The authors generally perform fixation of fifth metatarsal fractures without the use of tourniquet as the tourniquet can precipitate ischemia to tissues, muscular injury, leg pain, neurovascular injury, and postoperative bleeding. In this clinical tip, the authors present a technique for reproducibly achieving the correct entry point for the guidewire, facilitating proper trajectory during guidewire insertion, and safely guiding the passage of the wire in cases of a sclerotic fracture site. Sclerosis can make passage of the guidewire difficult. In addition, the fracture site may be sclerotic, depending upon the timing of injury and etiology of the fracture. Improper measurement may result in compromise of the lateral cortex by the screw or drill and may precipitate fracture development. The width of the canal should be measured on the anteroposterior (AP) view of the foot, as the oblique image may lead to overestimation of the canal width. Failure to note the natural curvature of the bone may impede guidewire placement and lead to intraoperative complications. It is important to appreciate certain osseous characteristics-specifically the size, shape, and cortical quality-when performing surgical fixation of the fifth metatarsal. Improper entry can result in refracture, delayed union or non-union, 6, 15 or surgical injury to the lateral dorsal cutaneous nerve. 7, 10 While the “high and inside” mantra is often repeated to orthopaedic trainees, achieving this position may still be difficult. 3, 10, 13Ī commonly cited technical article describes the “high and inside” guidewire starting point for optimal screw positioning. 4, 6, 15 Authors have described several techniques to minimize the risk of these complications including the utilization of larger diameter screws, passage of threads distal to the fracture site, percutaneous placement of pointed reduction forceps, and ensuring the proper entry point with correct trajectory within the medullary canal. Nonunion, refracture, symptomatic hardware, and sural nerve injury are the most frequent complications following intramedullary screw fixation. 2, 3, 7, 11, 13 For these reasons, this technique has become the standard of care when these fractures are treated surgically.Īlthough excellent outcomes have been described, 2 complications still occur. Intramedullary screw fixation of the fifth metatarsal for metaphyseal-diaphyseal and diaphyseal fractures results in improved time to union, faster return to sport, and lower rates of repeat fracture compared to nonoperative management with immobilization.
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