If fragmentation is such that the joint cannot be reconstructed, the options are:
Neither of these options is ideal.
The results may be unsatisfactory because of the fracture's intraarticular nature, and the patient may complain of pain and stiffness.
In the hallux, excisional arthroplasty is less tolerated due to instability.
Arthroplasty exists but will not be covered here.
As fusion is permanent, the decision to perform fusion should be considered for only significantly damaged articular surfaces.
The fusion can be completed using either lag screws or a plate.
The patient should be made aware that this procedure will shorten the toe.
Toe fractures versus long bone fractures
Toe fractures are different from long bone fractures.
The bones are very small
Fracture gaps are small
Fixation devices don't need to counter large forces
Thus, following the AO principles is less critical than for long bones, and often isolated screws or K-wires alone will work satisfactorily.
Restoration of length, rotation, and angulation are important for cosmesis.
The hallux is particularly critical due to its importance for walking.
Timing of surgery
The timing of surgery is influenced by the soft tissue injury and the patient's physiologic status.
Dislocation or injuries associated with the skin at risk requires immediate intervention regardless of the amount of soft tissue swelling.
If possible, swelling should be significantly decreased before surgery, which can take up to two weeks in some instances.
Open fractures should be promptly irrigated and debrided, and treated with antibiotics. Definitive fracture fixation may not be possible during this setting.
Forefoot fractures do not contribute to physiologic instability. If there is no soft tissue at risk, urgent intervention is not required.
Lag screws vs plate fixation
The fixation can be ensured using either lag screws or a plate.
Typically, lag screws are used when the construct is length-stable, and compression is possible.
Plates are an acceptable alternative to lag screws but result in more prominent hardware. Plates in combination with autogenous bone graft may also be used in cases with bone loss where maintenance of length is desirable. A dorsal plate is less prominent than a medially placed plate.