Which of the following radiographs demonstrates an injury that would be treated best by dorsal extension block splinting? Type in at least one full word to see suggestions list, 2022 California Orthopaedic Association Annual Meeting, COA Foot and Ankle End - Glenn Pfeffer, MD, Comminuted Fifth Metatarsal Fracture in 28M. Neurovascular compromise from fracture requires emergent reduction and/or orthopedic intervention. rest, NSAIDs, taping, stiff-sole shoe, or walking boot in the majority of cases. Because of the first toe's role in weight bearing, balance, and pedal motion, fractures of this toe require referral much more often than other toe fractures. Magnetic Resonance Imaging (MRI) scans. (SBQ07SM.41) Flexor and extensor tendons insert at the proximal portions of the middle and distal phalanges. toe mtp joint approach dorsomedial orthobullets topic. Providers can treat your broken bone with a cast, boot or shoe or with surgery. If the bone is out of place and your toe appears deformed, it may be necessary for your doctor to manipulate, or reduce, the fracture. Treatment is closed reduction and splinting unless volar plate entrapment blocks reduction or a concomitant fracture renders the joint unstable. Correction of any clinically evident angulation is a key part of Emergency Department Management. Content is updated monthly with systematic literature reviews and conferences. Diagnosis can be made clinically and are confirmed with orthogonal radiographs. Displaced Salter Harris fractures of the great toe may cause joint stiffness or growth arrest. (Right) Several weeks later, there is callus formation at the site and the fracture can be seen more clearly. Taping your broken toe to an adjacent toe can also sometimes help relieve pain. (SBQ12FA.46) Fractures of the lesser toes are four times as common as fractures of the first toe.3 Most toe fractures are nondisplaced or minimally displaced. What treatment offers the fastest time to bony union and return to sport? Joint hyperextension and stress fractures are less common. (OBQ05.226) Copyright 2023 American Academy of Family Physicians. Thompson, T.M., et al., Foot injuries associated with all-terrain vehicle use in children and adolescents. A combination of anteroposterior and lateral views may be best to rule out displacement. 11 The factors that cause fracture include wrong training and repetitive trauma; 8 fracture can also occur while wearing tight shoes or starting high-intensity training without warm-up. X-ray shows an avulsion fracture at the base of the fifth metatarsal (arrow). Bruising or discoloration your foot may be red or ecchymotic ("black and blue"), Loss of sensationan indication of nerve injury, Head which makes a joint with the base of the toe, Neck the narrow area between the head and the shaft, Base which makes a joint with the midfoot. Note that where there is bruising and swelling of toe 2, 3, 4 or 5 but no significant deformity and no open wound, it may be reasonable to diagnose a fracture clinically (i.e. Open fractures require immediate IV antibiotics and urgent surgical washout. Toe and forefoot fractures often result from trauma or direct injury to the bone. The patient reports that 12 weeks ago he sustained a similar injury and underwent surgery on his foot by a different surgeon. It is also detected that sports persons get broken toes due to over stress on certain toes. She has no history of ankle or foot trauma, and medical history is significant only for delayed menarche. 36(1)p. 60-3. Your foot may become swollen and discolored after a fracture. Stable, reduced phalanx fractures are immobilized but require close monitoring to ensure maintenance of fracture reduction. A prospective study on 284 digital fractures of the hand. A 25-year-old professional basketball player sustains a twisting injury to his foot. Phalanx fractures of the hand are some of the most common fractures occurring in humans. Your doctor will then examine your foot and may compare it to the foot on the opposite side. rays radiopaedia tarsal. The distal phalanx and border digits are most commonly injured. As the name implies a phalangeal fracture involves a fracture of any of the bones in the lesser toes. Phalangeal fractures are very common, representing approximately 10% of all fractures that present to the emergency room. (OBQ13.28) No follow up required if successfully reduced Petnehazy, T., et al., Fractures of the hallux in children. Maffulli, N., Epiphyseal injuries of the proximal phalanx of the hallux. Osteomyelitis is an infection of the bone. They are frequently related to sports, with lesions such as the mallet finger and the Jersey finger. Other symptoms may include: If you think you have a fracture, it is important to see your doctor as soon as possible. Pain is worsened with passive toe extension. For several days, it may be painful to bear weight on your injured toe. Which of the following is the primary advantage of operative intervention for these fractures compared to non-operative treatment? There are 3 phalanges in each toe except for the first toe, which usually has only 2. Kay, R.M. The Proximal Phalanx Bones Stock . The nail should be inspected for subungual hematomas and other nail injuries. Indirect pull of the central slip on the distal fragment and the interossei insertions at the base of the proximal phalanx, Intrinsic muscle fibrosis and intrinsic minus contracture, PIP joint volar plate attenuation and extensor tendon disruption, Rupture of the central slip with attenuation of the triangular ligament and palmar migration of the lateral bands, Flexor tendon disruption with associated overpull of the extensor mechanism. Hatch, R.L. Which of the following interventions will provide the best outcome? Toe fractures most frequently are caused by a crushing injury or axial force such. Orthopaedic team management is necessary in the case of toe fractures with associated open nailbed injury (Seymour fractures). Fractures of the toe are one of the most common lower extremity fractures diagnosed by family physicians. Which of the following would most likely lead to the quickest return to play? (Left) In this X-ray, a fracture in the proximal phalanx of the fifth toe (arrow) has caused the toe to become deformed. A 55 year-old woman comes to you with 2 months of right foot pain. High-impact activities like running can lead to stress fractures in the metatarsals. Proximal fractures in children Operative repair of the Lisfranc fracture. Stress fractures can occur in toes. This is when the fracture line extends through the physis or within the growth plate. He states he has a 30-year-old lumberjack who earlier today was playing softball in the county championship when he slid into home plate in the bottom of the 9th inning. A collegiate soccer player presents as a referral to your office after sustaining an injury to the right foot, which he describes as hyperdorsiflexion of the toes. Learn the principles of clinical research online. Metatarsal fractures are among the most common injuries of the foot that may occur due to trauma or repetitive microstress. Published studies suggest that family physicians can manage most toe fractures with good results.1,2. Finger (Phalanx) Fracture Proximal Middle Distal Examination Evaluate for tendon damage Always look for a second fracture Imaging Hand Xrays to rule out additional fractures Comminuted tuft fracture Tuft's fracture Stable Longitudinal fracture Usually non-displaced and stable Transverse fracture Evaluate for angulation/displacement Treatment involves immobilization or surgical fixation depending on location, severity and alignment of injury. To enhance comfort, some patients prefer to cut out the part of the shoe that overlies the fractured toe. phalanges toe foot bones toes feet anatomy pedal region phalangeal wellnessadvocate. The same mechanisms that produce toe fractures may cause a ligament sprain, contusion, dislocation, tendon injury, or other soft tissue injury. Immobilization of the distal interphalangeal joint is required for 2 weeks post-operatively, High rates of post-operative infection are common, Open reduction via an approach through the nail bed leads to significant post-operative nail deformity, Range of motion of the DIP joint in the affected finger is usually less than 10 degrees post-operatively, Type in at least one full word to see suggestions list, Management of Proximal Phalanx Fractures & Their Complications, Middle Finger, Proximal Phalangeal Head - Bicondylar Fracture - Fixation, Cleveland Combined Hand Fellowship Lecture Series 2020-2021, PIP Fracture & Dislocation: Case of the Week - Shaan Patel, MD, Ring Finger Proximal Phalanx Fracture in 16M, Fracture of the base of proximal phalanx of 5th finger. A fracture of the toe may result from a direct injury, such as dropping a heavy object on the front of your foot, or from accidentally kicking or running into a hard object. Most patients have point tenderness at the fracture site or pain with gentle axial loading of the digit. To check proper alignment, radiographs should be taken immediately after reduction and again seven to 10 days after the injury (three to five days in children).4 In patients with potentially unstable or intra-articular fractures of the first toe, follow-up radiographs should be taken weekly for two or three weeks to monitor fracture position. This page will discuss ankle and foot fractures and the role that physiotherapists play in the rehabilitation of such injuries. Open Fractures require orthopaedic consultation, including where a significant nailbed injury is suspected (see Seymour fracture, above in point 4). 24(7): p. 466-7. Displaced fractures of the lesser toes should be treated with reduction and buddy taping. Clin OrthopRelat Res, 2005(432): p. 107-15. ball striking fingertip), leads to tearing of the collateral ligaments and shearing of the volar plate off of the base of middle phalanx, commonly seen with small avulsion fracture of the base of the middle phalanx, middle phalanx remains in contact with condyles of proximal phalanx, base of middle phalanx not in contact with condyle of proximal phalanx, volar plate can act as block to reduction with longitudinal traction, results from rupture of one collateral ligament, with the other remaining intact, one of proximal phalangeal condyles buttonholes between the central slip and lateral band, results from rupture of one collateral ligament and at least partial avulsion of volar plate from middle phalanx, if simple dorsal dislocation, reduce with force directed volarly and in flexion, if complex dorsal dislocation, reduce with hyperextension of middle phalanx followed by palmar force, if rotatory volar dislocation, reduce by applying traction to finger with MCP and PIP joints in 90 of flexion, flexion relaxes volarly displaced lateral band, allowing it to slip back dorsally, dorsal dislocation that is stable after reduction, in closed dorsal dislocations, reduction is usually prevented by, in open dorsal dislocations, reduction is usually prevented by dislocated FDP tendon, in lateral dislocations, reduction is usually prevented by lateral band interposition, perform dorsal approach with incision between central slip and lateral band, PIP flexion contracture (pseudoboutonniere), may develop but usually resolves with therapy, PIPJ fracture-dislocations can be volar or dorsal, volar lip fractures are the most common fracture pattern seen with dorsal dislocations, highly comminuted fracture may occur, known as "pilon", in dorsal PIPJ fracture-dislocations, hyperextension leads to failure of the volar plate resulting in rupture or avulsion of the middle phalangeal volar lip, in volar PIPJ fracture-dislocations, hyperflexion leads to failure of the central slip resulting in rupture or avulsion of the middle phalangeal dorsal lip, axial loading of the finger with the PIPJ in flexion or extension leads to dorsal and volar fracture-dislocations, respectively, mount of P2 articular surface involvement), regardless of treatment, must achieve adequate joint reduction for favorable long-term outcome, articular surface reconstruction is desirable, but not necessary for a good clinical outcome, PIP subluxation inhibits the gliding arc of the joint and leads to a poor clinical outcome, highly comminuted "pilon" fracture-dislocations, reduction of the middle phalanx on the condyles of the proximal phalanx is the primary goal, adequate volar exposure of the volar plate requires resection of, DIPJ dislocations are usually dorsal or lateral, often associated with open wounds due to tight soft tissue envelope, associated with avulsion of dorsal lip/terminal tendon, associated with avulsion of volar lip/FDP, if dorsal DIPJ dislocation, reduce with longitudinal traction, direct pressure on dorsal aspect of distal phalanx, and DIPJ flexion, perform thorough irrigation and debridement if open, tuft fractures require no specific treatment, can consider temporary splinting, and rarely may require pinning, in closed dorsal DIPJ dislocation, volar plate interposition is most common block to reduction, FDP may be blocking reduction if injury is open, in volar DIPJ dislocation, terminal tendon interposition can prevent reduction, perform FDP repair if dorsal fracture-dislocation where FDP is attached to volar fragment, may require percutaneous pinning to support nail bed repair, highly community injuries without significant soft tissue loss or vascular injury, highly comminuted injuries with significant soft tissue loss or neurovascular injury, Lunate Dislocation (Perilunate dissociation), Gymnast's Wrist (Distal Radial Physeal Stress Syndrome), Scaphoid Nonunion Advanced Collapse (SNAC), Carpal Instability Nondissociative (CIND), Constrictive Ring Syndrome (Streeter's Dysplasia), Thromboangiitis Obliterans (Buerger's disease). A medial view of the bones of the left foot.. Fracture salter phalanx proximal radiology pathology rontgen thorax epiphysis ollier chondroma . Healing of a broken toe may take from 6 to 8 weeks. It is important to check for angulation/mal-alignment and for rotational deformity (the position of the nail plate will give a guide to this and compare with toes on the other foot) Summary. We describe a case of a traumatic avulsion fracture of the distal phalanx of the hallux. (OBQ18.111) Open subtypes (3) Lesser toe fractures. The skin should be inspected for open wounds or significant injury that may lead to skin necrosis. An X-ray can usually be done in your doctor's office. 21(1): p. 31-4. In this case, history of trauma, minimal degenerative changes and cortical irregularity along the distal phalanx of the great toe helped in making the diagnosis. Consider risk for compartment syndrome. Referral also should be considered for patients with other displaced first-toe fractures, unless the physician is comfortable with their management. Vollman, D. and G.A. Which of the following is true regarding open reduction and screw fixation of this injury? Metacarpal fractures account for 40% of all hand fractures. Open reduction and placement of two 0.045-inch K-wires placed longitudinally through the metacarpal head, Application of a 1.5-mm straight plate applied dorsally through and extensor tendon splitting approach, Open reduction and lag screw fixation with 1.3mm screws through a radial approach, Placement of a 1.5-mm condylar blade plate through a radial approach, Open reduction and retrograde passage of two 0.045-inch K-wires retrograde trough the PIP joint. If you have an open fracture, however, your doctor will perform surgery more urgently. The forefoot has 5 metatarsal bones and 14 phalanges (toe bones). Evaluation of foot pain and identification of associated problems. Although fracturing a bone in your toe or forefoot can be quite painful, it rarely requires surgery. Figure 2. Some metatarsal fractures are stress fractures. Turf Toe is a hyperextension injury to the plantar plate and sesamoid complex of the big toe metatarsophalangeal joint that most commonly occurs in contact athletic sports. Fracture position ideally will be maintained when traction is released, but in some cases the reduction can be held only with buddy taping. AP, lateral, and oblique radiographs are provided in Figures A, B, and C respectively. He came to the ER at that point to be evaluated. Fractures of the toes and forefoot are quite common. Toe fractures, especially intra-articular fractures, can result in degenerative joint disease, and osteomyelitis is a potential complication of open fractures. Location of fracture: which toe and which phalanx is affected. In young children this is most often from crush . MeSH terms Adult Bone Transplantation* Bone Wires Cohort Studies Female Finger Phalanges / injuries* Fracture Fixation, Internal / methods* Fracture Healing Fractures, Ununited / diagnosis Dorsomedial Approach To MTP Joint Of Great Toe - Approaches - Orthobullets www.orthobullets.com. Copyright 2023 Lineage Medical, Inc. All rights reserved. The dancer's fracture, or long spiral fracture of the distal metatarsal, is typically caused by the dancer rolling over their foot while in the demi-pointe position or sustained while landing a jump. Rest, ice, elevation. They are common in runners and athletes who participate in high-impact sports such as soccer, football, and basketball. A 27-year-old man falls on his hand at work. In children, a physis (i.e., cartilaginous growth center) is present in the proximal part of each phalanx (Figure 2). (SH I fracture of distal phalanx with associated nailbed injury or avulsion of proximal nail plate from eponychium), Needs orthopaedic admission for removal of nail, irrigation, repair of nailbed +/- fracture reduction. If irreducible, refer to Orthopaedics. Joint hyperextension and stress fractures are less common. and C.W. Unlike an X-ray, there is no radiation with an MRI. The metatarsals are the long bones between your toes and the middle of your foot. Referral is indicated in patients with circulatory compromise, open fractures, significant soft tissue injury, fracture-dislocations, displaced intra-articular fractures, or fractures of the first toe that are unstable or involve more than 25 percent of the joint surface. The proximal phalanx is the toe bone that is closest to the metatarsals. The proximal phalanx is the toe bone that is closest to the metatarsals. Like toe fractures, metatarsal fractures can result from either a direct blow to the forefoot or from a twisting injury. He reports that his physician released him to full activity 8 weeks ago because he had no pain. Kannus et al. 0. fibula fracture orthobullets. Although referral rarely is required for patients with fractures of the lesser toes, referral is recommended for patients with open fractures, fracture-dislocations (Figure 5), displaced intra-articular fractures, and fractures that are difficult to reduce. Pain that persists longer than a few months may indicate malunion, which may limit a patient's future activities significantly. 50(3): p. 183-6. A fractured toe may become swollen, tender, and discolored. She has pain and inability to bear weight on her injured foot. MTP joint dislocations. In most cases, a fracture will heal with rest and a change in activities. Phalanx fractures are classified by the following: Phalangeal fractures are the most common foot fracture in children. Post-reduction rehabilitation is discussed with the patient. without X-ray) with management as below (ie simply buddy-tape the affected toe and wear firm-soled shoes for 3 weeks), Figure 1: Seymour Fracture of the Great Toe (SH I with associated Nail Plate displacement). Distal phalanx fractures are among the most common fractures in the hand. A fracture, or break, in any of these bones can be painful and impact how your foot functions. The fifth metatarsal is the long bone on the outside of your foot. A current radiograph is seen in Figure A. Such an injury in the great toe has not been reported previously in the English orthopaedic literature to our knowledge. J AmAcad Orthop Surg, 2001. Toe fractures are relatively common and frequently managed by primary care and emergency physicians. The stubbed great toe: a cause of occult compound fracture and infection. If the wound communicates with the fracture site, the patient should be referred. A walking cast with a toe platform may be necessary in active children and in patients with potentially unstable fractures of the first toe. Displaced: Can be reduced in ED then buddy taped and firm soled shoe: - discuss with Orthopedics if reduction is unsuccessful, Nondisplaced fractures of the other toes do not require specific follow-up, Displaced fractures (or for any fractures involving the great toe) - Fracture clinic within 7 days. The proximal phalanges are those that are closest to the hand or foot. No sensory or vascular deficits are present. Proximal phalanx fracture toe orthobullets are metal plates that fit over the toes of the foot and help fix fractured bones in the proximal phalanx. The distal phalanx is the most common location for a non-physeal injury which typically involves a crushing mechanism, and the most common location for physeal injury is the proximal phalanx. A 23-year-old professional skier presents to the orthopedic clinic with foot pain after a mechanical fall at home. In the hand, the prominent, knobby ends of the phalanges are known as knuckles. A fracture of proximal phalanx in patients who engage in regular sports activities was reported only rarely, after it was first reported by Hukko and Orava in 1987. They are often noted to be in the more common of all upper extremity fractures and present with a long list of post-injury complications regardless of treatment, most commonly in relation to finger and hand function. . All material on this website is protected by copyright. Treatment can include protected weight bearing, immobilization or surgery depending on location of fracture, degree of displacement, and athletic level of patient. (SBQ18FA.12) If an avulsion fracture results in a large displaced fracture fragment, however, your doctor may need to do an open reduction and internal fixation with plates and/or intramedullary screws. He is diagnosed with a Zone II base of 5th metatarsal fracture and is recommended for internal fixation. Concerns with delayed healing and/or high activity demands may result in your doctor recommending surgery for an acute Jones fracture as well. A patient presents to your office with lateral midfoot pain after an inversion injury. Comminution is common, especially with fractures of the distal phalanx. Eves, T., Oddy, M.J. Do broken toes need follow up in fracture clinic? Sesamoids And Accessory Ossicles Of The Foot: Anatomical Variability link.springer.com This is called a "stress fracture.". While you are waiting to see your doctor, you should do the following: When you see your doctor, they will take a history to find out how your foot was injured and ask about your symptoms. It is one of the most common fractures of the foot and has unique characteristics that make it more likely to require surgery. First Distal Phalanx (toe) Fracture | Image | Radiopaedia.org radiopaedia.org. fracture phalanx distal toe radiopaedia nail small bed version . Which of the following structures most often prevents closed reduction of this injury? An avulsion fracture is also sometimes called a "ballerina fracture" or "dancer's fracture" because of the pointe position that ballet dancers assume when they are up on their toes. Patients should limit icing to 20 minutes per hour so that soft tissues will not be injured. Examination reveals a well-aligned foot with ecchymosis and swelling on the plantar aspect of the 1st MTP joint. A common complication of toe fractures is persistent pain and a decreased tolerance for activity. Clin J Sport Med, 2001. Since the fragment is pulled away from the rest of the bone, this type of injury is called an avulsion fracture. The injury was treated in a dorsal extension splint for eight . <5yrs discuss with local Orthopaedic team as reduction success rate may be affected by size of phalanx, Can typically be reduced and buddy taped, in ED (place some cotton between the toes to prevent skin maceration) This is particularly true of the fifth toe as malunion will cause longer-term issues such as fitting into shoes. Metatarsal and toe fractures in children, UpTodate.com Lisfranc injury), divided into tuberosity, base, metadiaphysis, diaphysis, neck, and head, is primarily cancellous and highly vascularized, site of peroneus brevis and lateral band of plantar fascia insertion, open apophysis or os peroneum may be confused for fracture (comparison radiographs warranted), has no tendinous attachments and is vascular watershed, peroneus tertius inserts on dorsal diaphysis, articulates with proximal phalanx to form metatarsophalangeal joint, blood supply provided by metaphyseal vessels and diaphyseal nutrient artery, fifth metatarsal forms lateral border of forefoot, functions as a lever in gait during push-off, Due to long plantar ligament, lateral band of the plantar fascia, or contraction of the peroneus brevis, Involves the 4th-5th metatarsal articulation, Distal to the 4th-5th metatarsal articulation, Associated with cavovarus foot deformities or sensory neuropathies, Narrow fracture line without intramedullary sclerosis, Widened fracture line with intramedullary sclerosis, Widened intramedullary canal with no callus, antecedent pain in setting of stress fracture, rapid increase in workload or change in training regimen, tenderness to palpation along bone at fracture site, excessive lateral wear pattern on shoe treads, evaluate for lateral ligamentous instability and whether varus hindfoot is correctable, pain with resisted foot eversion (indicates peroneal tendon weakness), intramedullary sclerosis and lack of periosteal callus reaction indicative of chronicity, callus forms medially first and progresses laterally, plantar fracture gap lends poor prognosis, plantarflexed first metatarsal and high Meary's angle indicating cavovarus deformity, suspicion for stress fracture with equivocal radiographs, to evaluate degree of fracture healing in setting of delayed/nonunion or following surgical fixation, suspicion for stress fracture with equivocal radiographs or bone scan, zone 1 fracture without rotational displacement, union achieved by 8 weeks, fibrous unions are infrequently symptomatic, early return to work but symptoms may persist for up to 6 months, high non-union rate and risk of re-fracture approaching 33% in zone 2 fractures, zone 1 fractures with rotational displacement or skin tenting, zone 2 (Jones fracture) in elite or competitive athletes, minimizes possibility of nonunion or prolonged restriction from activity, zone 3 fractures in athletic individuals, cavovarus alignment, or with sclerosis/nonunion (Torg Types 2-3), bony union rates approaching 100% in most series, salvage for nonunion following intramedullary screw fixation, early data show plate and screw construct has equivalent strength to intramedullary fixation, advance weight bearing as tolerated by pain, advance weight bearing with signs of radiographic callus (around 4-6 weeks), zone 3 fractures often require 6-7 weeks of non-weight bearing immobilization, reports of extracorpeal shock wave with similar union rates as internal fixation for zone 3 stress fractures, patient supine with bump under hip and fluoroscopy immediately available, short longitudinal incision proximal to tuberosity, parallel with plantar surface, blunt dissection past sural nerve branches to tuberosity, between peroneus longus and brevis tendons, using fluoroscopy, K-wire starting position superior and medial on tuberosity ("high and inside" position), k-wire does not need to be passed further than the metatarsal curvature, k-wire placed intramedullary, fluoroscopy to confirm location, soft tissue protector placed and wire may be removed or cannulated drill used to open canal and drill pilot hole, sequentially tap to be able to place screw, tap can be used to measure appropriate length screw, 4.5mm, 5.5mm, or 6.5mm diameter partially-threaded screw placed, recommended to use the largest diameter screw that can be accommodated, if fracture gap persists or in cases of nonunion/revision, bone graft material may be added at fracture site, short period of non-weight bearing (1-3 weeks) followed by protected weightbearing and beginning therapy focusing on range of motion and non-impact aerobic exercises, running and impact activities commenced at 6 weeks if surgical site pain-free and signs of radiographic callus, longitudinal incision centered over proximal 5th metatarsal, typical plantar fracture gap and/or rotational displacement able to be reduced, 3mm plate bent to contour to plantar-lateral surface of bone to compress fracture, nonunion rates for Zone 2 injuries are as high as 15-30%, zone 2 and zone 3 fractures due to vascular supply, smaller diameter screws (<4.5mm) associated with delayed or nonunion, nutritional (vitamin-D) or hormonal (thyroid) deficiencies, revision intramedullary screw fixation with use of bone grafting, return to sports prior to radiographic union, fracture distraction or malreduction due to screw length, screws that are too long will straighten the curved metatarsal shaft or perforate the medial cortex, screw that is too short will not compress fracture, cavovarus foot deformity, stress fractures, vitamin-D insufficiency, removal of intramedullary screw, internal fixation with surgical correction of cavovarus deformity if present, leave screw in place until end of patient's athletic career, rare complication following intramedullary screw fixation, screw head left prominent can irritate sural nerve branches, prominent screw head impinging on nerve branches, dorsolateral branch of sural nerve within 2-3 mm of tuberosity, prevented by using tissue protector during procedure and sinking screw head, uncommon, result of zone 1 fracture nonunion after initial conservative treatment, fragment excision and reattachment of peroneus brevis tendon, Posterior Tibial Tendon Insufficiency (PTTI).
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