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Figure 44-4. Expose the dorsal capsule of the metatarsophalangeal joint. Make
a longitudinal incision into the capsule.
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Figure 44-5. Retract the joint capsule to expose the metatarsophalangeal joint.
Dangers
The long extensor tendon should be protected during the procedure.
At the level of the metatarsophalangeal joints, the plantar nerves and
vessels lie between the metatarsal heads, beneath the deep transverse
metatarsal ligament. As long as the dissection remains on the dorsal aspect
of the ligament, the nerves are safe. Dissection around the metatarsal heads
and proximal phalanges must be carried out superficial to the deep
transverse metatarsal ligament so as to avoid damage to the nerves and
vessels that supply the weight-bearing skin of the toes (see Fig. 10-5).
REFERENCE
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1. Buckley R, Moran C, Apivatthakakul T. Midfoot and hindfoot. In: AO
Principles of Fracture Management. 3rd ed., Vol. 2. Thieme; 2017:994–
998.
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45
Dorsal Approach for Morton’s
Neuroma
Position of the Patient
Landmarks and Incision
Internervous Plane
Superficial Surgical Dissection
Dangers
How to Enlarge the Approach
Introduction
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The dorsal approach to the web space allows pathology of web spaces
to be explored. By far, the most common use of this approach is in the
identification and excision of Morton’s neuromas. The approach is
most commonly used for exploration of the cleft between the third and
fourth toes, the most common site for Morton’s neuroma. Less
common uses include drainage of web space infections, which are
much rarer in the foot than in the hand.
Position of the Patient
Place the patient supine on the operating table. Apply a tourniquet either at
the midpoint of the thigh or just above the ankle after the leg has been
exsanguinated. Alternatively, use a soft rubber bandage to exsanguinate the
foot, then use the bandage as a tourniquet at the ankle (see Fig. 44-1). Place
a firm wedge or several pillows under the patient’s thigh to flex the knees,
so that the foot lies flat on the operating table.
Landmarks and Incision
Palpate the metatarsophalangeal joint of the two adjacent toes by passively
flexing and extending them. Separate the two toes of the affected web
space. The easiest way to do this is to wrap a gauze swab around the
adjacent toes and use it to pull the two toes apart. Make a dorsal
longitudinal incision over the center of the web space starting at the distal
end of the web and extending proximally some 2 to 3 cm beyond the level
of the metatarsophalangeal joints (Fig. 45-1).
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Figure 45-1. Make a dorsal longitudinal incision over the center of the web
space starting at the distal end of the web and extending proximally some 2 to 3
cm beyond the level of the metatarsophalangeal joints.
Internervous Plane
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There is no internervous plane. No muscles or tendons are encountered in
the approach.
Superficial Surgical Dissection
Incise the deep transverse metatarsal ligament in line with the skin incision
initially with blunt dissection and then by opening a pair of scissors with the
blades in the longitudinal plane. Division of the deep transverse metatarsal
ligament will expose the neurovascular bundle (Figs. 45-2 and 45-3). The
neuroma, if one is present, often bulges into the wound. To make it more
prominent, apply digital pressure to the space between the metatarsal heads,
pushing your finger up on the plantar surface of the foot (see Fig. 45-3).
This surgical approach not only exposes the neuroma but also divides the
deep transverse metatarsal ligament that many surgeons believe is the cause
of the irritation in neuroma pathology.
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Figure 45-2. Incise the fascia in line with the skin incision.
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Figure 45-3. Incise the deep transverse metatarsal ligament in line with the skin
and fascial incision to reveal the neurovascular bundle.
Dangers
The only danger in an approach to a single cleft is the digital nerve and
vessel that are the target of the approach. Take care, however, to avoid
cutting any dorsal cutaneous nerves that run under the incision.
The arterial supply to the toes runs closely with the nerves. If more than
one cleft must be explored, take care to avoid disrupting the arterial
supplies of the toes. Accidental incision of one digital artery does not render
a toe ischemic, but if the second digital artery to the same toe is incised in
the next web space, ischemia may result (see Fig. 10-5).
Excising a neuroma from a web space usually leaves the weight-bearing
surface of the affected toes at least partially anesthetic, but trophic changes
do not occur.
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How to Enlarge the Approach
The approach is rarely enlarged and is used almost exclusively for specific
web space pathology.
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