Authors of section

Authors

Richard Buckley, Andrew Sands, Michael Castro, Christina Kabbash

Executive Editors

Joseph Schatzker, Richard Buckley

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ORIF: screw and plate fixation

1. Principles

Careful assessment of the T-MT joints is important. Minimal displacement of the 2 nd and 3 rd metatarsal bases, provided the joint is congruent, is usually well tolerated. However, if there is incongruity of the joint surface, painful arthritis can result. In such cases, primary arthrodesis of the involved T-MT joint might be advisable. These joints normally have little motion. Pain-free stability in good alignment is thus the goal of treatment.

2. Patient preparation and approach

Patient preparation

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

orif lag screw or plate fixation

Reduction and preliminary fixation

One or two proximal metatarsal fractures or dislocations can be approached through a single, appropriately placed, dorsal incision (see dorsal intermetatarsal approach).

orif screw and plate fixation

3. Reduction and Fixation

Reduction and preliminary fixation

Reduction is best done with pointed reduction forceps. First reduce the T-MT joint, which may need to be cleared of small fragments, and/or have its articular cartilage removed if arthrodesis is planned. The reduced joint is provisionally stabilized with one or two K-wires. The fracture of the metaphysis is then provisionally held with a pointed forceps, or additional temporary K-wires.

Reduction is best done with pointed reduction forceps.

Simple fractures

Lag screw insertion
If the fracture of the metaphysis is simple and if it is possible to fix it with a lag screw this should be done as it will increase the accuracy of reduction and will greatly improve fixation.

Lag screw insertion

Protection plate
However, a single screw is insufficient and such fixation must be protected with a plate which may have to bridge the T-MT articulation.

A single screw is insufficient and such fixation must be protected with a plate...

Multifragmentary fractures

A short proximal metatarsal segment may be difficult to fix securely. However, a dorsal plate can be attached proximally to the cuneiform, and bridge across the proximal metatarsal, with distal anchorage to the metatarsal shaft, as illustrated.

A dorsal plate can be attached proximally to the cuneiform, and bridge across the proximal...

4. Aftercare

Immobilization

A sterile dressing is applied and the patient is immobilized in a boot or in a below-knee cast.
If the state of the soft tissues is precarious, a padded bandage should be applied initially, and the limb should be maintained elevated until the swelling has subsided and healing of the soft tissues without further problems can be anticipated. The foot is then immobilized either in a boot or in a below-knee cast. The advantage of the boot is that it can be easily removed for inspection of the wound and for regular exercises and mobilization of the joints.

orif plate fixation

Weight bearing

Weight bearing is delayed until such time as the wound is healed.
The sutures are removed 2 weeks postoperatively and graduated weight bearing is started. The degree of loading of the extremity is determined by the severity of the injury and the stability of the fixation achieved. Early loading is important but not at the expense of loss of fixation. Intermittent elevation of the foot and extremity should be continued until such time as the swelling has subsided.

For percutaneous K-wire fixation

Weight bearing in a heel-wedge shoe is permitted. The K-wires are removed in the clinic at six weeks, at which point a flat postoperative or hard-sole shoe is permitted as tolerated.

Follow up

X-rays are taken at 6 weeks postoperatively to assess union and the integrity of the fixation.
The resumption of the use of normal footwear is guided by the clinical signs and x-ray evidence of union.