1 Principles top
Careful assessment of the T-MT joints is important. Minimal displacement of the 2nd and 3rd 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 Reduction and Fixation topenlarge
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).
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.
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.
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 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.