The guide pin was removed after documentation of the bicortical purchase of the screw. Each 4.0 mm screw had 16 mm threads, regardless of the overall length of the screw used. We used a washer in seven cases with mild comminution. A partially threaded, 4.0 mm, cannulated, cancellous, titanium screw was then inserted under image guidance over the guide pin to ensure bicortical placement of the screw for compression ( Fig. A cannulated drill was used to drill across the fracture to the medial cortex. After the incision, a 4.0 mm cannulated screw guide pin (Synthes Inc., Paoli, PA, USA) was inserted into the space between the plantar fascia and the peroneus brevis tendon under image guidance. The surgeon made a stab incision about 0.5 to 1 cm proximal to the fifth metatarsal bone. This arrangement helped us obtain the anteroposterior, lateral and oblique views of the foot with great ease and it allowed easy access to the base of the fifth metatarsal bone. The patient was placed supine with the affected foot resting over the image intensifier. Our percutaneous operative technique involved the use of local anesthesia, bicortical placement of the guide pin, cannulated drilling and bicortical screw fixation. We recorded the preoperative displacement and postoperative reduction following bicortical screw fixation in all the patients ( Tables 1 and 2). Twenty three patients with 23 fractures (17 in zone II and 6 in zone I) were operated on using bicortical screw fixation at a mean of 6.96 ± 5.39 days (range, 1 to 23 days) after injury. Fifteen right feet and seven left feet were involved. There were 12 males and 11 females (median age, 44.3 years range, 16 to 74 years). The articulations of the fifth tarsometatarsal joint were involved. In six of the zone I fractures, all the fractures were intraarticularily displaced more than 2 mm. The mechanism of injury was inversion of the ankle and adduction of the forefoot, which was twisting and falling in 20 patients and sports injury in 3 patients. The displaced zone III diaphyseal fractures were treated with intramedullary screw fixation. The chronic, open or severely comminuted fractures were treated with open reduction and internal fixation with screws or wires. Our inclusion criteria for percutaneous bicortical screw fixation was acute, closed, not severely comminuted and more than 2 mm displaced intraarticular zone I and zone II fractures. Extraarticular zone I avulsion fractures, zone III diaphyseal stress fractures, severely comminuted fractures, pediatric fractures, open fractures and fractures that were treated by other methods of fixation were excluded. There were 23 such fractures (17 in zone II and 6 in zone I) that were treated by bicortical screw fixation. However, in the present study we included only the displaced intraarticular zone I and zone II fractures with displacement of more than 2 mm, which were treated by percutaneous bicortical screw fixation. From January 2003 through August 2008, a total of 84 fractures of the proximal fifth metatarsal bone were treated operatively by one orthopaedic surgeon (JSS).
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