1 General considerations topenlarge
Undisplaced or minimally displaced fractures may be treated nonoperatively with buddy taping of the big toe to the second toe. Because of the intraarticular nature of the fracture, subsequent pain and stiffness may follow.
Soft tissue injury
These fractures often have significant associated soft tissue injury and may require stabilization with percutaneous K-wires or external fixators prior to definitive fixation or fusion.
2 Approach topenlarge
Comminuted intraarticular base fractures of the proximal phalanx of the hallux are best approached through a dorsal approach to the first MTP joint.
Pearl: use of distractor
Visualization of the joint may be improved by utilizing a mini-distractor on the dorsomedial surface. Examination of comminution at the articular surface of the base of the proximal phalanx and cartilage of the corresponding first metatarsal head will dictate ORIF versus fusion.
3 Irrigation and debridement topenlarge
Utilization of a syringe for irrigation is helpful. The displaced fracture fragment(s) is debrided and mobilized with a dental pick or Freer elevator.
Once adequate visualization has been achieved and the joint thoroughly irrigated, decide on the definitive mode of treatment.
If comminution is slight, then it may be possible to secure fixation with a T-plate as for a T-shaped or lambda fracture. Be careful not to overtighten the screws as that will displace the intraarticular part of the fracture.
If after reduction there is a large visible gap between the articular fragment and the shaft, a bone graft may be necessary.
4 ORIF with locking plate topenlarge
Impacted articular surface fragments are reduced with a small bone tamp or elevator.
Bone graft may be necessary to compensate for metaphyseal deficits.
Obtain and maintain reduction with K-wires.
A precontoured locking 2.0 mm / 2.4 mm T-plate is then applied to the dorsum of proximal phalanx. The plate is secured to the shaft with shaft screw(s), and locking screws are inserted to support the subchondral surface through the locking plate.
5 Fusion of MTP joint topenlarge
If comminution is such that the joint cannot be reconstructed then the options are either to excise the fragment and leave the patient with an excision arthroplasty or replace the missing bone with a prosthesis or proceed to a primary fusion. Neither of these options is ideal. Therefore we recommend that if one is not an expert foot surgeon, it is best to reduce the fracture as best as possible, transfix it with K-wires and allow the bone to heal. The result will be unsatisfactory because of the intraarticular nature of the fracture and the patient will likely complain of pain and stiffness. At that point the patient is best referred to a foot expert for definitive care.
Fusion is performed by removing cartilage on both sides of the joint. The hallux is positioned in 5-10° of valgus relative to the first metatarsal, and 15° of dorsiflexion relative to the plane of the floor, and then secured with K-wires or a small plate.
Correct alignment is confirmed with intraoperative radiographs.