• Dental pick

• Freer elevator

• Small AO (wood-handled) elevator

• Small point-to-point bone clamps

• Mini C-arm or large C-arm

• Percutaneous screw fixation

• Kirschner wires (0.45 and 0.62 in)

• Cannulated or solid drill bits (3.2 and 4.5 mm)

• Appropriate taps to match screw diameters

• Fully threaded or partially threaded solid screws (4.5, 5.5, and 6.5 mm)

• Open reduction and internal fixation

• 2.0-, 2.4-, and 2.7-mm plate/screw sets

• Patient positioning (Fig. 65-1A and B)

• Full lateral with appropriate padding

• Radiolucent table of cantilever type

• Beanbag under patient to assist with positioning

• Patient at far end of the table

• Ipsilateral arm across the chest, padded and secured

• Affected lower extremity prepared and draped proximal to the ipsilateral knee

• Thigh tourniquet or sterile calf tourniquet for hemostasis (rarely required)

• Ramp or blankets under extremity to elevate for imaging

• Mini C-arm is positioned at the same side of the bed as the surgeon stands.

• The formal imaging machine/screen is positioned to the right or left of the surgeon (depending on the side fractured).

• The collimator is positioned beneath the affected foot.

• Large C-arm is positioned on the opposite side of the affected extremity

• Appropriate imaging on anteroposterior, oblique, and lateral views is ensured before proceeding.

• Exposure for percutaneous screw fixation

• Incision is marked out using a wire in line with the medullary canal of the fifth metatarsal on the anteroposterior and lateral views. The crossing point of these lines can be used for the incision or for percutaneous wire placement.

• A 1-cm incision is made 2 to 3 cm proximal to the palpable base of the fifth metatarsal, at the juncture of the above-mentioned wire crossing.

• Blunt dissection should be performed once the skin is incised to avoid violating branches of the sural nerve.¹

• Exposure for open reduction and/or bone grafting (Fig. 65-2)

• This is performed separately from the percutaneous incision or combined as a single incision.

• The site of the fracture is localized under fluoroscopy.

• An incision is made just dorsal to the glabrous/nonglabrous skin junction.

• Branches of the sural nerve are identified and protected.

• The fascia overlying the abductor digiti quinti is incised.

• The muscle belly can be retracted either plantar or dorsal to gain exposure. Reduction and Fixation

• Percutaneous screw fixation

• A Kirschner wire or guidewire for the cannulated drill is placed in a “high and inside” starting position adjacent to the metatarsal-cuboid articulation.

▪ A poor starting point and trajectory will lead to malalignment.

▪ A common error is a lateral starting point with a medial trajectory leading to gapping of the lateral cortex or iatrogenic medial cortex fracture.

• The guidewire is advanced in line with the medullary canal on all fluoroscopic views until it is past the fracture (Fig. 65-3A and B).

• A 3.2-mm drill bit is advanced over the guidewire to just past the fracture.

• A cannulated 4.5-mm tap is then advanced over the wire to engage the diaphysis distal to the fracture (Fig. 65-4A and B).