Thanks for all the responses sent regarding the case from Dr. Weinraub with multiple central metatarsal fractures.  Below you will find the post operative radiographs and selected comments from readers.

According to Dr. Weinraub, the patient was initially treated with a modified compression Jones splint x 48 hrs, then ORIF was performed. The surgical plan was to pin the 3rd metatarsal shaft, and pin or plate 4th metatarsal shaft, hopeful that 2nd would reduce based on Vassel principle. In fact, this is what occurred, with note that a Steinman pin was used for fixation of the 4th metatarsal rather than a plate.

Please send your thoughts and comments for publication next week in this column. To do so, CLICK HERE.

John Steinberg, DPM
Editor - PRESENT

Pre-Op X-Rays for Reference
See Post-Op X-Rays BELOW

Post-Op X-Rays

Reader Feedback

Given the lack of lateral x-ray, it is hard to judge true sagittal plane displacement of the distal fragments. If there is more than 3-4mm of displacement, (probably so), I would opt for closed reduction with percutaneous pinning. If unsuccessful, I would open btw 3 and 4 and clean out and debride the fracture. I would then use a 0.062 pin and drive it through the distal fragment of 4th out through base of proximal phalanx. Next realign the fracture and advance though proximal fragment with fluoroscopy. I would treat the 3rd the same way. The second should reduce on its own and percutaneous pin should suffice. NWB 4-6 wks.

Mike Krynski, DPM
mkrynski@gmail.com

After assessment of neurovascular status, I would attempt closed reduction with temp fixation utilizing k wires and obtaining post reduction x-rays .Permanent fixation would be contemplated with x- fixation, or using plates.

Issam Mansour, DPM
issam_mansour@hotmail.com

An attempt at closed reduction under anesthesia with plantar percutaneous pinning under fluoroscopy should work well on 2& 3, 4th may require some open assistance. Follow-up with NWB and immobilization x 4-6 weeks.

Les Niehaus, DPM 
LNIEHAUSDPM@aol.com

Although the patient is not necessarily a professional athlete, one should consider his future potential and attempt for full restoration of function.

I would recommend ORIF after a 1-2 week period of edema reduction since he is already 48 hrs since the initial injury. ORIF choices would include small plates w/screws, small cannulated screws, absorbable/non-absorbable wires.

Mitchell Barber, DPM
mitchbkid@hotmail.com

CRIF/ORIF w/ 0.062 k-wires; e.g., pin it percutaneously w/ pins exiting plantarly; distract and insert pins thru skin; make incision only if necessary over 2nd and then prn between 3rd & 4th. as soon as you fix the 2nd the others should come into alignment. BKSL cast x 4-6 wks; then cam boot x 4-6 wks. Remove pins at 5-7 wks post-op. Then, wean to supportive stiff soled shoes and boots w/ a metatarsal arch support, dome pad, orthotic.

Will Godfrey DPM
williamtrekkie@earthlink.net