The main principle of operative treatment is removal of any painful impingement, or gross malorientation of the toe. In cases of excision, anatomical reconstruction of the joint is not always necessary.
In case of fresh trauma, large fragments may be fixed by screw or K-wire. If an open reduction is undertaken, one must strive to achieve an anatomical reduction.
In cases of late presentation, excision may be the preferable choice and at times an IP-fusion may be necessary.
2. Patient positioning
The patient is placed supine on a radiolucent table. A well-padded bump is placed under the ankle and heel of the surgical foot to elevate the foot for improved access and stabilize against rotation.
The nonoperative leg is secured with safety straps or taping.
To correct for external rotation of the leg and foot, a well-padded bump may be placed under the ipsilateral hip (a).
Alternatively, to correct for internal rotation of the leg and foot, a well-padded bump is placed under the contralateral hip (b).
3. K-wire fixation
K-wire fixation may be utilized for large fragments with angular deformity.
After manual reduction, a 2.0 mm K-wire is placed into the distal phalanx just plantar to the nail across the DIP joint and into the base of the proximal phalanx. It is not necessary to cross the MTP joint.
A second wire may be utilized if needed. Anatomic reduction is not required.
Large fragments can be fixed while small fragments are excised. The aim is to restore congruity of the joint. In this procedure, special care has to be taken not to injure the nerves in the vicinity.
Immediate postoperative treatment is rest, ice and elevation.
The patient should be encouraged to begin early weight bearing. A stiff-soled, rocker bottom orthosis is helpful in protecting the toe, but a flat, rigid sole shoe may suffice.
X-ray the toe at 6 weeks to confirm satisfactory union, and remove K-wires if present. Once the fracture is united, the orthosis may be gradually discarded.