Diagnostic Imaging

Orthogonal radiographs (dorsopalmar/dorsoplantar [DP] and lateral views) are standard for evaluation of fractures in this region. Additional radiographic views can be considered if needed, including (1) 45° lateral oblique views to evaluate fractures from the lateral aspect without superimposition of the metacarpals/metatarsals, (2) medial/lateral stressed views of the carpus/tarsus to evaluate for collateral laxity, and (3) DP and lateral views with the toes spread to evaluate the digits more thoroughly. The digits can be spread by applying tape to each of the digits and adhering the other end of the tape to the radiology table to spread them. A computed tomography (CT) scan can also be performed to evaluate these fractures but typically is not required prior to surgery.

Cases that are presented secondary to serious trauma should be fully evaluated and stabilized prior to surgical repair being considered. During systemic stabilization, support of the fractures with a splinted bandage to improve patient comfort and wound care, if applicable to the case, are recommended until definitive repair can be pursued. Open wounds associated with fracture fragments should be evaluated and given wound management prior to surgical fixation. These wounds can range from pinpoint dermal defects secondary to puncture from the underlying sharp bony fragments, which are still likely to be successfully addressed with surgical stabilization of the fracture(s), to large shearing wounds with loss of the overlying soft tissue. Extensive tissue loss, as is seen in shearing injuries, is challenging when considering surgical fixation of this region, as there is minimal neighboring loose skin to close defects in this area. Due to this, these defects often must be healed by second intention. Recognizing this is important, as any implants applied to the metatarsal or metacarpal bone fractures are likely to be exposed while the overlying tissue heals, increasing the risk of infection. A plan to remove implants once healed is often required. This should be taken into consideration when making the initial surgical plan, as some implants and fixation methods used in this area are especially challenging to remove, such as dowel pinning. As such, implants that may result in high morbidity to the patient with attempted explantation should be avoided in these cases.

Patients who present with wounds (either small or large) should be given basic wound care and started on a broad‐spectrum antibiotic (such as amoxicillin–clavulanic acid or cefpodoxime) prior to surgery to help reduce the risk of infection. Generally, fractures that are simple in nature will have more load‐sharing between the fracture fragments and the implants when reconstructed. In cases like these, simpler constructs can be successful. In cases with heavy comminution and minimal load‐sharing between the bone fragments and the construct and in larger patients, stronger constructs, such as bone plating, are typically indicated.