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The tendon of extensor hallucis longus should lie lateral to the plane of
dissection but may be injured if the incision is placed too dorsally.
The terminal branches of the saphenous nerve cross the operative field
from lateral to medial. Damage to these nerves can result in impaired
sensation on the dorsal aspect of the hallux, and division of the nerve may
be associated with the development of a painful neuroma. The nerve needs
to be identified and gently retracted before the dissection proceeds down to
the periosteum.
How to Enlarge the Approach
The approach can be extended both proximally and distally to expose all the
bones of the first ray from the proximal phalanx of the hallux to the
navicular. Create full-thickness flaps to prevent skin necrosis.
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35
Dorsal Approach to the Second to
Fifth Metatarsal Bones
Position of the Patient
Landmarks and Incision
Internervous Plane
Superficial Surgical Dissection
Deep Surgical Dissection
Dangers
How to Enlarge the Approach
Introduction
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The dorsal approach to the second to fifth metatarsal bones provides
safe access for surgery in a number of conditions. Because the
metatarsals lie in an almost subcutaneous position, access is relatively
easy; however, care must be taken to respect the neurovascular
structures on the dorsum of the foot, especially the cutaneous nerves.
Damage to these nerves may produce hyperesthesia or at worst a
neuroma. Both these complications produce significant postoperative
problems for patients. The uses of the approach include the following:
Plating of the shaft of the metatarsal bones in cases of trauma
1
Access to the distal part of the bone for wiring in cases of trauma
Biopsy or excision of bone tumor
Treatment of osteomyelitis of the metatarsal bone
Corrective osteotomy in cases of fracture malunion
Position of the Patient
Place the patient supine on the operating table. After exsanguination, use a
tourniquet placed on the mid-thigh. Alternatively, use a soft rubber bandage
to exsanguinate the foot, then wrap the leg tightly just above the ankle (see
Fig. 1-1).
Landmarks and Incision
Palpate the shafts of the second to fifth metatarsal bones on the dorsal
aspect of the foot. In cases of trauma where usually there is considerable
swelling, identification of the metatarsal shafts by palpation may be
difficult. In such cases, the use of radiologic control via an image intensifier
will ensure that the incision is accurately localized over the area of
pathology.
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Make a longitudinal incision centered over the site of the pathology (Fig.
35-1). The length of the incision will be determined by the procedure. If
surgery is contemplated on two adjacent metatarsal bones, center the
incision between the bones to be treated. It is possible to treat two adjacent
metatarsal bones through a single incision. Note, however, that this requires
more retraction than would be needed for a single metatarsal bone. To
reduce the risk of flap necrosis, increase the length of the incision. If all five
metatarsal bones are to be treated, make two longitudinal incisions—one
over the second to the third interspace and the second over the fourth to
fifth interspace.
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Figure 35-1. Make a longitudinal incision centered over the site of the
pathology. The length of the incision will be determined by the procedure. If
surgery is contemplated on two adjacent metatarsal bones, center the incision
between the bones to be treated.
Internervous Plane
There is no true internervous plane. These bones are almost subcutaneous.
The tendons of the extensor digitorum longus and brevis lie in the field of
dissection, but these muscles receive their nerve supply proximal to the
approach and the muscles themselves cannot be denervated by it.
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Superficial Surgical Dissection
Incise the deep fascia in line with the incision. Take care to identify and
preserve the cutaneous nerves derived from the saphenous nerve, and the
deep and superficial peroneal nerves. Identify the extensor digitorum longus
tendon, mobilize it and retract it medially or laterally depending on the
siting of the original skin incision (Fig. 35-2).
Deep Surgical Dissection
Deepen the approach in the line of the skin incision. Identify and, if
possible, preserve the tendons of the extensor digitorum brevis muscle,
which insert onto the lateral side of the second, third, and fourth tendons of
the extensor digitorum longus muscle. Appropriate retraction of the tendon
will bring you down onto the periosteum covering the respective metatarsal
bone (Fig. 35-3).
In cases of trauma, try to preserve as much periosteum as possible.
Extensive periosteal stripping will significantly reduce the blood supply to
the fracture.
The length and extent of the deep surgical dissection depends on the
pathology to be treated and treatment modality selected. For plating of the
fractured metatarsals, the length of the incision will depend on the plate
selected. Plates should be placed in an epiperiosteal plane. Fractures to be
treated with wiring need exposure of the distal end of the affected
metatarsal. For wiring, incise the metatarsophalangeal joint of the affected
metatarsal bone. Incision of the dorsal capsule will allow the proximal
phalanx to be flexed, giving access to the metatarsal head for retrograde
insertion of a wire across the fracture site (Fig. 35-4).
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Figure 35-2. Incise the deep fascia in line with the incision. Take care to identify
and preserve the cutaneous nerves derived from the deep and superficial
peroneal nerves. Identify the extensor digitorum longus tendon, mobilize it and
retract it medially or laterally depending on the siting of the original skin incision.
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Figure 35-3. Identify and preserve, if possible, the tendon of extensor digitorum
brevis. Appropriate retraction of the tendon will bring you down onto the
periosteum covering the respective metatarsal bone.
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Figure 35-4. For wiring, incise the metatarsophalangeal joint of the affected
metatarsal bone. Incision of the dorsal capsule will allow the proximal phalanx
to be flexed, giving access to the metatarsal head for retrograde insertion of a
wire across a fracture site.
Dangers
The tendon of the extensor digitorum longus muscle lies directly in the line
of the skin incision. Take care to identify, preserve, and appropriately retract
these tendons.
Superficial cutaneous branches of the deep and superficial peroneal
nerves run in line with the skin incision. They are easily identified in the
subcutaneous dissection and can be and should be preserved. The dorsal
metatarsal arteries are frequently damaged by pathology in cases of trauma.
Damage to these vessels is usually not significant. The arcuate artery
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branch of the dorsalis pedis passes into the plantar aspect of the foot at the
proximal end of the first intermetatarsal space. It may be injured in trauma
centered on Lisfranc’s joint, but it should lie well proximal to the field of
dissection in cases of metatarsal shaft fracture.
How to Enlarge the Approach
This approach is indicated only for local metatarsal pathology and cannot
be usefully extended for other surgical procedures.
REFERENCE
1. Buckley R, Moran C, Apivatthakakul T. Midfoot and forefoot. In: AO
Principles of Fracture Management. 3rd ed. Vol 2. Thieme; 2017:994–
998.
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