The patient presented at 5 weeks after injury; these blisters were healed. Radiographs of the right foot included an AP, lateral, and oblique view, which exhibited transverse fractures of the proximal and distal aspects of the right second and third metatarsals (Fig. 17.2a–c). Since her proximal metatarsal fractures had started to heal with minimal displacement, it was determined that only the distal fractures would be addressed in the operating room in order to correct the malalignment. Typically, proximal metatarsal fractures have bony support and little ligamentous disruption, which make them stable and nondisplaced, and they respond well to nonoperative treatment [1]. Because of the very distal nature of the third metatarsal fracture, it was determined that a plate would likely not get enough screw purchase for stable fixation—therefore the fracture would be pinned.

Indications for fixation of metatarsal shaft fractures vary—typically similar rules apply for all metatarsals except for the proximal fifth metatarsal fracture. Generally, displacement can be tolerated in the transverse plan, but sagittal plane displacement can lead to prominent metatarsal heads during weight bearing. The most consistent recommendations for operative fixation are any sagittal malalignment greater than 10° or 3–4 mm of displacement in any plane [2, 3]. Multiple metatarsal fractures may also be indicated for operative fixation; however, they will often move as a unit due to inter-metatarsal ligaments [1].

About 6 weeks after the injury was sustained, the patient went to the operating room. Again, this delay was not ideal, but due to her difficulty getting to appointments to check her blisters, her surgery could not be set up in a timely manner. She underwent general anesthesia and a tourniquet was used on her right lower extremity. The skin incision was made on the dorsal aspect of the foot, between the second and third metatarsals. Dissection was carried down to the periosteum where abundant callus was found around the fracture sites. This was removed from the distal fractures of both metatarsals and the fracture ends were cleaned. The second metatarsal was fixed with a 2.5 mm 5-hole plate, which allowed screws to be inserted on both the proximal and distal portions of the bone without approaching the fracture line or joint surface. The third metatarsal fracture was pinned, using 0.062 in. double ended Kirschner wire, for reasons listed above. It was pinned using an antegrade-retrograde intramedullary technique. The pin started in the dorsal incision since it was already open, then exited the distal portion of the metatarsal followed by retrograde advancement of the distal portion of the pin into the proximal metatarsal. The proximal portion of the Kirschner wire extended to the body of the lateral cuneiform, because of the segmental nature of the fracture. The incisions were irrigated and closed (Fig. 17.3a–c).