the 
remaining bone.2 The typical treatment for a fifth 
metatarsal fracture, including an avulsion fracture, 
is a non-surgical, conservative 
approach.4 Immobilization of avulsion fractures 
has been determined to ensure union and proper 
healing of the bones occurs, which is a common 
concern with this injury.2 For athletes that sustain 
pseudo-Jones fractures, effective immobilization is 
essential, as it can dramatically affect return to 
play. The method of immobilization for an avulsion 
fracture of the fifth metatarsal has been 
compared in several different studies,5-7 including 
use of a short leg cast versus a removable device 
such as a splint. The effect of each of these 
methods has been debated with no clear results 
as to the effectiveness of a short leg cast as 
compared to a removable support for the 
patient.5-7 As the best method of non-operative 
care for a pseudo-Jones fracture is 
debated, there is a need to review 
and compare the functional outcomes of 
treatment between a short leg cast and 
removable splint for avulsion fractures of the fifth 
metatarsal.  

mailto:winkelz@mailbox.sc.edu
https://doi.org/10.31622/2022/0005.01.8


Casting and Splinting Options for Pseudo-Jones Avulsion Fractures: An Evidence-to-Practice Review 
 

 

54 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                              Volume 5 – Issue 1 – April 2022 
 

 SUMMARY OF LITERATURE  

The authors of the guiding systematic review 
performed a structured search of Medline and 
Scopus databases to locate published clinical 
trials of treatment options for fractures of the fifth 
metatarsal bone published between database 
inceptions to October 29, 2016. The authors 
established 4 criteria for published studies to be 
included in the guiding systematic review. The 
criteria included: (1) Patients diagnosed with 
pseudo-Jones avulsion fractures, (2) studies that 
utilized a comparison of outcomes between short 
leg cast and removable splint for treatment, (3) 
use of foot functional outcome scales or the Visual 
Analog Scale (VAS) for pain as outcome 
measures, (4) studies that were written in 
English.8   

The database search of Medline and Scopus 
identified 127 total studies, and 104 studies were 
reviewed after 17 duplicate 
studies were removed. A quality assessment was 
conducted for risk of bias using the Preferred 
Reporting Items for Systematic Reviews and Meta-
analysis guidelines for randomized control trials 
and the modified Newcastle-Ottawa scale for 
cohort studies. The search yielded five studies that 
were included in the guiding systematic review 
and meta-analysis as they matched all inclusion 
criteria listed above. The eliminated studies 
included: 86 that were non-comparative, 13 
studies with other interventions and 2 that were 
non-English. All five included studies utilized a foot 
functional outcome measure, four studies assessed 
patients with non-union fractures, 
two studies were randomized control trials, and 
three studies were cohort studies. Four of the 
studies included a follow-up assessment after 12 
months, while the fifth study had a follow-up after 
24 months.8  

SUMMARY OF INTERVENTIONS  

The guiding systematic review compared the short 
leg cast and the removable splint as treatment 

options for pseudo-Jones fractures. The 5 studies 
used in the systematic review all used the short leg 
casting. A short leg cast is defined as a foot cast 
that immobilizes one joint above and below 
the fracture.8 Additionally, in the guiding 
systematic review, there were 3 types of 
removable splints that were discussed. A 
removable splint, for the purpose of the guiding 
systematic review, included devices such as an 
elastic bandage, a Jones’ bandage, and a boot 
splint. Three of the studies used a bandage as 
their removable splint,7,9,10 one study used a boot 
splint,6 and the final study used a 
Jones’ bandage.5   

SUMMARY OF OUTCOMES  

The five studies in the guiding systematic review 
all used the American Orthopaedic Foot and 
Ankle Society (AOFAS) score for the ankle-
hindfoot and the VAS for foot and ankle pain. 
Four of these studies also checked for the fracture 
nonunion. From the 5 studies included in the 
systematic review, three studies assessed mean 
function within 1 month of the fracture. The last 
follow-up to assess mean function was at 12 
months in four of the studies and 24 months in the 
fifth study.  

FINDINGS AND CLINICAL IMPLICATIONS  

The guiding systematic review utilized the AOFAS 
and VAS for foot and ankle scores in the 
5 studies. The short cast intervention reported 
lower scores for function compared to the 
removable splint intervention. By utilizing these 
patient-rated outcome measures, the authors were 
able to objectively measure the patients’ functions. 
The lower function scores were observed in the 1 
month and the last follow-up visits in the respective 
studies. Table 1 illustrates the last follow-up scores 
and non-union rates for the short leg cast group 
compared to the removable splint group. All five 
studies reported mean function scores at the last 
follow-up with patients, which was 12 months for 
four of the studies and 24 months for the  



Casting and Splinting Options for Pseudo-Jones Avulsion Fractures: An Evidence-to-Practice Review 
 

 

55 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                              Volume 5 – Issue 1 – April 2022 
 

 

remaining study. Once again, it was found that the 
foot function scores were lower for the short leg 
casting intervention group. Four of the studies 
reported non-union rates of the fifth metatarsal 
bone and found that there was a lower risk for 
fracture non-union with the splinting intervention 
group. Between better foot function scores and a 
lower risk of fracture non-union rates, the 
removable splint is the better intervention.  

There are other studies that have explored the 
outcomes from other interventions such as a 
controlled motion ankle boot, a hard-sole shoe, 
and a foot cast. For the foot cast, the methods 
were to immobilize above (tarsometatarsal joint) 
and below (metatarsophalangeal joint) the fifth 
metatarsal. The investigation of the foot cast and 
the short leg cast also utilized the AOFAS and the 
VAS for pain, where they took the patients’ 
responses at 6-weeks and 8-weeks. The authors 
were able to determine with both the AOFAS and 
the VAS scales that there were no significant 
differences in pain level.11 A different study that 
explored the controlled ankle motion (CAM) boot, 
and the hard-sole shoe for non-casting options of 
treatment for a Zone 1 avulsion fracture of the 
proximal fifth metatarsal also utilized the VAS for 
pain, AOFAS score, and return to activity 
timeline to investigate patients’ clinical 
outcomes. The study found that at 8 weeks, both 
the hard-sole shoe and the CAM boot had the  

 

 

same score output for both the VAS for pain and 
the AOFAS. Similarly, there was no significant 
difference between the two groups for the VAS 
for pain and the AOFAS at 12 weeks. The study 
also identified that both groups had similar 
timeframes when participants were returning to 
their activities and sports.12 Patients who utilized 
the removable splint for avulsion fractures of the 
fifth metatarsal had better function scores and 
non-union rates and had a faster return to activity, 
making the removable splint the ideal intervention 
for this injury.  

CLINICAL BOTTOM LINE  

Patients that experience avulsion fractures of the 
fifth metatarsal will want the most effective 
treatment with the best outcomes. The patients 
may include athletes, and it is important that the 
immobilization method allows them to return to 
activity at the same level prior to injury. Increased 
foot function and non-union rates are both 
essential when determining the course of 
treatment for an avulsion fracture. In the pursuit of 
providing better care for patients, as clinicians we 
need to know and explore what options are 
available. In the literature that we have reviewed 
and provided, there are several non-
surgical treatment options for immobilization of 
the foot and ankle for patients with fractures of 
the fifth metatarsal. Short leg casting and 
splinting were two of the most common methods 
of immobilization for pseudo-Jones fractures. Foot 

Table 1. Comparison of Outcomes of Interest for Intervention of fifth Metatarsal Fracture  
Study AOFAS foot functional score (mean ± SD) Nonunion of fifth Metatarsal 

  Short Leg Cast Removable Splint Short Leg Cast Removable Splint 

Zenios et al.9 80 ±  11.6 89.5 ± 13.6 Yes: 3 
No: 22 

Yes: 0 
No: 25 

Gray et al.6 87.5 ± 5.8 90.5 ± 5.2 Yes: 0 
No: 17 

Yes: 1 
No: 19 

Shahid et al.7 93 ±  7 96 ± 7 N/A N/A 

Akimau et al.10 93 ± 19.8 93 ± 23.7 Yes: 0 
No: 24 

Yes: 0 
No: 36 

Wiener et al.5 86 ± 16 92 ± 16 Yes: 0 
No: 30 

Yes: 0 
No: 30 



Casting and Splinting Options for Pseudo-Jones Avulsion Fractures: An Evidence-to-Practice Review 
 

 

56 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                              Volume 5 – Issue 1 – April 2022 
 

function scores and nonunion rates both had better 
results with a removable splint as an 
intervention. Ultimately, the patient should be 
included in the shared decision making relevant to 
their care plan and make an informed choice 
based off their goals and potential to adhere to 
the plan. As the healthcare provider, the athletic 
trainer should use this review to educate the 
patient on the best option for non-surgical 
treatment of fifth metatarsal avulsion 
fractures. For those fractures that do not require 
surgery, utilizing a removable splint has better 
results for overall patient outcome and function, 
which is ideal for athletes returning to play after 
an injury.  

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Casting and Splinting Options for Pseudo-Jones Avulsion Fractures: An Evidence-to-Practice Review 
 

 

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Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                              Volume 5 – Issue 1 – April 2022 
 

leg cast in pseudo-Jones avulsion fracture: a 
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https://doi.org/10.1186/s13047-019-0359-5
https://doi.org/10.1186/s13047-019-0359-5

	ABSTRACT

