Two fractures a few millimetres apart, on the same bone, after the same misstep. One heals on its own in six weeks and deserves little more than a rigid shoe. The other sits in a zone where two vascular networks meet without overlapping, fails to heal in nearly one case in three without surgery, and refractures one time in ten even when operated on. Telling them apart on the radiograph is the central act of this article.

A synthesis written from primary sources verified one by one on PubMed: identifier resolved, journal, year and author list checked, abstract read before citation. Full bibliography at the end of the article.

Clinical summary

At the base of the fifth metatarsal, the prognosis is read not in the appearance of the fracture line but in its position. A few millimetres separate a fracture treated in a shoe from a fracture that gets a screw.

Where exactly does the fracture line run, and why does that decide everything?

The classification is not an academic exercise here: it is the only thing that distinguishes two opposite kinds of management.

The three zones of Lawrence and Botte

The most widely accepted classification is that of Lawrence and Botte, which divides the proximal portion of the fifth metatarsal according to the location of the fracture line, and not according to its appearance. Bušková et al., in their critical review published by JBJS Reviews, are a reminder that it was indeed the potential for union that guided that division1 :

• Zone 1: avulsion of the tuberosity. The fracture line involves the tuberosity (styloid), at the proximal end of the bone. Union is as a rule excellent, non-operative treatment usually recommended1.
• Zone 2: metaphyseal-diaphyseal junction. This is the Jones fracture proper. The fracture line sits at the junction between metaphysis and diaphysis and extends as far as the joint between the fourth and fifth metatarsals2. This is the zone of the vascular problem.
• Zone 3: proximal diaphysis. Beyond the intermetatarsal joint. This is the preferred site of stress fractures and, according to Polzer, the zone whose treatment failure is best documented4.

The tendon insertions, and what they say about the mechanism

The anatomical study by DeVries et al., conducted on ten frozen cadaveric specimens, measured precisely the insertions in the proximal 1.5 cm of the bone. From it they draw a subdivision into three zones A, B and C, whose value is that it ties each site to a mechanism :

• Zone A, the most proximal: it is the lateral band of the plantar fascia that inserts there, 6.6 ± 2.2 mm from the inferior border. The authors propose that fractures sitting there arise from traction by that fascia, and can be treated by immobilisation with weight bearing.
• Zone B : this is peroneus brevis, inserting 12.0 ± 2.2 mm from the inferior border. The authors see fractures there as arising from traumatic tension in the tendon, justifying strict non-weight-bearing immobilisation, or even fixation.
• Zone C : the portion articulating with the cuboid14.

This reading by mechanism sheds light on an everyday clinical observation: the fracture most often occurs on a foot in forced inversion, a movement that simultaneously tensions peroneus brevis, which opposes inversion, and the lateral plantar fascia. It is the same movement that produces the lateral ankle sprain, which is why the two injuries are so often confused in practice.

Why does zone 2 unite so poorly?

It is one of the rare occasions, in foot trauma, where an anatomical explanation was demonstrated experimentally before being invoked clinically.

Smith's study, and what it establishes exactly

The founding work is that of Smith, Arnoczky and Hersh, published in 1992 in Foot & Ankle. Ten fresh cadaveric or amputation specimens were studied after arterial injection of India ink or barium sulphate. The result comes down to three observations, which must be read in order3 :

1. The tuberosity receives its blood from numerous metaphyseal vessels that enter the non-articular surfaces in a radial, random arrangement. It is a rich, redundant network.
2. The proximal diaphysis is supplied mainly by the nutrient artery, which gives longitudinal intramedullary branches. It is a single network, in series.
3. The two supplies meet in the region just beyond the tuberosity, and that region corresponds exactly to the one with a poor prognosis for union.

The authors conclude that a relative deficiency of blood supply following a proximal diaphyseal fracture may contribute to delayed union and non-union. The term is not in their abstract, but that is the very definition of a watershed zone: a territory served by the far ends of two networks, where each arrives at the limit of its reach.

What this explanation does not explain

It would be convenient to stop the reasoning here. Honesty requires it to be pointed out that the vascular argument has never been linked directly to a measured non-union rate : Smith describes an anatomy, the clinic observes failures, and matching the two remains a hypothesis, a solid, coherent one, but not tested as such.

That matters all the more because the systematic review by Polzer et al. disputes, on prospective data, the clinical description usually drawn from that anatomy. We come to it in the treatment chapter.

Who fractures the base of the fifth metatarsal, and how?

Two very different populations share the same bone: the woman over forty who twists her foot, and the pivoting athlete.

The mechanism predicts the zone

One clarification first: out of 411 metatarsal fractures recorded in one year in a Scottish series, of mean age 42, the fifth metatarsal is the most often fractured of all, with an increasing proportion of women in the higher age bands20. It is this bone that is seen, and it is at its base that the prognostic distinction is played out.

The series by Kane et al., which reviewed 1,275 fifth metatarsal fractures in a multicentre orthopaedic practice, delivers a result directly usable in the clinic: the injury mechanism predicts the location. Twisting injuries are a statistically significant predictor of zone 1 injuries. Women sustain 75 % of zone 1 injuries and 84 % of dancer's fractures. In young patients, men predominate; in older patients, it is women19.

That age-related swing is not trivial. Schwagten et al., who studied the dancer's fracture specifically (a spiral fracture of the distal shaft, distinct from the three proximal zones), find that in the group over 40, all patients had a low-energy mechanism, against only 27 % in those under 40. From that they draw a strong clinical conclusion: treat this fracture as a fragility fracture17.

The athlete, the other population

The true Jones fracture, the zone 2 one, preferentially affects the pivoting athlete: football, basketball, American football. Attia's meta-analysis, which includes only studies covering athletes exclusively, brought together 646 Jones fractures from 22 studies, with return-to-sport rates detailed by discipline: 99.0 % in American football, 96.6 % in football, 91.1 % in basketball5.

That gap between disciplines, modest but consistent, draws out the logic of the injury: basketball, with its pivoting on a foot planted on the floor and its landings from jumps, loads the lateral border of the foot harder than running in a straight line.

How do you distinguish a zone 1 avulsion from a true Jones fracture?

This is the central point of this article. The two fractures look alike on a poorly read radiograph, and what you do differs completely.

The question to ask in front of the film

One question alone decides it: does the fracture line extend to the joint between the fourth and fifth metatarsals? If yes, it is a zone 2: a Jones fracture. If the line stays proximal to it, confined to the tuberosity, it is a zone 12.

Two errors are made in opposite directions, and they must be named:

• Taking a zone 2 for a zone 1 : the serious error. The patient leaves in a rigid shoe with permission to walk, for a fracture that has a one in three chance of not uniting without surgery in an athlete5.
• Taking a zone 1 for a zone 2 : the costly error. You immobilise without weight bearing, you delay the return, you propose surgery for a fracture that would have healed on its own4.

The radiographic false friends

Three images can be mistaken for a fracture, and a fourth for a zone 1 when it is something else:

Os vesalianum

This is an accessory ossicle at the lateral border of the foot, immediately adjacent to the base of the fifth metatarsal. The most recent meta-analysis of it, covering 21,312 feet from 22 studies, puts the pooled prevalence at 0.6 % (95 % CI 0.4-0.9), with a comparable distribution between the sexes and a prevalence of 0.6 % on radiographic examinations. The authors conclude explicitly that it must be differentiated from fifth metatarsal fractures and from Iselin's disease15.

What distinguishes it: smooth, corticated margins, a constant position, and above all, when doubt persists, its usual presence on the opposite foot, which a comparative film reveals.

Iselin's apophysis in the child and adolescent

In the adolescent, the secondary ossification centre of the tuberosity appears on the radiograph as a separate fragment. It runs parallel to the axis of the metatarsal, whereas a zone 1 fracture line is usually transverse, that is, perpendicular to that axis. That difference in orientation is the simplest reading criterion. The subject is developed in our article on growth conditions of the lower limb in children and adolescents.

The dancer's fracture

This is not a trap of interpretation but a neighbouring entity, often confused in everyday language. It is a spiral, oblique fracture of the distal shaft, therefore far further out than the three proximal zones. O'Malley, Hamilton and Munyak described the original series of 35 dancers from two national ballet companies: the line starts distal-lateral and runs proximal-medial. Treatment was mainly non-operative, including for displaced fractures, with pain-free walking at a mean of 6.1 weeks, return to the barre at 11.6 weeks and return to performance at 19 weeks. All the dancers returned to their professional activity without limitation18.

The distinction matters because the prognosis is the opposite of that of zone 2: the dancer's fracture is a fracture with a good prognosis, whatever its displacement.

Acute fracture or stress fracture: what does the distinction change?

Two different clinical histories can produce the same image, and they do not call for the same strategy.

Two entities that coexist on the same bone

The classic Jones fracture is acute: a step, immediate pain, inability to bear weight. The stress fracture of the fifth metatarsal is something else entirely: prodromal pain along the lateral border of the foot, increasing over weeks, which ends by completing itself, sometimes abruptly, on an ordinary step that gives the illusion of trauma.

This is the distinction Polzer makes: zone 3 fractures are explicitly described as “diaphyseal stress fractures”, at the distal limit of the intermetatarsal joint or just beyond, and it is they that show a significantly higher failure rate when treated without surgery in a non-weight-bearing boot4.

Our article devoted to stress fracture in the athlete deals with the general mechanism, the imbalance between microdamage and bone repair under cyclical loading, with imaging and with relative energy deficiency. This article does not repeat it : it deals with one particular site, where the acute fracture and the stress fracture coexist and get confused, and where the site of the fracture line governs the prognosis more than the mechanism does.

What the history must look for

The question to ask is simple and rarely asked: “Did it hurt there before?” A positive answer changes three things:

• The prognosis for union : a bone already in trouble, with a periosteal reaction or sclerosis of the line, unites less well than a healthy bone broken cleanly.
• The search for a systemic cause. The case-control study by Shimasaki et al., covering 37 athletes of whom 18 had a history of fifth metatarsal stress fracture in zone 2 or 3, measured a striking link: a serum 25-hydroxyvitamin D level below 30 ng/mL multiplies by 23.3 the odds of fifth metatarsal stress fracture, after adjustment for multiple confounders. A level of 10 ng/mL corresponded to odds 5.1 times higher, and 20 ng/mL to 2.9 times10.
• Training load, which must be reconstructed over the preceding weeks, exactly as for any bone overload injury.

Should you operate from the outset, and on whom?

This is the question where the literature frankly contradicts itself, and where the contradiction itself is instructive.

The dominant position: operate on the athlete

Three pieces of work converge, with different methodologies. The review published by the Journal of the American Academy of Orthopaedic Surgeons sums up the current position: the Jones fracture, sitting at the metaphyseal-diaphyseal junction, carries an increased risk of non-union and persistent pain, and delayed union and refracture can occur despite excellent surgical technique and postoperative management16.

Attia 2021, American Journal of Sports Medicine. A meta-analysis conducted according to PRISMA, 22 eligible studies, 646 Jones fractures exclusively in athletes. The results:

• Overall return to sport 98.4 % (95 % CI 97.3-99.4); 98.8 % after intramedullary screw fixation against 71.6 % with non-operative treatment (95 % CI 45.6-97.6, a very wide interval).
• Three studies compared the two strategies directly: significant superiority of surgery (odds ratio 0.033; 95 % CI 0.005-0.215; p < 0.001).
• Time to return to sport 9.6 weeks after screw fixation against 13.1 weeks without surgery.
• Union rate 97.3 % with surgery against 71.4 % without.
• Delayed union 2.5 %, refracture 10.2 %.

The authors recommend surgical fixation for all Jones fractures in athletes5.

Roche and Calder 2013, KSSTA. A systematic review of 26 studies, of which 22 were level 4 and only one a randomised trial. Union of acute fractures: 76 % non-operatively, 96 % after screw fixation. For delayed unions: 44 % against 97 %. For screw-fixed non-unions: 97 %. Return to sport after screw fixation of an acute fracture: 4 to 18 weeks. The authors explicitly advise against returning before complete radiological union, because of the risk of refracture6.

Yates 2015, The Foot. A meta-analysis of 6 studies and 237 patients: the non-operative group had significantly higher odds of non-union, OR 5.74 (95 % CI 2.65-12.40; p < 0.001), with a longer time to union and to return to sport7.

The dissenting position, and why it must be read

Polzer et al. published in Injury a systematic review whose conclusion directly contradicts the three-zone reading. Their method is explicit: include only prospective trials comparing either the same treatment for different fractures, or different treatments for the same fracture. Six prospective trials met that criterion. Their conclusions4 :

• All avulsions of the tuberosity (zone 1) unite well with functional treatment, including multifragmentary, displaced and intra-articular ones. A plaster boot significantly delays return to the previous level compared with functional treatment.
• Jones fractures (zone 2) likewise give good to excellent results and complete union with functional treatment.
• By contrast, diaphyseal stress fractures (zone 3) show a significantly higher failure rate with non-operative treatment; early intramedullary screw fixation significantly shortens the time to union and to return to sport.

The authors therefore propose reducing the classification to two entities : metaphyseal fractures not going beyond the distal end of the intermetatarsal joint, to be treated functionally whatever the number of fragments, the displacement and the joint involvement; and metadiaphyseal fractures sitting at that limit or just beyond, which require early screw fixation.

A fourth synthesis, not restricted to athletes, points the same way without having the same force: Wang's meta-analysis, on 11 papers and 404 participants of mean age 29.8, finds a medium to large favourable effect of surgery on the non-union rate, the time to union and the time to resuming activity22. Its value is that it covers a less selected population; its limitation is that it mixes the zones.

Zone 1: the case where surgery changes little

The comparison by Valkier et al. covers 51 feet with an avulsion fracture, of which 31 treated without surgery and 20 operated on. An unexpected and instructive result: 11 of the 31 non-operated patients (35.5 %) developed a non-union, against none of the operated ones (p = 0.004). But (and this is the second half of the sentence, which people often forget to quote), all the patients were asymptomatic at one year, whichever group they were in. The authors recommend surgery for avulsions displaced by more than 2 mm, and insist on realistic expectations13.

It is a useful reminder: a radiological non-union is not a clinical non-union. On the tuberosity, a fragment that never fuses can remain perfectly painless. A Chinese randomised trial in 46 young or sporting patients with an avulsion displaced by 2 to 3 mm points the same way: the functional score was better at 6 months in the operated group, but no longer differed at 12 months ; only the time to full weight bearing and to returning to work were significantly shortened by surgery25.

What factors predict non-union and refracture?

Three families of factors, of which two can be corrected, and that is where the physiotherapist has purchase.

The alignment of the foot: an attractive hypothesis, half confirmed

Raikin, Slenker and Ratigan measured hindfoot alignment in 20 patients operated on for a Jones fracture. The result is clear-cut: 18 of the 21 hindfeet were in radiographic varus, and clinical varus was present in 16 cases. The mean calcaneal pitch angle was 28.5° and Meary's angle 13° with an upward convexity. All the patients united and none refractured, at a mean follow-up of 49 months: the patients in varus having been fitted postoperatively with a lateral off-loading insole for the hindfoot and the forefoot8.

The authors' hypothesis is mechanically clear: a varus hindfoot overloads the lateral column of the foot, predisposes to the fracture, and predisposes to treatment failure.

A recent meta-analysis seriously tempers that reading. Riegger et al. pooled eight studies (296 patients), five of them in quantitative synthesis (132 patients), to compare three angles between fractured patients and controls. Result: only the midfoot adduction angle stands out, with a pooled mean difference of 4.62° (95 % CI 1.31-7.92) and considerable heterogeneity (I² = 76.1 %). Neither calcaneal pitch nor Meary's angle differs significantly. In other words: midfoot adductus seems correlated with risk, but the relationship with hindfoot varus and pes cavus has not been demonstrated9.

When failure has already happened: what becomes of a non-union

The question often arises in rehabilitation, faced with a patient who arrives with a fracture line still visible months later. The series by Hunt and Anderson covers 21 elite athletes operated on for a revision for non-union or refracture of a Jones fracture, by intramedullary screw fixation combined with autologous cancellous bone graft or with a mixture of bone marrow aspirate and demineralised bone matrix. All regained their previous level of competition, at a mean of 12.3 weeks, with complete clinical and radiographic cortical union, and only one had a further refracture. The authors recommend a solid, large-diameter screw (5.5 mm or more) and an autologous graft21.

The message is useful to pass on to the worried patient: a first-line failure is not a dead end, and revision surgery has good documented results.

The timetable for return: the most actionable factor

This is the item most directly useful to the physiotherapist, and it comes from the series by Lee et al. covering 168 fifth metatarsal stress fractures in elite athletes, treated by modified tension band wiring. Eleven non-unions and eighteen refractures were recorded. The factors associated with refracture were a higher weight and two radiological parameters reflecting protrusion of the fifth metatarsal head (4-5 intermetatarsal angle on the AP view, lateral deviation of the 5th MT on the oblique).

But the most telling observation is chronological: all the refractures occurred after a new injury, once union had been achieved; 13 of the 18 within six months of the start of rehabilitation, and 8 within three months. The authors conclude that patients with a prominent 5th metatarsal head and a high body mass index must approach rehabilitation cautiously before considering a return to their previous sporting level11.

The window of vulnerability does not close at union. It stays open for the six months following the start of rehabilitation, and that is exactly the period when the patient feels cured.

The plantar gap, a radiographic sign worth knowing

A second series from the same team, covering 86 fifth metatarsal stress fractures, tested a simple radiographic criterion: the presence of a plantar gap of 1 mm or more on incomplete fractures. Result: incomplete fractures with a gap of ≥ 1 mm united in 115.5 ± 45.4 days, against 73.9 ± 26.7 days for those whose gap was smaller (p < 0.001). Counter-intuitively, complete fractures united faster (67.5 ± 28.8 days) than incomplete ones taken as a whole (103.2 ± 47.7 days)12.

This result deserves to be known by the rehabilitation clinician, because it contradicts intuition: faced with two radiographs, the one that looks less serious (an incomplete line, with a thin plantar lucency) may herald a union twice as long.

What do you rehabilitate, and on what timetable for return to weight bearing?

With this fracture, rehabilitation is not first of all analytical work: it is the management of a return to weight bearing in a window where the bone is not yet safe.

What the sources allow you to state, and what they do not

It has to be said directly: none of the sources consulted describes a validated rehabilitation protocol for the Jones fracture. The studies measure times to union, return-to-sport rates and complications; they do not compare rehabilitation programmes with each other. What follows is therefore built from three solid elements (the measured times to union, the chronology of refractures, and the factors predicting failure) and not from a published protocol.

The four objectives of rehabilitation

1. Steer the return to weight bearing without outrunning the bone

This is the main objective, and it is chronological before it is technical. The marker is simple: pain on weight bearing along the lateral border of the foot is the signal, and the progression follows union, not the theoretical timetable. In zone 1, weight bearing is allowed from the outset and functional treatment does better than a plaster boot on the time to return to the previous level4. In zone 2, the question depends on the strategy chosen and must be settled with the surgeon.

2. Restore the ankle and foot without loading the fracture site

The period of immobilisation or non-weight bearing costs ankle mobility and triceps surae strength. Analytical work on dorsiflexion, mobilisation of the midfoot and open-chain strengthening can start early without loading the lateral border. Work on the peroneals, by contrast, requires caution: peroneus brevis inserts on the tuberosity14, and its resisted contraction tensions the zone 1 fracture site. Our article on peroneal tendinopathies sets out the loading progression for those muscles.

3. Correct what can be corrected in the way the foot loads

Raikin's series provides the only documented item of orthotic care: the patients in varus were fitted postoperatively with a lateral off-loading insole for the hindfoot and forefoot, with 100 % union and no refracture at a mean follow-up of 49 months8. It has to be read for what it is: a series with no control, in which the effect of the insole cannot be separated from that of fixation with a 4.5 mm screw. But the orthosis is cheap and low-risk, which makes it a reasonable option when there is frank clinical varus.

4. Watch the refracture window

This is the objective the literature supports most directly, and paradoxically the one most often forgotten: vulnerability persists for months after union. An athlete who has returned and reports discomfort along the lateral border is not an athlete who has not warmed up properly: it is an athlete to re-examine.

What do concrete clinical cases teach us?

Two published observations, chosen because they show what meta-analyses cannot: what happens when the patient does not follow the treatment, and what a front-line physiotherapist sees.

How do you apply all this from Monday morning?

What reading the sources changes in practice, for the patient who arrives with a painful foot and a radiograph in their file.

The decision tree, starting from the film

What to say to the patient, and in what words

• When it is a zone 1. “Your fracture involves the most proximal part of the bone, the one with the best blood supply. It heals well, including when the fragment is displaced, and you can walk on it.” It is useful to add that the fragment may never fuse on the radiograph without that causing a problem: in one series, 35.5 % of non-operated patients had a radiological non-union and all were asymptomatic at one year13. That avoids alarm at the follow-up.
• When it is a zone 2. “Your fracture sits a few millimetres from the previous one, but in a zone where two blood networks meet without overlapping. That is what explains why it unites more slowly, and sometimes not at all.” The image of the vascular crossroads works well in the clinic, and it is accurate3.
• On returning. “Uniting does not mean being solid. Refractures occur after union, and most of them within six months of the start of rehabilitation11.” It is the most important message to get across, and the least spontaneously accepted.

Five errors that cost dear

The decisive act is not therapeutic, it is radiological: look at whether the fracture line reaches the joint between the fourth and the fifth metatarsals.

Frequently asked questions

What is the difference between a Jones fracture and a fracture of the base of the 5th metatarsal?

All Jones fractures are fractures of the base of the fifth metatarsal, but the reverse is not true. The Lawrence and Botte classification distinguishes three zones: the tuberosity (zone 1), the metaphyseal-diaphyseal junction that extends as far as the joint between the 4th and 5th metatarsals (zone 2), and the proximal diaphysis (zone 3)1. Only zone 2 is a Jones fracture in the strict sense. The confusion is frequent because all three sit within a few centimetres of the same bone.

Why does this fracture not unite well?

Because zone 2 is a vascular crossroads. Smith's anatomical study on ten injected cadaveric specimens shows that the rich, redundant network of the tuberosity meets the territory of the nutrient artery of the diaphysis exactly in the region of poor prognosis3. A fracture there cuts one supply with no back-up route to take over.

Should a Jones fracture be operated on?

In athletes, the answer from the available syntheses is yes: union reaches 97.3 % after screw fixation against 71.4 % without, with return to sport of 98.8 % against 71.6 % and 3.5 weeks gained5. In the patient with no requirement on timing, the question is open: Polzer's systematic review, which includes only prospective trials, finds good to excellent results with functional treatment for zone 24. The decision is made with the surgeon, according to the level of demand and the exact site of the fracture line.

How long before walking again, and before returning to sport?

For a zone 1, weight bearing is allowed from the outset with functional treatment4. For a zone 2 in an athlete, return to sport occurs at a mean of 9.6 weeks after screw fixation and 13.1 weeks without surgery5. These values are averages from sporting populations, and a plantar gap of at least 1 mm on an incomplete fracture lengthens union from 74 to 116 days12. The timetable is set by union, not by the average.

Can you refracture after healing?

Yes, and it is the most underestimated risk: the refracture rate reaches 10.2 % even after surgery5. In a series of 168 fractures in elite athletes, all the refractures occurred after a new injury on a united bone, and 13 out of 18 within six months of the start of rehabilitation11. That is why the loading progression continues well beyond radiological union.

My podiatrist speaks of a varus hindfoot, is that related?

It is a solid but unconfirmed hypothesis. Raikin found radiographic varus in 18 patients out of 21 operated on for a Jones fracture, and proposes that overloading of the lateral column predisposes to the fracture and to its failure8. But Riegger's meta-analysis, on 8 studies, confirms neither hindfoot varus nor pes cavus: only the midfoot adduction angle stands out, with a mean difference of 4.62°9. The lateral off-loading insole remains a reasonable option when there is frank varus, without its effect being something one can promise.

I have a “little bone” next to the 5th metatarsal on my radiograph, is that a fracture?

Perhaps an os vesalianum, an accessory ossicle whose most recent meta-analysis, on 21,312 feet, puts the prevalence at 0.6 %15. It is distinguished by smooth, corticated margins, a constant position, and its usual presence on the other foot: which a comparative film reveals. In the adolescent, it may also be the growth apophysis, running parallel to the axis of the bone, whereas a zone 1 fracture is transverse.

What is a dancer's fracture, and is it the same thing?

No, and the prognosis is in fact the opposite. It is a spiral, oblique fracture of the distal shaft of the fifth metatarsal, well beyond the three proximal zones. The original series on 35 professional dancers reports mainly non-operative treatment, including for displaced fractures, with pain-free walking at a mean of 6.1 weeks and return to performance at 19 weeks; all the dancers returned without limitation18. It accounts for 25 % of fifth metatarsal fractures, of which 80 % in women17.

Bibliography

Twenty-seven references, all verified individually on PubMed: identifier resolved, title, journal, year and author list checked, abstract read before citation. The links point to the PubMed record.

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