Mechanically stable but biologically inactive Jones fracture nonunion managed without immediate revision surgery: a case report

Jones fractures are prone to delayed union and nonunion because of the vascular characteristics and mechanical loading environment of the fifth metatarsal metaphyseal–diaphyseal junction. Although nonunion is often attributed to mechanical insufficiency, host-related biological and functional factors may also be clinically relevant in selected cases. We report an illustrative case of Jones fracture nonunion with maintained implant integrity and radiographic stability that united without immediate revision surgery after integrated clinical assessment and management. A 17-year-old male competitive basketball player sustained a zone 2 fifth metatarsal fracture and underwent acute intramedullary screw fixation. Computed tomography (CT) at injury demonstrated cortical thickening and intramedullary canal narrowing, suggesting a pre-existing stress reaction rather than a purely acute traumatic fracture. At 7 months after injury, he had persistent pain, a persistent fracture line on radiographs and CT, absence of bridging callus, and no hypertrophic response. Implant integrity and radiographic stability were maintained. Laboratory evaluation demonstrated 25-hydroxyvitamin D insufficiency (12.8 ng/mL) and elevated undercarboxylated osteocalcin (20.3 ng/mL), while bone mineral density was normal. Hip internal rotation was restricted to 5°. Immediate revision surgery was deferred after radiographic assessment of mechanical stability. Eldecalcitol, vitamin K2 supplementation, structured hip internal rotation stretching, continued low-intensity pulsed ultrasound, and activity modification were used as part of an integrated management approach. Radiographic bridging callus was observed 3 months after initiation of treatment at our institution, followed by staged return to jogging, basketball practice, and full unrestricted play after radiographic union. At 5 years, union was maintained without refracture, hip internal rotation remained 60°, and the patient was pain-free during occasional recreational basketball. This single case illustrates that, in carefully selected Jones fracture nonunion with maintained implant integrity and radiographic stability, metabolic evaluation and kinetic-chain assessment may be considered as part of clinical assessment before immediate revision surgery. However, causality cannot be established, and the observed union cannot be attributed to any single intervention. This report is hypothesis-generating and not evidence that host optimization can replace revision surgery.