There are more than one way to set metarsal fractures.  It depends on the location, extent, and comminution of the osseous trauma.

 

The first case here demonstrates percutaneous pinning of the 1st & 5th metatarsals.  Note the very distal plantar aspects of the 2nd & 3rd met heads.  These were allowed to seek there own levels, heal, and the patient went on to do very well with this.  Percutaneous pinning has the advantage of being less traumatic, avoids long incisions, hardware is removed at appropriate interval (i.e., when bone callus and osseous bridging is seen radiographically), puts the patient at less risk for post-op infection, and no need for suture removal.  In my experience, I have never encountered a pin tract infection; and most patients have been compliant with pin exit site care (e.g., cleaning with cotton tipped swab & peroxide, and application of some kind of abx ointment).  I have even had most patients be good with showering after the first few days with the standing rule being:  running water is okay, standing water is bad; that is, do not soak the foot.

 

125_2571

125_2572

 

 

 

 

 

 

 

However, sometimes it becomes necessary to perform the open reduction internal fixation.  Here is an example of a 5th metatarsal repair to the shaft.  I believe, if I recall correctly, I employed Osteomed screws from a small set that I had kept on on consignment through the rep at the base hospital; the agreement so long as I utilized at least 1-2 screws per week, I could keep the set on hand indefinitely. {*}

126_2699

 

127_2702

 

 

 

 

 

 

 

{*}  See, my philosophy is or was, to have all the different sized and types of screws and harware on hand as possible because foot bones come in all sizes and shapes, and one never knows what to expect in surgery nor what you [I] would need at any given point.  This proved to be true week in and week out.  I advise the same for all young surgeons.

 

WG

P.S.  Any comments, input, feedback, or otherwise pearls of wisdom are welcome.

 

 

  • Comments (2)
  • Quote:
    The first case here demonstrates percutaneous pinning of the 1st & 5th metatarsals.  Note the very distal plantar aspects of the 2nd & 3rd met heads.  These were allowed to seek there own levels, heal, and the patient went on to do very well with this.  Percutaneous pinning has the advantage of being less traumatic, avoids long incisions, hardware is removed at appropriate interval (i.e., when bone callus and osseous bridging is seen radiographically), puts the patient at less risk for post-op infection, and no need for suture removal.

    125_2571

    125_2572

     

     

     

     

     

     

     

    Will:

    In cases where you are free floating structures to heal where they must also deal with the forces of gravity and hard ground without your input too often lead to poorly positioned bones, transfer lesion and supinated rays.

    I suggest that the use of well placed biomechanically oriented pads, straps, OTC orthotics and previously fabricated custom orthotics (PostopThotics) that reduce pathological tissue stress by applying a plantarflectory sagittal plane   moment on your pinned mets and the foot as a whole.

    MIS procedures are especially receptive to this surgical biomechanical paradigm.

    Postop Centering Pads

     

    Dennis

  • I often used Steinman pins (.062) for fixation of metatarsal fractures as I obtained good results as well as ease of fixation as compared to plating. In cases involving comminution, mini- monorail external fixation was my preference. Again, ease of reduction & fixation with consistent good results. Others may do well with plating and that's fine, the end result is what ultimately matters.Cost may also have a role depending on the institution / facility and here, pinning is the obvious winner in "simple" cases.