1 Principles topenlarge
Proper alignment of the metatarsal heads is a critical goal in restoring the pathomechanics of the forefoot. On the AP view, a normal curved “cascade” (Lelièvre’s parabola) appearance, symmetric with the other foot, is mandatory. See illustration.
This ensures that the normal length of the metatarsal is restored.
It is also critical to restore the metatarsals in their axial or horizontal plane so that in the axial or tread view all the metatarsal heads are on the same level.
Any malalignment particularly flexion will recreate focally high pressure during the stance phase and toe-off and will result in pain and subsequent callus formation.
Note that for the first ray, it is the sesamoids rather than the first metatarsal head, that bear weight, and therefore one must look at the sesamoid level in establishing the alignment in the axial or horizontal plane of the first metatarsal.
2 Patient preparation and approach topenlarge
This procedure is normally performed with the patient in a supine position.
Multifragmentary diaphyseal fractures of the fifth metatarsal can best be approached through a lateral incision (see Lateral approach to MT5).
3 Reduction topenlarge
An open, direct reduction is done. Great care must be taken to preserve the soft-tissue attachments to the fragments.
Reduction is achieved under direct vision by matching the fracture fragments to one another. A number of pointed reduction forceps are used to maintain the provisional reduction. At this point, an intraoperative x-ray may be helpful to check the accuracy of the reduction. The contralateral foot is often a useful aid in checking the alignment of Lelièvre’s parabola.
4 Fixation topenlarge
The plate must be contoured anatomically to the bone surface.
The plate is applied to the bone and is fixed both proximally and distally making certain, that the length, rotation and axial alignment have been restored. If possible, lag screws are used to secure compression between the fragments prior to the application of the plate. Lag screw(s) can also be inserted through the plate. This depends on the fracture configuration.