Authors of section


Richard Buckley, Andrew Sands, Michael Castro, Christina Kabbash

Executive Editors

Joseph Schatzker, Richard Buckley

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ORIF: screws or plate

1. Open reduction and preliminary fixation


Intraarticular base fractures of the proximal phalanx of the hallux are best approached through a medial approach. Extension of the incision allows for visualization of the entire dorsal surface.

medial approach to the hallux

Pearl: Use of distractor

Visualization of the joint may be improved by releasing the dorsal insertion of the EHB and utilizing a mini-distractor on the dorsal surface.

orif screws or plate


Utilization of a syringe for irrigation is helpful. The displaced fracture fragment(s) is/are mobilized using a dental pick or Freer elevator.

orif screws or plate

Reduction and preliminary fixation

The fracture is held reduced with pointed reduction forceps. Provisional K-wires are then placed to maintain the reduction.

orif screws or plate

2. Definitive internal fixation

For a short T-type fracture with a transverse shaft pattern, a T-plate is recommended. For a long T-type or lambda fracture, fixation with two lag screws is sufficient.

hallux proximal phalanx base intraarticular t type

Fixation of short T-type fractures

After provisional fixation is obtained, a T-plate which will best capture the fracture fragments should be molded to the medial contour of the proximal phalanx.

Choose a T-plate of appropriate length and contour the plate to fit the proximal phalanx.

orif screws or plate

The first screw should be a 2.0 mm or a 2.4 mm shaft screw inserted in the distal most screw hole to secure the plate to the proximal phalanx, predrilling the cortices with a 1.5 mm or 1.8 mm drill bit.

orif screws or plate

Fix the plate to the base of the phalanx with two lag screws which will compress and provide stability for the vertical intraarticular component.

Do not forget to overdrill the proximal cortex at the base in order to achieve the lag effect.

orif screws or plate

While the plate is held to the shaft, loosen the distal most screw and insert a screw eccentrically through the first or through the second hole distal to the fracture (position 3 or 4 in the illustration) in order to bring the transverse part of the fracture under compression.

Tighten then the distal most screw and insert a screw through the last screw hole.

For fixation use either the 2.0 or 2.4 mm shaft screw.

orif screws or plate

Fixation of long T-type or lambda fractures

After provisional fixation is obtained, two lag screws may be placed, capturing and securing the fracture fragments. The lag screws should be perpendicular to the fracture plane.

If the oblique screw should fail to provide secure fixation of the shaft component, resort to the application of a plate as you would for the fixation of a short T-type fracture.

orif screws or plate

Small phalangeal bones are adequately reduced and fixed with lag screws.

orif screws or plate

3. X-rays

Obtain x-rays to confirm alignment and hardware placement.

4. Aftercare

Weight bearing may be allowed as long as the patient is provided with a flat, rigid sole shoe which is continued for 6-10 weeks, until X-rays or clinical examination is consistent with healing.

To prevent stiffness, range of motion for the first MTP joint is initiated at two weeks.

nonoperative treatment