Intramedullary Screw Fixation of Jones Fracture: the Crucial Starting Point and Minimizing Complications

CLINICAL TIP

Intramedullary Screw Fixation of Jones Fracture: The Crucial Starting Point and Minimizing Complications

ABSTRACT Michael Aynardi, MD1,2 Intramedullary screw fixation of the fifth metatarsal for metaphyseal-diaphyse- Kempland C. Walley BS1 2 al and diaphyseal fractures results in improved time to bony union, faster return Jacob M. Wisbeck MD to sport, and lower rates of repeat fracture compared to nonoperative treatment with immobilization. Although excellent outcomes have been described, complications may still occur.

In this technical tip, the authors present a technique for reproducibly achieving the correct entry point for intramedullary screw fixation of a Jones Fracture, facilitating proper trajectory during guidewire insertion, and safely guiding wire passage in cases of a sclerotic fracture site.

AUTHOR AFFILIATIONS LEVEL OF EVIDENCE Level V Expert Opinion 1Department of Orthopaedic Surgery, KEYWORDS Jones fracture, fifth metatarsal fracture, intramedullary screw Penn State Hershey Bone and Joint Institute, Penn State Milton S. Hershey fixation, foot fracture, surgical complications, foot surgery technique Medical Center, Hershey, PA 2Department of Orthopaedic Surgery, MedStar Union Memorial Hospital. Intramedullary screw fixation of the fifth metatarsal for metaphyseal-diaphyseal Baltimore, MD and diaphyseal fractures results in improved time to union, faster return to sport, and lower rates of repeat fracture compared to nonoperative management with immobilization.2,3,7,11,13 For these reasons, this technique has become the standard of care when these fractures are treated surgically. CORRESPONDING AUTHOR 2 Although excellent outcomes have been described, complications still occur. Non- Michael C. Aynardi, MD union, refracture, symptomatic hardware, and sural nerve injury are the most frequent 4,6,15 Penn State Milton S. Hershey Medical complications following intramedullary screw fixation. Authors have described several Center techniques to minimize the risk of these complications including the utilization of larger 30 Hope Drive, EC089 diameter screws, passage of threads distal to the fracture site, percutaneous placement of P.O. Box 859 pointed reduction forceps, and ensuring the proper entry point with correct trajectory Hershey, PA 17033 within the medullary canal.3,10,13 Phone: (717) 531-4801 A commonly cited technical article describes the “high and inside” guidewire starting point for optimal screw positioning.7,10 While the “high and inside” mantra is often repeat- Fax: (717) 531-0498 ed to orthopaedic trainees, achieving this position may still be difficult. Improper entry [email protected] can result in refracture, delayed union or non-union,6,15 or surgical injury to the lateral dorsal cutaneous nerve.5 It is important to appreciate certain osseous characteristics—specifically the size, shape, and cortical quality—when performing surgical fixation of the fifth metatarsal. Failure to note the The authors report no conflict of natural curvature of the bone may impede guidewire placement and lead to intraoperative com- interest related to this work. plications. The width of the canal should be measured on the anteroposterior (AP) view of the foot, as the oblique image may lead to overestimation of the canal width. Improper measurement may result in compromise of the lateral cortex by the screw or drill and may precipitate fracture ©2019 by The Orthopaedic Journal at development. In addition, the fracture site may be sclerotic, depending upon the timing of injury Harvard Medical School and etiology of the fracture. Sclerosis can make passage of the guidewire difficult.

42 THE ORTHOPAEDIC JOURNAL AT HARVARD MEDICAL SCHOOL Intramedullary Screw Fixation of Jones Fracture

In this clinical tip, the authors present a technique for re- recommend against the use of the oblique view for this purpose. producibly achieving the correct entry point for the guidewire, The canal is narrowest on the AP imaging, and this measurement facilitating proper trajectory during guidewire insertion, and is representative of the true width of the canal. A lateral radio- safely guiding the passage of the wire in cases of a sclerotic graph is then performed, and the guidewire is centered on the fifth fracture site. metatarsal with its trajectory marked on the skin. Ensuring that the guidewire is centered on the AP and lateral views is paramount STARTING POINT TECHNIQUE for achieving the correct trajectory of the screw. At this point, there are two lines drawn on the skin. Next, the lateral view is used to mark a point 1 cm proximal to the The authors generally perform fixation of fifth metatarsal frac- fifth metatarsal base, and a 1-cm skin incision is made proxi- tures without the use of tourniquet as the tourniquet can precip- mally to this mark but along the lateral line. This incision en- itate ischemia to tissues, muscular injury, leg pain, neurovascu- sures that soft tissue will not resist guidewire positioning. Blunt lar injury, and postoperative bleeding.1,8,9,12,14 However, surgeons dissection is utilized to protect the peroneus brevis and sural may elect to utilize a tourniquet in order to improve visualization. nerve (Figure 1A-E). After prepping and draping, the foot is positioned on the C-arm The guidewire is inserted utilizing the AP view of the foot as and a true AP image is obtained. The guidewire is placed over the the surgeon and assistant ensure that the path of the guidewire center of the intramedullary canal and marked on the skin. It is is paralleling the lines drawn. Depending on patient anatomy, important to note that the intramedullary canal of the fifth meta- it may be beneficial to freehand the wire onto the start point tarsal is more medial than it appears on surface anatomy. Pressing because the lateral foot may impede optimal positioning of the the wire against the foot may help to achieve appropriate align- wire driver (Figure 1E). Radiographs are performed to ensure a ment (Figure 1A). central location in the AP and lateral views. The wire should be Many technical descriptions emphasize establishing the posi- driven up to but not past the fifth metatarsal curvature to avoid tion of the guidewire on the oblique view.7 However, the authors risk of cortical penetration.

FIGURE 1 Guidewire placed over fifth metatarsal shaft on image intensifier (A); position of guidewire on the true AP radiograph (B); guidewire placed atop the skin over the canal of the fifth metatarsal preparing for a lateral radiograph (C); lateral radiograph demonstrating the position (D); freehand insertion of the guidewire following the marking drawn at the beginning of the case (E).

A. B. C.

D. E.

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FREEHAND DRILLING TECHNIQUE

FIGURE 2 Radiograph demonstrating sclerosis of the The use of a freehand drilling technique can aid in passing fracture site. The drill was advanced using a the guidewire beyond a sclerotic fracture site while ensuring freehand technique. that the wire passes centrally within the fifth metatarsal canal. For this technique, the start point is determined as previously described. However, the guidewire is only inserted far enough to obtain the start point but not engage the sclerotic bone. Un- der fluoroscopy, the drill is advanced along the proper trajectory up to and across the fracture site, opening the canal (Figure 2). The guidewire is then inserted through the drill and safely beyond the fracture site (Figure 3). Its position is confirmed on two fluoroscopic views, and the screw is measured, tapped, and inserted (Figures 4 and 5).

CONCLUSION

Intramedullary fixation of Jones’ fractures can result in improved patient outcomes in athletic populations,2,6,11 but avoiding complications is paramount. The majority of intraoperative complications result, either directly or indirectly, from improper starting point and poor screw trajectory.7 The technical pearls in this article have helped the authors to avoid these complications, and these techniques may result in improved component alignment, decreased surgical time, and improved surgical technique for resident and fellow orthopaedic trainees.

FIGURE 3 After drilling past the fracture site, the FIGURE 4 The fracture and metatarsal shaft are tapped guidewire is placed through the cannulated with a standard screw tap before screw drill and the distal aspect of the metatarsal is insertion. predrilled.

44 THE ORTHOPAEDIC JOURNAL AT HARVARD MEDICAL SCHOOL Intramedullary Screw Fixation of Jones Fracture

FIGURE 5 Oblique postoperative views after solid screw insertion (A); AP postoperative view after screw insertion (B).

A. B.

REFERENCES 8. Horlocker TT, Hebl JR, Gali B, Gali B, Jankowski CJ, Burkle CM, Berry DJ, Zepeda FA, Stevens SR, Schroeder DR. Anesthetic, patient, and surgical risk factors for neurologic complications af- 1. Bogdan Y, Helfet DL. Use of Tourniquets in Limb Trauma Sur- ter prolonged total tourniquet time during total knee arthroplasty. gery. Orthop Clin North Am. 2018 Apr;49(2):157-165. Anesth Analg. 2006 Mar;102(3):950-5.

2. Clapper MF, O’Brien TJ, Lyons PM. Fractures of the fifth meta- 9. McEwen JA, Inkpen K. Tourniquet safety: preventing skin inju- tarsal. Analysis of a fracture registry. Clin Orthop Relat Res. 1995 ries. Surg Technol. 2002;34(8):6-15. Jun;(315):238-41. 10. Nunley JA. Fractures of the base of the fifth metatarsal: the 3. DeLee JC, Evans JP, Julian J. Stress fracture of the fifth metatar- Jones fracture. Orthop Clin North Am. 2001 Jan;32(1):171-80. sal. Am J Sports Med. 1983 Sep-Oct;11(5):349-53. 11. Quill GEJ. Fractures of the proximal fifth metatarsal. Orthop 4. Donley BG, McCollum MJ, Murphy GA, Richardson EG. Risk of Clin North Am. 1995 Apr;26(2):353-61. sural nerve injury with intramedullary screw fixation of fifth metatarsal fractures: a cadaver study. Foot ankle Int. 1999 Mar;20(3):182-4. 12. Sharma JP, Salhotra R. Tourniquets in orthopedic surgery. In- dian J Orthop. 2012 Jul;46(4):377-83. 5. Fansa AM, Smyth NA, Murawski CD, Kennedy JG. The lateral dorsal cutaneous branch of the sural nerve: clinical importance of 13. Torg JS, Balduini FC, Zelko RR, Pavlov H, Peff TC, Das M. the surgical approach to proximal fifth metatarsal fracture fixa- Fractures of the base of the fifth metatarsal distal to the tuberosity. tion. Am J Sports Med. 2012 Aug;40(8):1895-8. Classification and guidelines for non-surgical and surgical management. J Bone Joint Surg Am. 1984 Feb;66(2):209-14. 6. Glasgow MT, Naranja RJJ, Glasgow SG, Torg JS. Analysis of failed surgical management of fractures of the base of the fifth 14. Wilgis EF. Observations on the effects of tourniquet ischemia. metatarsal distal to the tuberosity: the Jones fracture. Foot ankle J Bone Joint Surg Am. 1971 Oct;53(7):1343-6. Int. 1996 Aug;17(8):449-57. 15. Wright RW, Fischer DA, Shively RA, Heidt RSJ, Nuber GW. Refrac- 7. Den Hartog BD. Fracture of the proximal fifth metatarsal. J Am ture of proximal fifth metatarsal (Jones) fracture after intramedullary Acad Orthop Surg. 2009 Jul;17(7):458-64. screw fixation in athletes. Am J Sports Med. 2000 Sep-Oct;28(5):732-6.

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