Clinical and Biomechanical Determinants of Fixation Failure in Fifth Metatarsal Fractures: Implications for Surgical Decision-Making

<b>Objectives</b>: To provide a mechanism-oriented integration of clinical and biomechanical evidence regarding fixation failure in fifth metatarsal fractures, with particular emphasis on Jones and diaphyseal stress fractures, and to clarify the mechanical determinants that influence construct performance under physiologic gait-related loading. <b>Methods</b>: A narrative, concept-driven review was conducted focusing on experimental biomechanical investigations and clinically relevant outcome studies addressing cyclic shear, bending, torsion, interfragmentary gap behavior, and loading direction. Special attention was given to studies employing advanced experimental models, including three-dimensional printed anatomical constructs combined with digital image correlation (DIC), to evaluate fixation strategies under simulated gait-phase loading conditions. Literature selection was guided by thematic relevance to construct mechanics and clinical fixation outcomes rather than systematic retrieval criteria. <b>Results</b>: Available evidence indicates that fixation constructs relying predominantly on interfragmentary compression demonstrate increased sensitivity to imperfect reduction, interfragmentary gaps, and multidirectional cyclic shear forces, particularly during midstance loading. Experimental models suggest that loading angle and gap size significantly influence stress concentration and failure patterns. Plate-based and hybrid constructs may provide improved resistance to cyclic bending and shear in specific experimental conditions, maintain stability in the presence of small fracture gaps, and distribute mechanical loads more uniformly across the fracture site. These biomechanical characteristics may help explain reported clinical patterns of delayed union, refracture, and hardware failure in high-demand patients or in cases with cortical compromise. <b>Conclusions</b>: Fixation failure in fifth metatarsal fractures appears to result from the interaction between fracture morphology, patient-specific loading demands, and construct biomechanics. Mechanism-based integration of biomechanical findings with clinical context may support individualized surgical decision-making. However, given the heterogeneity of available clinical data and the inherent limitations of experimental models, biomechanical insights should be interpreted as hypothesis-generating and complementary to clinical judgment rather than prescriptive guidance.