The Journal of Bone and Joint Surgery (American). 2008;90:560-564.
doi:10.2106/JBJS.G.00743
© 2008 The Journal of Bone and Joint Surgery, Inc.
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The Safety of Forefoot Metatarsal Pins in External Fixation of the Lower Extremity

Matthew O. Barrett, MD1, Allison M. Wade, MD2, Gregory J. Della Rocca, MD, PhD2, Brett D. Crist, MD2 and Jeffrey O. Anglen, MD3

1 Anderson Orthopaedic Research Institute, 2501 Parkers Lane, Alexandria, VA 22306. E-mail address: barrettmat{at}yahoo.com
2 Department of Orthopaedic Surgery, University of Missouri, MC213, DC053.00, One Hospital Drive, Columbia, MO 65212
3 Department of Orthopaedics, Indiana University School of Medicine, Indianapolis, IN 46202
Investigation performed at the Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, and the Department of Orthopaedics, Indiana University School of Medicine, Indianapolis, Indiana

Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

Background: External fixation is widely used for trauma and reconstruction of the lower extremity. External fixator devices spanning the ankle or portions of the foot often utilize pins placed across the metatarsal bases. While this forefoot fixation is occasionally necessary to achieve reduction and alignment, it is also useful to prevent an equinus contracture. We undertook an anatomical study to evaluate the safety of pins placed across the bases of the first and second metatarsals, spanning the first intermetarsal space.

Methods: Under fluoroscopy, a single 4.0-mm Schanz pin was advanced percutaneously from medial to lateral across the bases of the first and second metatarsals in ten cadaver feet. This was accomplished in a fashion identical to the application of typical forefoot external fixation as described in the literature. Specimens were then dissected. Injury to the deep plantar branch of the dorsalis pedis artery, when present, was recorded. When injury was not present, the distance from the pin to the deep plantar branch was recorded.

Results: In five of the ten feet, the deep plantar branch of the dorsalis pedis artery was lacerated by the transmetatarsal pin. In four feet, the pin contacted the artery but did not visibly damage it. In the remaining foot, the pin was noted to be only 4 mm from the artery. Any pin with a starting point within 18 mm of the first metatarsocuneiform joint placed the artery at risk.

Conclusions: Placement of external fixation pins through the proximal bases of the first and second metatarsals, within 2 cm of the first tarsometatarsal joint, consistently places the deep plantar branch of the dorsalis pedis artery at risk. Given the clinical importance of this artery, transmetatarsal pinning in this fashion is not advised. Other methods of obtaining forefoot or midfoot external fixation are recommended in order to avoid vascular injury.


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