Perform reduction as quickly as possible, since there is a risk of neurovascular compromise. Reduction is accomplished by reproducing the mechanism of injury. The proximal phalanx is extended and traction is applied to free the inferior rim from its impingement on the dorsal surface of the metatarsal. The toe is then translated in a plantar direction to effect the reduction. In the toes, the ligamentous support is sometimes sufficient to maintain reduction, which makes fixation unnecessary. However, if the reduction is unstable, then fixation must be accomplished.
Pitfall: Interposition of the plantar plate
Sometimes, reduction fails because the plantar plate may become interposed in the joint. In such a case, a dorsal incision will allow visualization of the joint and removal of the interposed tissue which then allows reduction to follow.
2. Pin fixation
There are two options to secure fixation. Fixation of the fracture with a K-wire through the distal phalanx is the preferred technique as it is easier.
The first option is to drive a K-wire through the toe beginning just under the nail and then driving the K-wire in line with the axis of the toe across the IP-joints, and then across the MTP-joint, while it is kept reduced, into the shaft of the metatarsal.
The alternative option would be to drive a K-wire which catches the base of the proximal phalanx.
While the reduction is maintained, the K-wire is driven across the joint into the shaft of the first metatarsal.
The difficulty with this option is to catch the base of the proximal phalanx with the K-wire.
Instruct the patient in daily pin care to avoid pin-track infection.
The foot is immobilized in a cam walker.
If the pins are inserted through the plantar aspect, weight bearing must be withheld until the pins are removed. If the pins are inserted through the toes into the metatarsals, then full weight bearing can commence early, as soon as swelling and pain allow.
The foot should be elevated intermittently through the first two weeks with application of ice packs to control edema.