Executive Editor: Joseph Schatzker, Richard Buckley

Authors: Michael Castro, Richard Buckley, Andrew Sands, Christina Kabbash

Phalanges - Hallux, distal phalanx, base, impression fractures

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1 Principles top

The main principle of operative treatment is removal of any painful impingement, or gross malorientation of the toe. In cases of excision, anatomical reconstruction of the joint is not always necessary.

In case of fresh trauma, large fragments may be fixed by screw or K-wire. If an open reduction is undertaken, one must strive to achieve an anatomical reduction.

In cases of late presentation, excision may be the preferable choice and at times an IP-fusion may be necessary.

2 Patient positioning top


Supine position

The patient is placed supine on a radiolucent table. A well-padded bump is placed under the ankle and heel of the surgical foot to elevate the foot for improved access and stabilize against rotation.


The nonoperative leg is secured with safety straps or taping.

To correct for external rotation of the leg and foot, a well-padded bump may be placed under the ipsilateral hip (a).

Alternatively, to correct for internal rotation of the leg and foot, a well-padded bump is placed under the contralateral hip (b).

3 K-wire fixation top


K-wire fixation may be utilized for large fragments with angular deformity.

After manual reduction, a 2.0 mm K-wire is placed into the distal phalanx just plantar to the nail across the DIP joint and into the base of the proximal phalanx. It is not necessary to cross the MTP joint.

A second wire may be utilized if needed. Anatomic reduction is not required.

4 Debridement top

Special care has to be taken not to injure the nerves in the vicinity. enlarge

Large fragments can be fixed while small fragments are excised. The aim is to restore congruity of the joint.
In this procedure, special care has to be taken not to injure the nerves in the vicinity.

v2.0 2017-03-23