import { OnePagerSummary, ExamWarning, InfoCardGrid, InfoCard, MnemonicCard, EvidenceCard, VivaScenarioSection, VivaScenario, ExamCheatSheet, ContentSection, ExamPearl, SafetyAlert, NumberHighlightRow, NumberHighlight, Tabs, Tab, ComparisonTable } from '@/components/mdx' **Superficial peroneal nerve - dorsal branches cross metatarsals with variable anatomy, 1-2cm deep to skin, injury causes dorsal foot numbness and painful neuroma** **Deep peroneal nerve - runs between 1st and 2nd metatarsals with dorsalis pedis artery at 2-3cm depth, injury causes weakness of toe extensors** **Dorsalis pedis artery - between 1st and 2nd MT, palpable on dorsum, 2-3cm from skin, injury causes vascular compromise** **Extensor digitorum longus tendons - must be retracted laterally, not transected, injury causes toe drop** **Plantar neurovascular bundle - runs 8-10mm plantar to metatarsal shaft, protected by maintaining periosteal sleeve plantarly** **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. ### 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. **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.' - 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. **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.' - 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. **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.' - 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. ### Step 4: Fracture Exposure and Hematoma Evacuation **Exposure**: Complete exposure of fracture site by subperiosteal dissection. Evacuate fracture hematoma. Identify fracture pattern (transverse, short oblique, long oblique, comminuted). **Assess Stability**: Simple two-part fractures versus comminuted patterns requiring different fixation strategies. ### Step 5: Fracture Reduction Technique **Reduction Goals**: Restore length, alignment, and rotation. **Length**: Use pointed reduction clamps or temporary K-wires. Longitudinal traction helps with impacted or shortened fractures. **Alignment**: Restore anatomic sagittal and coronal plane alignment. Too much plantar angulation causes metatarsalgia. Dorsal angulation causes transfer lesions to adjacent metatarsals. **Rotation Assessment - CRITICAL**: Align metatarsal head with base orientation. All toes should point in same direction when reduced. Compare to contralateral foot. Rotational malunion is easily missed on X-ray but causes crossed toes deformity. **Reduction Aids**: Pointed reduction clamps, temporary K-wires, or small periosteal elevators can help maintain reduction. **Technical Tip**: EXAM KEY: 'ROTATION is critical and easily missed. I align metatarsal head with base - all toes should point same direction. Too much plantar angulation causes metatarsalgia under that metatarsal head. I compare to contralateral foot for rotational alignment.' - Rotational malunion leading to crossed toes (requires revision) - Plantar angulation greater than 10° causing transfer metatarsalgia - Dorsal angulation causing transfer lesion to adjacent metatarsals This completes the reduction technique section. ### Step 6: Dorsal Plate Fixation - Standard Technique **Plate Selection**: 2.0mm or 2.4mm low-profile dorsal locking plate, or mini-fragment 2.7mm system. **Biomechanical Principle**: Plantar cortex is TENSION side during gait (plantar fascia pull). Dorsal plate acts as neutralization/buttress plate, not compression plate. However, compression at fracture site is still achieved with screw technique. **Plate Application**: - Contour plate to metatarsal shaft anatomy - 3-4 screws each side of fracture (6-8 cortices total minimum) - Bridge plating for comminution (do not compress comminuted fragments) - Lag screw technique for simple oblique fractures before plate application **Screw Insertion**: Drill perpendicular to bone. Check depth to avoid penetration into adjacent metatarsal interspace. Locking screws in osteoporotic bone. **Technical Tip**: EXAM KEY: 'I use 2.0-2.4mm low-profile dorsal plate. Plantar cortex is tension side during gait. I aim for 3-4 screws (6-8 cortices) each side of fracture. For simple oblique patterns, I place interfragmentary lag screw first, then neutralization plate.' - Plate prominence causing shoe irritation (keep low-profile) - Inadequate fixation in osteoporotic bone (use locking screws) - Screws penetrating into adjacent metatarsal causing pain ### Step 7: Alternative Fixation - K-wires **Indications**: Soft tissue concerns precluding plate, minimally displaced fractures, temporary fixation in polytrauma, pediatric patients. **Technique**: - 1.6-2.0mm K-wires - Cross two or three K-wires for rotational stability - Antegrade insertion from fracture site or retrograde from metatarsal head - Bend and cut wires outside skin for later removal **Post-operative**: Pin site care. Removal at 4-6 weeks after fracture healing. **Technical Tip**: EXAM KEY: 'K-wires are alternative when soft tissues compromised or for temporary fixation. I use crossed wires for rotational control. Disadvantages: require removal at 4-6 weeks, pin site infection risk, and less stable than plate fixation.' - K-wire migration (must bend end outside skin) - K-wire infection and pin site inflammation - Loss of reduction before wire removal ### Step 8: Alternative Fixation - Intramedullary Screw **Indications**: Shaft fractures of 2nd-4th metatarsals, minimally comminuted patterns, desire for buried hardware avoiding removal. **Technique**: - Achieve anatomic reduction first - Entry point at metatarsal base (antegrade) or metatarsal head (retrograde) - 3.5-4.5mm cannulated screw with short thread - Bury screw head beneath cortex - Confirm position on fluoroscopy **Advantages**: Less soft tissue dissection, buried hardware, good for shaft fractures. **Disadvantages**: Requires good reduction first, limited rotational control, technically demanding. **Technical Tip**: EXAM KEY: 'IM screw increasingly popular for central ray shaft fractures. Advantages: buried hardware, minimal dissection, no removal needed. I achieve reduction first, then insert screw antegrade from base or retrograde from head. Good for 2nd-4th metatarsals.' - Loss of reduction during screw insertion - Screw penetration into TMT or MTP joint - Inadequate rotational control requiring supplemental fixation This completes the fixation options section. ### Step 9: Multiple Metatarsal Fractures **Sequencing**: Fix most unstable first, usually central rays (2nd/3rd) which are keystone of transverse arch and have least mobility. **Central Rays (2nd/3rd)**: Lack mobility, critical for arch. Fix first to restore arch anatomy. **Lateral Rays (4th/5th)**: More mobile, can compensate. Fix after central rays stabilized. **Severe Injuries**: For three or more metatarsal fractures with severe soft tissue injury, consider damage control with external fixator acutely, then staged ORIF when soft tissues recovered. **Compartment Syndrome Risk**: High-energy multiple metatarsal fractures have compartment syndrome risk. Maintain high index of suspicion. **Technical Tip**: EXAM KEY: 'Multiple metatarsals: I fix central rays (2nd/3rd) first - they are keystone of arch with no mobility. Lateral rays (4th/5th) more mobile. Restore transverse arch. For severe injuries, consider damage control with external fixator.' - Compartment syndrome in high-energy injuries (requires fasciotomy) - Soft tissue compromise from multiple incisions - Loss of transverse arch causing pes planus deformity ### Step 10: Neck and Head Fractures **Metatarsal Neck Fractures**: Often have apex plantar angulation causing pseudo-shortening. This leads to increased pressure under metatarsal head during gait (metatarsalgia). **Fixation Options**: - Plantar-to-dorsal lag screws (requires plantar incision) - Dorsal plate with special attention to reduction - K-wires if soft tissue concern **Metatarsal Head Fractures**: Often intra-articular requiring anatomic reduction to prevent MTP arthritis. **Fixation Options**: - Mini-plate (1.5mm) - Headless compression screws buried beneath cartilage - K-wires for severely comminuted patterns **AVN Risk**: Metatarsal head has limited blood supply. Minimize soft tissue stripping. **Technical Tip**: EXAM KEY: 'Neck fractures typically have plantar angulation apex - causes metatarsalgia if not reduced anatomically. Head fractures need anatomic reduction to prevent arthritis of MTP joint. AVN risk with head fractures if soft tissue stripped excessively.' - Plantar angulation greater than 10° causing transfer metatarsalgia - Intra-articular malreduction causing MTP arthritis - AVN of metatarsal head from soft tissue stripping (uncommon but devastating) This completes the special situations section. ### Step 11: Fluoroscopic Verification **Standard Views**: Check reduction on AP, lateral, and oblique views under fluoroscopy. **Confirmation Checklist**: - No rotation: all metatarsal heads aligned, toes parallel - Alignment restored in all planes - No intra-articular screw penetration into TMT or MTP joints - Plate profile acceptable (not prominent) - Hardware position satisfactory **Weight-bearing Simulation**: If patient awake with ankle block, can simulate weight-bearing under fluoroscopy to assess stability. **Technical Tip**: EXAM KEY: 'I verify on three views - AP, lateral, oblique. Rotation assessment: all metatarsal heads should be aligned and toes pointing same direction. Check no screws violating TMT or MTP joints. Low-profile hardware minimizes shoe irritation.' - Missing rotational malreduction on fluoroscopy - Intra-articular screw causing joint pain and arthritis - Prominent hardware causing shoe irritation ### Step 12: Wound Closure and Dressing **Hemostasis**: Irrigate wound copiously. Release tourniquet and achieve meticulous hemostasis with bipolar cautery. Ensure no vascular compromise to toes. **Closure Technique**: - Close dorsal interosseous muscles if elevated (2-0 absorbable) - Subcutaneous layer (3-0 absorbable) - Skin (4-0 monofilament or subcuticular) **Dressing**: Soft dressing with gentle compression. Alternatively, posterior splint in neutral position for comfort. **Elevation**: Strict elevation post-operatively to minimize swelling and wound complications. **Technical Tip**: EXAM KEY: 'Meticulous closure and hemostasis. Soft dressing or posterior splint for comfort. Strict elevation critical. Post-op protocol: NWB in CAM boot 4-6 weeks, then protected weight-bearing. Full WB at 6-8 weeks based on radiographic healing.' - Wound complications from swelling (elevation essential) - Early weight-bearing causing loss of fixation - Compartment syndrome development post-operatively (high-energy mechanisms) This completes the closure and final steps section. **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. ## References 1. Petrisor BA, Ekrol I, Court-Brown C. The epidemiology of metatarsal fractures. Foot Ankle Int. 2006;27(3):172-174. doi:10.1177/107110070602700303 2. Shereff MJ, Yang QM, Kummer FJ, Frey CC, Greenidge N. Vascular anatomy of the fifth metatarsal. Foot Ankle. 1991;11(6):350-353. doi:10.1177/107110079101100605 3. Coughlin MJ, Anderson RB. Hallux valgus. In: Coughlin MJ, Mann RA, Saltzman CL, eds. Surgery of the Foot and Ankle. 8th ed. Mosby Elsevier; 2007:183-362. 4. Laughlin RT, Carson JG, Calhoun JH. Displaced intra-articular calcaneus fractures treated with the Galveston plate. Foot Ankle Int. 1996;17(2):71-78. doi:10.1177/107110079601700203 5. Armagan OE, Shereff MJ. Injuries to the toes and metatarsals. Orthop Clin North Am. 2001;32(1):1-10. doi:10.1016/s0030-5898(05)70189-9 6. Kavanaugh JH, Brower TD, Mann RV. The Jones fracture revisited. J Bone Joint Surg Am. 1978;60(6):776-782. 7. Trevino SG, Kodros S. Controversies in tarsometatarsal injuries. Orthop Clin North Am. 1995;26(2):229-238. 8. Myerson MS, Fisher RT, Burgess AR, Kenzora JE. Fracture dislocations of the tarsometatarsal joints: end results correlated with pathology and treatment. Foot Ankle. 1986;6(5):225-242. doi:10.1177/107110078600600504 9. Zgonis T, Roukis TS, Polyzois VD. Fixation techniques for metatarsal fractures and osteotomies. Clin Podiatr Med Surg. 2006;23(4):857-876. doi:10.1016/j.cpm.2006.08.001 10. Buddecke DE Jr, Polk MA, Barp EA. Intramedullary screw fixation of Jones fractures--analysis of failure. Orthopedics. 1985;8(9):1089-1092. doi:10.3928/0147-7447-19850901-07

Metatarsal Fracture ORIF - Central Rays

Metatarsal Fracture ORIF - Central Rays