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.
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.
Utilization of a syringe for irrigation is helpful. The displaced fracture fragment(s) is/are mobilized using a dental pick or Freer elevator.
Reduction and preliminary fixation
The fracture is held reduced with pointed reduction forceps. Provisional K-wires are then placed to maintain the reduction.
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.
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.
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.
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.
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.
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.
Small phalangeal bones are adequately reduced and fixed with lag screws.
Obtain x-rays to confirm alignment and hardware placement.
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.