Authors of section

Authors

Richard Buckley, Andrew Sands, Michael Castro, Christina Kabbash

Executive Editors

Joseph Schatzker, Richard Buckley

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ORIF or K-wire fixation

1. General considerations

Anatomical considerations

Proper alignment of the metatarsal heads is a critical goal in restoring the pathomechanics of the forefoot. On the AP view, a normal curved “cascade” (Lelièvre’s parabola) appearance, symmetric with the other foot, is mandatory. See illustration. This ensures that the normal length of the metatarsal is restored.

It is also critical to restore the metatarsals in their axial or horizontal plane so that in the axial or tread view all the metatarsal heads are on the same level.

Any malalignment particularly flexion will recreate focally high pressure during the stance phase and toe-off and will result in pain and subsequent callus formation.

Note that for the first ray, it is the sesamoids rather than the first metatarsal head, that bear weight, and therefore one must look at the sesamoid level in establishing the alignment in the axial or horizontal plane of the first metatarsal.

orif lag screw or plate fixation

Nonoperative treatment

Usually if the first MT head is broken, the foot has sustained significant trauma. Most of these fractures are displaced. But minimally displaced fractures with the hallux in good alignment may be treated nonoperatively with buddy taping and a rigid sole shoe.

orif or mtp joint fusion

Displaced fractures

Displaced fractures may be associated with first MTP joint dislocation. Reduction of the articular surface and alignment of the first MTP joint and its associated soft tissues are important in treating this injury.

Pearl
Look for damage to the plantar plate by assessing sesamoid position on an AP radiograph. Check whether they are spread apart or not. If the volar plate was avulsed, it may interpose itself into the metatarsophalangeal joint and block reduction.

orif or k wire fixation

2. Patient preparation

This procedure is normally performed with the patient in a supine position.

orif lag screw or plate fixation

3. Closed reduction and K-wire fixation

Reduction

Closed manual reduction and percutaneous pinning may be attempted. However, as this is an intraarticular fracture anatomic reduction of the metatarsal head is preferred.

orif or k wire fixation

Fixation

Once alignment of the fragments is obtained, a 1.6 mm K-wire may be placed percutaneously through each fracture fragment, perpendicular to the fracture lines, exiting the MT shaft proximal to the fracture site.

Reduction is confirmed with intraoperative fluoroscopy or radiographs.

orif or k wire fixation

4. Open reduction internal fixation

Reduction

If the fracture cannot be reduced with manual traction, carry out an open reduction through a dorsal approach to the first metatarsal. The fracture fragments may have to be disimpacted and reduced with a Freer elevator.

If a neutralization plate is intended, then a medial approach to the MT1 is preferred.

Preliminary fixation

Maintain the reduction with pointed reduction forceps and secure provision fixation with K-wire fixation.

orif or k wire fixation

Definitive fixation

A 2.0 mm or 2.4 mm lag screw may be placed into one of the fracture fragments perpendicular to the plane of the fracture.

The remaining stabilized fracture fragments are similarly treated with lag screws.

For fractures on the lateral aspect of the head, the lag screws may be placed percutaneously.

orif or k wire fixation

A second or third lag screw may be placed for long oblique fractures. If one is dealing with osteoporotic bone, then a washer under the head of the screw is useful to prevent the head from sinking.

orif or k wire fixation

Final fixation with two small lag screws securing the intraarticular fracture.

orif or k wire fixation

5. Aftercare

Maintain weight bearing in a flat, rigid sole shoe for six weeks or until union. Then splint or tape toe for an additional six weeks to maintain alignment.

orif or mtp joint fusion