Metatarsal Neck Fractures

Curtis T. Adams

Stefanos Haddad

Andrew J. Rosenbaum

Positioning/Preparation

Discuss pain management with anesthesia; regional nerve block recommended.
Place in supine position with a towel bump under the hip on operative side to make foot neutral with operating table.
Place operative foot at end of operating table.
Pad bony prominences (eg, contralateral heel).
Place distal thigh or proximal calf tourniquet and secure with silk tape.
Surgeon and assistants may stand or sit on provided stools.
Administer prophylactic antibiotics (1-2 g cefazolin or a similar antibiotic).
Drape with one to two U-drapes and an extremity drape, leaving entire foot on sterile field; toes should be prepped into field.

Surgical Approach

Varies depending on metatarsal fracture. There are three generally accepted rays or longitudinal segments of the metatarsals, with corresponding surgical approaches and fixation techniques: first metatarsal, second to fourth metatarsals, and fifth metatarsal.

First Metatarsal

Requires anatomic reduction because of importance in weight-bearing during gait cycle
Center a longitudinal incision along dorsal or medial aspect of first metatarsal, from medial cuneiform to first proximal phalanx. Avoid areas of soft-tissue injury if possible, or extend skin defect into necessary surgical incision.

Dorsal incision (Figures 27-1, 27-2, 27-3)

Figure 27-1. Incision runs medial to extensor hallucis longus tendon; beware of the dorsomedial cutaneous nerve. Capsular incision is medial to the skin incision, along the medial border of the bone and joint. From Miller SD. Interposition resection arthroplasty for hallux rigidus. Tech Foot Ankle Surg. 2004;3(3):158-164. doi:10.1097/01.btf.0000135271.60598.d5.

Figure 27-2. Dorsal view of metatarsophalangeal exposure, with the extensor hallucis brevis identified and already retrieved distally. From Ortiz C, Wagner E. Hallux varus and plantar plate repair. Tech Foot Ankle Surg. 2017;16(3):99-107. doi:10.1097/BTF.0000000000000151.

Figure 27-3. Intraoperative photograph showing incision placement, capsular exposure, and retraction of the extensor hallucis longus. From Hasselman CT, Shields N. Resurfacing of the first metatarsal head in the treatment of hallux rigidus. Tech Foot Ankle Surg. 2008;7(1):31-40. doi:10.1097/BTF.0b013e318165c356.

Sharply dissect, creating full-thickness skin flaps.
May ligate dorsal superficial vein as it crosses first metatarsal; protect and retract longitudinal vessels.
Identify the extensor hallucis longus and retract medially; retract the extensor hallucis brevis laterally.
Protect dorsomedial and dorsolateral cutaneous nerves lying on either side of metatarsal shaft; laterally protect the deep peroneal nerve and digital nerve branch to second metatarsal (branching in first dorsal web space).
Proximally, identify and protect the dorsalis pedis vessels.

Medial incision (Figures 27-4, 27-5, 27-6)
- Recommended for isolated first metatarsal fractures
- Incision should be the length of the metatarsal and similar to the dorsal approach, centered over medial border of the first ray.
- Angle incision dorsally along dorsal plane of foot to remain centered over the metatarsal; extend to distal prominence.
- Identify and retract dorsal margin of the abductor hallucis muscle.
- If first tarsometatarsal joint must be exposed, may elevate distal fibers of tibialis anterior tendon along proximal metatarsal shaft.

Figure 27-4. Medial incision over the first metatarsal extending over the distal prominence. From Klein J, Zachwieja E, Donnally C III, Aiyer A, Baitner A. A modified technique for the treatment of severe adolescent hallux valgus: a modification of the first metatarsal double osteotomy. Tech Foot Ankle Surg. 2018;17(2):90-102. doi:10.1097/BTF.0000000000000169.

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