Khairul Faizi Mohammad, Brad Yoo
Markku T Nousiainen, Richard Buckley
These fractures involve small segments, which typically only permit fixation with one lag screw.
Anatomical reduction of the joint surface is important to prevent chronic instability or posttraumatic degenerative joint disease.
The lag screw may be inserted alone or in combination with a plate.
A plate is typically indicated when additional stability is required, and the fragment size is large enough.
The lag screw should ideally be inserted through the plate when a plate is used, as such a construct is more stable.
Toe fractures are different from long bone fractures.
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.
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.
This procedure is typically performed with the patient placed supine and the knee flexed 90°.
Intraarticular head fractures of the proximal phalanx of the hallux may be approached through either:
Reduction starts with traction to restore length.
Lateral pressure exerted by the surgeon's thumb and index finger will reduce the fracture.
Confirm reduction using image intensification.
Visualization of the joint is challenging.
Visualization may be improved by longitudinal distraction or by using a percutaneous reduction aid such as a mini distractor.
Clean the fracture using a dental pick. Direct suction or irrigation is helpful.
The fracture edges are exposed, and the fragment mobility is assessed. It is essential to maintain the vascularity of small fragments.
The extent of articular involvement is assessed, including separate osteochondral fragments.
The fracture is reduced using one of the below techniques.
If K-wires are used to secure the fixation, they should not interfere with the planned screw or plate placement.
Restore anatomical axial rotation, length, and angulation.
Depending on the size of the fragment, a 2.0 mm or 2.4 mm bicortical lag screw is inserted.
Implants larger than 2.7 mm will frequently cause fragmentation.
A 2.4 or 2.0 mm plate is contoured to fit the medial bone surface and fixed with a minimum of two screws in the shaft inserted in neutral mode.
Contour a 2.4 or 2.0 mm plate to fit the medial bone surface.
Insert a 2.0 or 2.4 mm lag screw perpendicular to the fracture line through the plate.
Insert a minimum of two additional screws in neutral mode to secure the plate to the shaft.
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.
Range of motion exercises (both actively and passively) may be initiated once soft tissues permit.