Early Ultrasound-Guided Detection and Surgical Management of Jones Fracture Fibrous Nonunion in a Recreational Female Runner

Abstract

BACKGROUND: Jones fractures at the metaphyseal–diaphyseal junction of the fifth metatarsal are prone to delayed union and nonunion due to limited vascularity and repetitive mechanical load. Postmenopausal female athletes represent a particularly high-risk group because hormonal changes, metabolic alterations, and repetitive stress can further impair bone healing. This report presents an integrated approach combining serial ultrasound monitoring and metabolic optimization to guide early intervention in a recreational runner with a fibrous nonunion Jones fracture.

METHODS: A 49-year-old female recreational runner sustained a non-displaced Jones fracture following an inversion injury while running. She was postmenopausal (menopause at age 45) and otherwise healthy, with no history of fragility fractures or metabolic bone disease.
Initial management included protected weight-bearing in a controlled ankle motion (CAM) boot, low-intensity pulsed ultrasound (LIPUS), and comprehensive metabolic evaluation with dual-energy X-ray absorptiometry (DXA). DXA scan showed normal bone density with T-scores of +2.5 (spine) and +1.9 (hip). Laboratory testing revealed mild vitamin D insufficiency (33 ng/mL) and elevated thyroid-stimulating hormone consistent with mild hypothyroidism (TSH, 8.3 mIU/L), prompting initiation of vitamin D supplementation and levothyroxine therapy.

RESULTS: Serial imaging with radiographs and musculoskeletal (MSK) ultrasound demonstrated a persistent hypoechoic fracture gap with cortical sclerosis suggestive of impaired healing. At 14 weeks post-injury, computed tomography (CT) confirmed fibrous nonunion (4.5 mm fracture gap, cortical sclerosis). The patient underwent open reduction and internal fixation (ORIF) with ipsilateral autologous proximal tibial cancellous bone grafting. Radiographic union was achieved by 10 weeks post-operatively, and the patient returned to running at 16 weeks post-op without pain or functional limitation.

CONCLUSION: Musculoskeletal ultrasound is a valuable, dynamic modality for assessing fracture healing, often identifying early signs of nonunion before they appear on radiographs. Early recognition allows for timely intervention addressing both mechanical and biological barriers to recovery. In post-menopausal athletes, optimizing metabolic factors—such as correcting vitamin D insufficiency and treating thyroid dysfunction—supports the systemic environment for bone repair. When nonunion persists despite these measures, surgical fixation with autologous bone grafting remains an effective option for achieving union and enabling safe return to sport (RTS). Emerging biologic therapies may further enhance healing and serve as adjuncts to surgical and metabolic optimization in complex cases of nonunion.