A 20-year-old man presented to the emergency department after sustaining a major laceration to his right forefoot when he jumped off a boat into a saltwater river and cut his foot on the boat's spinning propeller. He had no relevant medical history. His surgical history was notable for open reduction and internal fixation of his right lateral malleolus during adolescence.
On initial presentation, he was in severe pain. He had a 15- to 20-cm laceration extending from the base of the fifth metatarsal across the dorsum of the foot to the great toe with exposed subcutaneous tissue and apparent tendon lacerations (Figure 1). He had no dorsal sensation to light touch distal to the laceration and decreased strength in the flexor hallucis longus and tibialis anterior, with no appreciable function of the dorsal foot extensors. His dorsalis pedis and posterior tibial pulses were palpable but weak, his capillary refill was less than 3 seconds, and his toes were warm and well perfused. Radiographs of the right foot showed fractures at the head of the first metatarsal, the great toe proximal phalanx, and the distal diaphysis of the second, third, and fourth metatarsals. There was also subluxation of the fourth and fifth tarsometatarsal joints with the distal cuboid visualized in the wound. There was also a corticated fragment proximal to the base of the fifth metatarsal (Figure 2a-c).
Immediately on arrival to the emergency department, the patient was given intravenous cefazolin (2 g), gentamicin (300 mg; 4 mg/kg/dose), and doxycycline (100 mg), as well as a tetanus booster. His wounds were irrigated with 2 L of normal saline mixed with betadine and covered with betadine-soaked gauze. A temporary posterior slab splint was applied.
He was then taken promptly to the operating room, where the wound was carefully debrided and thoroughly irrigated with 12 L of antibiotic solution (consisting of 40 mg of neomycin and 200,000 units of polymyxin B) using cystoscopy tubing. Attention was then turned to reduction of the open fractures. Starting with the great toe, the proximal phalanx was reduced with a point-to-point reduction clamp. Two Kirschner wires (K-wires) were used to hold the reduction. For the second metatarsal, a K-wire was first placed antegrade out of the metatarsal at the open fracture site and then sent retrograde into the proximal portion of the second metatarsal after reduction was performed. The same procedure was used to achieve and maintain reduction of the third metatarsal. The fourth toe was found to be subluxated at the fourth metatarsophalangeal joint. As described above, a K-wire was first sent antegrade from the base of the proximal phalanx to the tip of the toe, reduction was performed, and the K-wire was then passed retrograde into the fourth metatarsal base to stabilize the reduction. This K-wire in the fourth metatarsal base stabilized the patient's fourth tarsometatarsal joint dislocation by sending it retrograde into the cuboid with the cuboid-metatarsal articulation held reduced. Further stabilization of the cuboid-fifth metatarsal was achieved with a K-wire that was passed retrograde from the lateral aspect of the fifth metatarsal base into the cuboid. The patient's great toe metatarsophalangeal joint was also grossly unstable, and a K-wire was passed antegrade from the proximal phalanx out of the medial cortex and then retrograde into the first metatarsal. Intraoperatively, it was noted that there was significant bone loss from the first metatarsal head. Intraoperative fluoroscopy was used to confirm adequate positioning for all of the reductions described above (Figure 3a-c).
After open reduction and pinning of the fractures, the patient's second, third, fourth, and fifth extensor digitorum longus and extensor digitorum brevis tendons were repaired with 4-0 Prolene sutures (Ethicon, Somerville, NJ). A Bunnell-type suture augmented with a running epitendinous suture was used, and the ankle was held in dorsiflexion while the extensor tendons were repaired. Intraoperatively, the patient was given prophylactic cefazolin, gentamicin, and doxycycline.
The wound was first grossly reapproximated with 2-0 Nylon vertical mattress sutures to relieve tension. The edges were then slowly reapproximated, first with 2-0 Monocryl and then with 3-0 Nylon sutures. The wound was completely closed at the conclusion of the case, and no skin tension was noted. After wound closure, the patient was given a right ankle block for postoperative pain control. His wound was then dressed with Xeroform petrolatum wound dressing (DeRoyal Industries, Powell, TN), 4-in   gauze pads, and sterile soft-roll gauze. A posterior slab splint with a stirrup was then applied with the ankle held in neutral dorsiflexion.
The patient recovered well after surgery and continued treatment with cefazolin and gentamicin for 24 hours for his open fractures and doxycycline for 96 hours for Vibrio prophylaxis. On postoperative day 1, he reported substantial pain that was not alleviated by multiple breakthrough doses of intravenous hydromorphone hydrochloride. A popliteal nerve catheter was placed by the anesthesia team. The popliteal nerve catheter, in combination with oral hydromorphone hydrochloride, provided symptom relief, and his pain was well controlled by postoperative day 4. He was discharged on postoperative day 4 with the popliteal nerve catheter in place and was advised to remain nonweightbearing for 6 to 8 weeks. The popliteal nerve catheter was discontinued on postoperative day 7, at which time the patient's pain level had decreased considerably.
At his 2-week postoperative visit, darkened eschar was visible over the great toe wound, although no sign of infection was noted. He was insensate to the dorsal foot distal to the laceration at that time. His splint was changed to a cast at that time, and he was advised to remain nonweightbearing. He was followed in clinic every 2 weeks, and at 8 weeks after the initial procedure, he returned to the operating room for removal of the pins and debridement of the great toe eschar. He was again placed in a posterior slab splint with a stirrup and advised to remain nonweightbearing for an additional 2 weeks, which was determined in consultation with the plastic surgery service for optimal healing of the great toe wound. He recovered without complication. Two weeks after pin removal (10 weeks after the initial procedure), his splint was changed to a boot and he began bearing weight. He also began physical therapy twice weekly for 8 weeks. Physical therapy sessions included an evaluation of ankle range of motion/sensation/strength, manual therapy (massage), electrical stimulation, gait training, and stretching/strengthening exercises. Active plantarflexion of the toes was encouraged, as well as active dorsiflexion, actively assisted dorsiflexion, and passive dorsiflexion. Passive plantarflexion was permitted at 3 months after surgery. His great toe wound ultimately healed with local wound care.
Three months after the initial procedure, he was transitioned from a boot to a postoperative shoe. At the 5-month postoperative visit, his wounds were healed (Figure 4) and he had good strength with ankle dorsiflexion and plantarflexion, although he had limited range of motion and weakness of his toes in dorsiflexion (extensor hallucis longus/extensor digitorum longus strength of 2/5, with a score of 5 indicating maximum strength). He continued to remain insensate to the dorsal foot distal to the laceration. Radiographs at the 9-month postoperative visit showed progression of healing of the fractures (Figure 5a-c). At this visit, he was cleared to return to his regular activities, including competitive weightlifting.
At his 1-year postoperative visit, he reported continued stiffness and pain in his great toe. Although the pain did not prohibit him from participating in his regular activities, he had extremely limited active and passive range of motion at the first metatarsophalangeal joint. Otherwise, he had full strength in ankle dorsiflexion and plantarflexion, and the sensation of his dorsal foot distal to the laceration had returned. His toe extensors had 20 degrees less extension than those of the contralateral side, but he reported no functional deficits in his activities of daily living. Radiographs showed complete healing of the metatarsal shaft fractures with arthritis of the first metatarsophalangeal joint (Figure 6a-c). Given his persistent pain and stiffness, he was interested in potential surgical treatment. On the basis of imaging findings and his limited range of motion, a metatarsophalangeal joint arthrodesis was presented to him as an excellent option for pain relief. He plans to undergo surgery in the near future.