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Authors of section


Khairul Faizi Mohammad, Brad Yoo

Executive Editors

Richard Buckley, Markku T Nousiainen

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Lag-screw fixation

1. General considerations

Goal of surgery

The main goals of the surgery are to restore the length of the medial column without compromising the blood supply of the cuneiform.

Simple cuneiform fracture

Timing of surgery

The timing of surgery is influenced by the soft tissue injury and the patient's physiologic status. 


timing of surgery

2. Temporizing measures

Medial and lateral external fixation (with a distractor device to restore columnar length) should be applied as soon as possible to stabilize the foot and decrease further injury to the soft tissues.

Temporary percutaneous K-wires can be used to reduce displaced fragments and are left as temporary fixation.

Medial and lateral external fixation with a distractor device to restore columnar length

3. Patient preparation and surgical approach

The procedure is performed with the patient placed supine with the knee flexed 90°.

Supine position knee flexed 90°

The percutaneous approach to the cuneiform may be used for screw fixation in nondisplaced or minimally displaced simple/noncomminuted fractures (ie, midbody stress fractures).

Percutaneous approach to the cuneiform

If a closed reduction cannot be performed, a dorsomedial approach is made directly over the fracture.

The fracture is entered directly and dealt with as necessary.

Dorsomedial approach for the cuneiform

4. Reduction


Insert the pointed reduction forceps through two small stab incisions placed dorsomedially and dorsolaterally.

Careful clamp placement prevents obstruction of lag screws.

reduction of a simple cuneiform fracture with reduction forceps

Preliminary K-wire fixation

Provisional fixation can be performed using K-wires. Be sure to place the K-wires so that they will not interfere with the subsequent screw placement.

Preliminary K-wire fixation of a reduced simple cuneiform fracture

Check reduction

Ensure that the joints are anatomically reduced. The reduction can be inspected under direct vision if the joint has been correctly distracted.

Otherwise, the articular surface can be palpated with an elevator inserted dorsally.

If the reduction cannot be inspected under direct vision, use image intensification. Remember that the resolution of the image intensifier may not be sufficient to appreciate small joint incongruities. If in doubt, get intraoperative x-rays.

Preliminary K-wire fixation of a reduced simple cuneiform fracture

5. Fixation

Screw insertion

Use an image intensifier to verify the appropriate screw length.

Insert the proximal lag screw according to the standard technique. In contrast to lag screws inserted in the diaphysis, these lag screws will typically not penetrate the far cortex, as this would damage the opposite articular surface. 

Afterward, insert a second lag screw in the same fashion.

If the bone is porotic, insert a washer under the screw head to prevent it from sinking into the bone.

Lag screw fixation of a reduced simple cuneiform fracture

6. Aftercare


The non-adherent antibacterial dressing is applied as a first layer. Sterile undercast padding is placed from toes to knee. Extra side and posterior cushion padding are added.


The foot should be immobilized for the first two weeks, which can be achieved using a three-sided plaster splint. The anterior area is left free of plaster to allow for swelling. Ensure that the splint’s medial and lateral vertical portions do not overlap anteriorly and that the splint does not compress the popliteal space or the calf.

Immobilization of the foot with a three-sided plaster splint


The patient should be counseled to keep the leg on a cushion and elevated. Remember not to elevate the leg too much as it may impede the inflow. The foot’s ideal position is halfway between the waist and the heart when the patient is sitting. While seated, the foot should be on a cushion and elevated, but if badly swollen, the patient must be supine since elevating the foot while seated decreases swelling less effectively.

Avoid direct pressure against the heel during recumbency to prevent decubiti.

Patient seated with the foot immobilized in a plaster splint and the leg elevated on a cushion

The OR dressing is usually left in place and not changed until the first postoperative visit at two weeks when x-rays are obtained once the dressing is removed. If any complication is suspected (eg, infection or compartment syndrome), the dressing must be split and, if necessary, removed to allow full inspection.

The strict non-weight bearing should be maintained until there is evidence of healing and any transfixion K-wires (6–12 weeks) or bridging devices (min 12 weeks) are removed.

Daily toe movement is encouraged.

Formal physical therapy should not begin in the early postoperative period.

A gastrocnemius release may need to be performed in cases with postoperative gastrocnemius contracture. This occurs more typically in the mid and hind-foot.