High-yield overview

Dorsal longitudinal approach in intermetatarsal space | intermediate

Critical Danger Structures

Danger 1

Superficial peroneal nerve - dorsal branches cross metatarsals with variable anatomy, 1-2cm deep to skin, injury causes dorsal foot numbness and painful neuroma

Danger 2

Deep peroneal nerve - runs between 1st and 2nd metatarsals with dorsalis pedis artery at 2-3cm depth, injury causes weakness of toe extensors

Danger 3

Dorsalis pedis artery - between 1st and 2nd MT, palpable on dorsum, 2-3cm from skin, injury causes vascular compromise

Danger 4

Extensor digitorum longus tendons - must be retracted laterally, not transected, injury causes toe drop

Danger 5

Plantar neurovascular bundle - runs 8-10mm plantar to metatarsal shaft, protected by maintaining periosteal sleeve plantarly

Mnemonic

DORSALIndications for ORIF - DORSAL Mnemonic

Hook:Think DORSAL for the dorsal approach and key surgical indications

Mnemonic

PIMPFixation Options - PIMP Technique

Hook:PIMP your fixation choice based on fracture pattern and soft tissues

Positioning and Preparation

Patient Position: Supine with bump under ipsilateral hip. Tourniquet on thigh (280-300mmHg). Foot positioned at end of table or on radiolucent arm board for fluoroscopy access.

Surgical Approach: Dorsal longitudinal approach in intermetatarsal space

Incision: Dorsal longitudinal incision in intermetatarsal space, 4-6cm long, centered over fracture site. For 2nd MT, incision between 1st and 2nd. For 3rd/4th MT, incision between 2nd-3rd or 3rd-4th interspace.

Skin Bridge Consideration: When multiple metatarsals fractured, maintain skin bridges of at least 3-4cm between parallel incisions to prevent skin necrosis. Consider single midline incision if 2nd and 3rd both require fixation.

Operative Technique

Step 1: Preoperative Planning and Imaging

Imaging Requirements: Obtain AP, lateral, and oblique foot X-rays. These three views are essential for complete assessment.

Assessment Parameters:

Fracture location: base, shaft, neck, or head
Displacement: measure in millimeters (greater than 3-4mm = operative)
Angulation: measure in degrees (greater than 10° = operative)
Rotation: assess toe alignment compared to contralateral
Adjacent injuries: look for multiple metatarsal involvement
TMT joint involvement: CT may be needed for base fractures

Weight-bearing views: If patient able to stand, weight-bearing films show true displacement and arch disruption.

Clinical Pearl

Technical Tip: EXAM KEY: 'Three views of foot essential - AP, lateral, oblique. I assess displacement greater than 3-4mm, angulation greater than 10°, rotation, and multiple fractures. Base fractures may need CT to rule out Lisfranc injury pattern.'

Dangers at this step

Missing Lisfranc injury component with base fractures
Missing rotation on plain X-rays (compare to contralateral)
Operating on minimally displaced fractures that would heal with conservative care

Step 2: Incision Selection and Surface Anatomy

Anatomical Considerations: The dorsal intermetatarsal approach exploits the natural intervals between metatarsals while avoiding the extensor tendons that overlie each metatarsal shaft.

Incision Placement by Metatarsal:

2nd MT: Incision between 1st and 2nd - PROTECT dorsalis pedis artery
3rd MT: Incision between 2nd and 3rd OR between 3rd and 4th
4th MT: Incision between 3rd and 4th (preferred)
Multiple fractures: Avoid parallel incisions less than 3-4cm apart

Single Midline Option: For simultaneous 2nd and 3rd MT fractures, a single dorsal incision can access both through subperiosteal dissection.

Clinical Pearl

Technical Tip: EXAM KEY: 'I use dorsal intermetatarsal approach between the metatarsals - this avoids extensor tendons and gives access to both adjacent metatarsals if needed. Skin bridges must be greater than 3-4cm. For 2nd MT, I protect dorsalis pedis between 1st and 2nd.'

Dangers at this step

Dorsalis pedis injury in 1st-2nd interspace (2-3cm deep)
Superficial peroneal nerve branches (variable anatomy)
Skin necrosis with multiple close incisions

Step 3: Superficial Dissection and Nerve Protection

Technique: Incise skin sharply down to subcutaneous tissue. Identify and protect dorsal cutaneous nerve branches.

Superficial Peroneal Nerve: Variable anatomy with multiple branches crossing dorsum of foot. Injured nerve ends retract and form painful neuromas. Use loupe magnification if available. Retract branches gently or dissect free and protect with vessel loops.

Extensor Tendons: Identify EDL tendons overlying each metatarsal. Retract laterally - DO NOT TRANSECT.

Deep Dissection: Elevate dorsal interosseous muscles carefully from fracture site. Minimal periosteal stripping preserves blood supply.

Clinical Pearl

Technical Tip: EXAM KEY: 'I protect superficial peroneal nerve branches carefully - variable anatomy, and cut ends retract causing neuromas. Retract extensor tendons, elevate interosseous muscles subperiosteally. Minimal periosteal stripping preserves blood supply and prevents nonunion.'

Dangers at this step

Nerve injury causing dorsal foot numbness and painful neuroma
Excessive periosteal stripping increases nonunion risk
Tendon injury causing toe extension weakness

This completes the surgical approach section.

Complications

Post-operative Care

Immediate Post-operative (Day 0-1):

Neurovascular examination documented
Elevation above heart level to minimize swelling
Gentle toe ROM exercises begin immediately
Pain control with multimodal analgesia

Week 0-6:

Non-weight-bearing in CAM boot or cast
Continue toe ROM exercises
Wound check at 2 weeks, suture removal
Serial X-rays at 2, 4, 6 weeks to monitor healing

Week 6-8:

Transition to protected weight-bearing based on radiographic healing
Progressive weight-bearing as tolerated
Physiotherapy for gait re-education

Week 8-12:

Advance to full weight-bearing
Transition to supportive athletic shoe
Return to normal activities as tolerated

Hardware Removal: Rarely needed unless prominent and symptomatic. Typically performed after 12-16 weeks if required. IM screws and buried hardware can remain permanently.

Evidence Base

The epidemiology of metatarsal fractures

Level IV

Petrisor BA, Ekrol I, Court-Brown C • Foot & Ankle International

Clinical Implication: A central-ray fracture should prompt a deliberate search for adjacent metatarsal injury, because contiguous multi-ray patterns are the rule rather than the exception and change fixation sequencing.

Verify on PubMed (PMID 16539897)

Union Rate and Rate of Hardware Removal Following Plate Fixation of Metatarsal Shaft and Neck Fractures

Level III

Bryant T, Beck DM, Daniel JN, Pedowitz DI, Raikin SM • Foot & Ankle International

Clinical Implication: Low-profile dorsal plating of central-ray shaft and neck fractures reliably achieves union with low residual malalignment and a low symptomatic hardware-removal rate, supporting it as the default fixation for displaced central-ray injuries.

Verify on PubMed (PMID 29513603)

Fixation of displaced fifth metatarsal shaft and neck fractures

Level V

Kamin K, Notov D, Marx C, Rammelt S • Operative Orthopadie und Traumatologie

Clinical Implication: Contemporary technique emphasises restoration of the metatarsal parabola and rotation with low-profile 2.0-2.4mm interlocking plates and lag-screw compression where the pattern permits.

Verify on PubMed (PMID 34811573)

Elastic Stable Intramedullary Nailing (ESIN) of Metatarsal Fractures

Level IV

Hettchen M, Strauss AC, Pennekamp PH, Burger C, Weber O, Muller MC • Zeitschrift fur Orthopadie und Unfallchirurgie

Clinical Implication: Minimally invasive intramedullary fixation is a valid alternative to dorsal plating for short central-ray shaft and neck fractures, avoiding extensive soft-tissue dissection while delivering high functional scores.

Verify on PubMed (PMID 26670302)

Surgical controversies and current concepts in Lisfranc injuries

Level V

Ahluwalia R, Yip G, Richter M, Maffulli N • British Medical Bulletin

Clinical Implication: Metatarsal base fractures must be screened for an associated Lisfranc injury with weight-bearing imaging or CT, because a missed tarsometatarsal injury and non-anatomic reduction are the dominant drivers of poor outcome.

Verify on PubMed (PMID 36151742)

Clinical Decision Scenarios

Use these scenarios to practise clinical reasoning and management decisions

CLINICAL SCENARIOStandard

CLINICAL PROMPT

"A 35-year-old construction worker sustains a displaced 2nd metatarsal shaft fracture with 5mm displacement and 15° plantar angulation after a heavy object fell on his foot. Walk me through your management."

PRACTICAL APPROACH

Thank you. This is a displaced 2nd metatarsal shaft fracture requiring surgical fixation based on displacement greater than 3-4mm and angulation greater than 10°. I would take a systematic approach: First, complete assessment with AP, lateral, and oblique foot X-rays to assess displacement, angulation, rotation, and rule out additional injuries including Lisfranc injury. Second, examination to assess neurovascular status, skin integrity, compartments, and rule out open fracture. My management would be ORIF via dorsal intermetatarsal approach between 1st and 2nd metatarsals with protection of dorsalis pedis artery and superficial peroneal nerve branches. Fixation with dorsal low-profile plate (2.4mm) with 3-4 screws each side, ensuring anatomic reduction especially in rotation. I would counsel about risks of nonunion, malunion particularly rotational, transfer metatarsalgia, hardware prominence, infection, and nerve injury. Post-operatively non-weight-bearing for 6 weeks then progressive weight-bearing.

CLINICAL SCENARIOStandard

CLINICAL PROMPT

"You are fixing a 3rd metatarsal fracture and notice that despite anatomic reduction on AP and lateral views, the 3rd toe is crossing over the 2nd toe. What is the problem and how do you fix it?"

PRACTICAL APPROACH

Thank you. This indicates rotational malreduction of the 3rd metatarsal despite appearing anatomically reduced in standard planes. Rotation is easily missed on plain radiographs. The problem is that I have malrotated the capital fragment. To fix it, I need to: First, remove the fixation. Second, reassess the rotational alignment by ensuring the metatarsal head orientation matches the base orientation - imagine a line down the center of the metatarsal from base to head. Third, ensure all toes point in the same direction when the foot is at rest. Fourth, compare to the contralateral foot. Fifth, re-fix with corrected rotation. The key is that rotational deformity causes functional problems (crossed toes, shoe wear pain) despite radiographic appearance of union. Prevention requires careful intra-operative assessment of toe alignment and comparison to contralateral foot.

CLINICAL SCENARIOStandard

CLINICAL PROMPT

"A 42-year-old presents with pain under the 2nd metatarsal head 3 months after ORIF of a 3rd metatarsal shaft fracture that has united. What is the likely cause and how do you prevent this?"

PRACTICAL APPROACH

Thank you. This is transfer metatarsalgia - the patient has increased pressure under the 2nd metatarsal head due to alteration of the normal metatarsal parabola. The likely causes from the 3rd MT fracture fixation are: First, dorsal malunion of the 3rd MT causing the 3rd to be shorter, transferring load to the 2nd MT. Second, excessive shortening of the 3rd MT from impaction. Third, possible plantar angulation of the 3rd MT was present initially. Prevention requires: First, restoring anatomic length of the fractured metatarsal. Second, avoiding plantar angulation greater than 10° which causes pseudo-shortening. Third, maintaining the metatarsal parabola where the 2nd MT is longest, then 1st and 3rd are progressively shorter. Fourth, fluoroscopic confirmation of sagittal plane alignment. Management of established transfer metatarsalgia includes conservative measures (metatarsal pad, rocker-bottom shoe modifications) first. If failed conservative care, surgical correction with shortening osteotomy of the 2nd MT or lengthening/plantarflexion osteotomy of the malunited 3rd MT.