1. PATIENT POSITIONING
Position the patient in a semi-lateral position utilizing a bean bag body positioner. The patient should be moved to the distal end of the bed and the operative leg draped free as the side up. Exertion of the operative limb should be checked prior to prep and drape to confirm that
the operative limb can be positioned on the mini c-arm during surgery.
2. INDICATION AREA OUTLINE
The base of the fifth metatarsal is outlined, including the insertions of the peroneus brevis and tertius tendons.
3. APPROACH AND EXPOSURE
The guide wire, .062″, for the 4.7 Screw can be positioned at the base of the fifth metatarsal under fluoroscopic guidance. A small incision is made at the base of the fifth metatarsal at the intersection of the peroneus brevis and tertius tendons. Care is made to identify and protect the sural nerve branches which run over the peroneal tendons. If necessary, fibers of the lateral aponeurosis and peroneus brevis tendon are separated and retracted away from the styloid process of the base of the fifth metatarsal. A mini Hohman Retractor is placed on the plantar aspect of the base of the fifth metatarsal. The surgeon’s fingers can be used to reduce the fifth metatarsal fracture by placing them in between the fourth and fifth metatarsals. This closes down the fifth metatarsal fracture site during guide wire, drill, and screw placement. A guide wire is drilled from the base of the fifth metatarsal into the central portion of the metatarsal shaft. It is maintained within the intramedullary canal in order to avoid distal penetration. Confirm placement with fluoroscopy.
4. MEASURE DEPTH
Depth is measured from the exposed portion of the guide wire with the cannulated depth gauge.
5. ADVANCE GUIDE WIRE
After selecting the size, advance the guide wire approximately 5 mm to maintain distal pin fixation before drilling.
Caution: Make sure not to compromise distal joint surfaces when advancing the guide wire.
6. SOFT TISSUE GUIDE PLACEMENT
Place the soft tissue guide (the guide should be used throughout) over the guide wire and open the near cortex using the appropriate cannulated profile drill.
Leaving the soft tissue guide in place, drill into the far fragment with the appropriate cannulated, long drill. Reference the markings on the drill to confirm desired depth.
Tip: The long drill is recommended to mitigate the effects of varying bone density and distraction upon screw insertion.
8. FRACTURE COMPRESSION
In order to account for countersinking and fracture compression, a screw that measures 5 mm shorter than the measured total depth is inserted over the guide wire while protecting the soft tissues with a soft tissue guide.
9. SCREW INSERTION
The screw is placed while under fluoroscopic guidance in order to avoid cortical penetration. Postoperative protocol: The patient is placed into a soft dressing, supported by a fiberglass splint. Patients can be made non-weight-bearing for a period of 2–6 weeks postoperatively depending upon Torg type of fracture, bone quality, and underlying morbidities.