Usually, these fractures are undisplaced and do not require surgery, although they may be slow to heal. Indications for operative treatment is displacement, because of unreduced, they result in post-traumatic arthritis. If the fragment is too small or if the patient presents some weeks after the fracture with a non-union it may be more practical to excise the fragment and perform a capsulorrhaphy to stabilize the joint.
Indications for fixation:
Instability of the toe
High comorbidities (diabetes)
The larger the fragment, the more likely it is to require fixation.
2. Patient preparation and approach
This procedure is normally performed with the patient in a supine position.
The surgical incision is best placed over the fragment to facilitate reduction and fixation. A medial approach is usally best suited (see Medial approach to the hallux).
Reduction is maintained with pointed reduction forceps, which may be placed percutaneously on the opposite side. A small fragment may make fixation difficult. Helpful aids are an integrated drill guide or forceps with a forked tip.
Confirm anatomic reduction with intraoperative imaging to avoid any articular incongruity.
A lag screw must be used for fixation to achieve compression and absolute stability. Extreme caution is necessary if the fragment is small or if the bone is osteoporotic, as overtightening of the screw may result in fragmentation which would make subsequent fixation very difficult.
Care must be taken to avoid any articular incongruity, and postoperative imaging may be required to confirm this.
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. Once the fracture is united, the orthosis may be gradually discarded. Removal of the lag screw is necessary only if the screw is causing symptoms.