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Dr. Budoff’s Injury Update: Dez Bryant

Dr. Jeffrey E. Budoff is a board-certified orthopedic surgeon who wades through misleading coach-speak and vague team injury information to offer advice for your fantasy team.

Jones Fracture

Here’s the information that I currently have on Dez Bryant. On 9/14/15 Bryant underwent surgical fixation plus bone grafting of a Jones fracture. A Jones fracture is one type of fracture of the fifth metatarsal, the bone on the outside of the foot that supports the small toe.

A “Jones fracture” is a fracture of the fifth metatarsal’s proximal meta-diasphyseal junction (where the shaft/narrow part of the bone meets the bigger part of the bone; sort of like the junction between a scoop of ice cream and its cone).

Capture

So, not all fifth metatarsal fractures are Jones fractures, but all Jones fractures are fifth metatarsal fractures.

Diagnosis Discrepancy

The original timeframe given for Bryant’s fifth metatarsal injury was four to six weeks, implying that it was not a Jones fracture. A regular fifth metatarsal fracture would take, in a young, healthy non-smoker, three weeks to heal, and possibly another three weeks to heal strongly to the point where the athlete could put a lot of force on it. Then often some additional time to get back into ‘playing shape.’ So, with the information we had originally, a return to play at 6 weeks, plus or minus a week, seemed realistic to me.

However, upon further review, Bryant has a Jones fracture, not an acute (regular) fracture. At least that’s what I read. And it required bone graft. A bone graft (taking bone or bone components from one place in the body to another) is used if there is a “pre-existing stress component” to the fracture. So what does that mean?

Before a regular (acute) fracture, the bone is fine. Then something happens (a collision, fall, etc.) and the bone is suddenly broken. These break quick, and usually heal quick. However, stress fractures are chronic injuries in which the bone breaks due to repeated stresses that are too great for the body to heal over time. Before the bone actually fractures, there are changes in the bone, and often some pain with use. Then the straw comes that breaks the proverbial camel’s back, and the bone breaks. Because stress fractures take a long time to occur, they also take a long time to heal.

So it’s basically elementary mathematics: Jones fracture + screw + bone graft = Jones stress fracture. Again, not all Jones fractures are stress fractures; you can have a regular (acute / non-stress) Jones fracture.

Prognosis

The Cowboys say that Bryant will return in 6-8 weeks. Far be it for me to argue with Dr. Jeruh Jones, but color me skeptical. If you read the literature on Jones fracture (all comers, not just stress fractures), it seems to be optimistic: A study of NFL players that is so recent that it hasn’t yet been formally published in print showed that, following fixation of Jones fracture, NFL players returned at an average of 8.7 weeks (5.9-13.6 weeks) with a 12 percent re-fracture rate (from returning to play so early).1 Another study using large (4.5 mm) screws showed an average time of 7.5 weeks to return to sport.2

However, those were studies of all Jones fractures, not just the subset of Jones stress fractures that we’re concerned about here. A study of Jones fractures that failed to unite and were then surgically fixed showed that the average time to heal was 13.3 (8 to 20) weeks. All patients were able to start full weight bearing without pain at an average of 10.2 weeks.3  However, these were all fractures not initially treated surgically that went on to not heal.

So the truth probably lies somewhere in between. Thankfully there’s an alternative to sitting on my you-know-what and reading the Orthopedic literature between surgical cases. I spoke to an NFL foot surgeon, who pretty much confirmed (thanks, bro) what I tweeted yesterday when the news came out: for a Jones stress fracture, players are usually OK to return to sport after three months BUT but one must still be cautious, as these can still re-fracture.

Most surgeons are much happier giving athletes four to five months to heal these before returning them to play. In fact, he told me he’d be “shocked” if Bryant returned in less than three months. How about at three months? Well, how much risk will the Cowboys assume with their star player, especially if they’re not doing well in the standings later this year, as Tony Romo is also out for a prolonged period of time? Don’t ask me: I’m only a simple surgeon, not a Jeruh Jones confidant.

Of interest, ESPN noted that DeMarcus Lawrence, a Dallas Cowboys defensive end, had a similar surgery last year, including a bone graft, and was out for a little over three months. However, wide receivers tend to stress this area of the foot more than other positions, so it’s not a perfect comparision. Still, three months is a reasonable timeframe, if still somewhat risky.

References:

1) Lareau CR, Hsu AR, Anderson RB. Return to Play in National Football League Players After Operative Jones Fracture Treatment. Foot Ankle Int. 2015 Sep 9.

2) Porter DA, Duncan M, Meyer SJ. Fifth metatarsal Jones fracture fixation with a 4.5-mm cannulated stainless steel screw in the competitive and recreational athlete: a clinical and radiographic evaluation. Am J Sports Med. 2005 May;33(5):726-33.

3) Habbu RA, Marsh RS, Anderson JG, Bohay DR.Closed intramedullary screw fixation for nonunion of fifth metatarsal Jones fracture. Foot Ankle Int. 2011 Jun;32(6):603-8.

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