Complication of these injuries can result in osteochondral defects, avascular necrosis, or more commonly sagittal plane malunion. Osteochondral injuries are often caused by axial load, and the cartilage surface sustains a shear-type injury. The majority of the literature pertains to reconstruction of avascular necrosis. However, several authors have described a variety of applicable treatments for osteochondral defects of the metatarsal head [2, 7–10]. These treatments include debridement, excision, synovectomy, and dorsal closing-wedge osteotomy. The treatment depends on the size of the fragment. If the fragment is small, simple excision is sufficient treatment. If the articular insult is large, excision is not recommended and more advance reconstructive techniques should be considered. Rotational dorsal wedge osteotomies have shown to be an excellent option. These osteotomies use the viable and uninjured plantar cartilage to interface with the base of the proximal phalanx. A dorsal wedge is removed from the metatarsal head, and the viable plantar cartilage is rotated dorsally (Fig. 10.2).

Fixation of osteochondral fractures and these reparative osteotomies present another challenge to the surgeon. If the fixation is inadequate, the potential for avascular necrosis and subchondral fatigue fracture increases [7, 11]. Absorbable pin fixation has improved the surgeon’s ability to achieve mechanical stabilization of these injuries. Two crossed absorbable pins provide excellent stability for these revision osteotomies [7, 9]. Zhongguo et al. reported complete union in all subjects who underwent revision dorsal wedge osteotomy with absorbable fixation [9] (Figs. 10.3, 10.4, and 10.5).

Central metatarsal head malunions and intra-articular metatarsal head fractures are rare. Retroversion of the fracture segment is more uncommon but has been described by Atik [10].

Corrective osteotomies for metatarsal fractures have been described in Avian literature [12]; however, this author does not see the clinical relevance in including their findings in this text.

Complications of central metatarsal fractures are usually a result of failure to realign the metatarsal heads and the metatarsal parabola [6]. Corrective realignment osteotomies are used in cases of symptomatic metatarsalgia from malunion. The surgeon should focus on restoration of anatomic alignment for resolution of pain and disability [13]. The surgeon must realize that despite the diligence of restoring the metatarsal parabola, this does not always result in asymptomatic gait.

Fractures of the central metatarsal diaphysis are often treated nonsurgically as well. Certain fracture patterns of the metatarsal shafts are more appropriately treated with surgical stabilization. When the fracture is displaced and surgical treatment is being considered, the pattern of the fracture helps determine the most appropriate fixation. A vertical oriented fracture can be treated in with a 0.062 in. or 0.045 in. retrograde Kirschner wire. Spiral fractures should be stabilized with interfragmentary fixation . The perpendicular placement of this screw is challenging due to inference of the adjacent metatarsals. Because of this, additional dorsal plating is recommended for neutralization. Deviation from this technique can lead to healing complications including nonunion and malunion. Bridge plating works well for comminuted metatarsal shaft fractures. Bridge plating allows the surgeon to “bridge or span” the comminuted segment while concurrently receiving osseous stability from the bone proximal and distal to the area of comminution. This provides stabilization of the fracture without disrupting the biology around the fracture. Another option for stabilizing these fractures is external fixation. This technique is most useful in highly comminuted or open fractures. The surgeon should pay close attention to the metatarsal declination angle when using external fixation. The external fixation bars should be oriented parallel to the long axis of the metatarsal. This will prevent sagittal plane malposition of the metatarsal. Much like metatarsal head malunions, a sagittal plane malunion of the shaft is corrected with realignment osteotomies. When there is a dorsiflexory sagittal plane malunion , the patient will present with symptomatic metatarsalgia juxtaposition to the malunited metatarsal. The treating physician may be tempted to address the symptomatic metatarsal; however, correcting the malunited metatarsal is more prudent. Highly comminuted or segmental fractures of the metatarsal diaphysis can result in painful nonunion. Several techniques have been described to revise these nonunions. The preferred method of revision treatment is intercalary autogenous bone grafting and dorsal plating.