There has been a sharp reduction in complications associated with tibial pilon fractures with the introduction of the two-step approach to treatment. However, there has yet to be any real reevaluation of the standard anterior approach used to expose and reduce these fractures. Now, with the ability to obtain computed tomographic (CT) scans after initial reduction, the fracture pattern of the tibia can be seen more clearly, suggesting that perhaps other surgical approaches may be better suited to visualize, reduce, and stabilize these injuries. At our institution, a two-incision approach using standard medial and lateral incisions, when appropriate to the fracture pattern, was found to allow improved visualization of the tibial articular surface and talus, ease of fixation placement with the new plate designs, and a low complication rate regarding soft-tissue issues when compared with published methods.

The authors present a retrospective study of fifth metatarsal fractures. These fractures include Jones fractures, avulsion fractures, spiral and oblique midshaft fractures, and the author-termed "tulip" fracture (impaction fracture of the fifth metatarsal head). These fractures were fixated with the cannulated screw, Kirschner wires, and cerclage loop wires combined with Kirschner wires. A one-way analysis of variance (ANOVA) was performed on the data to test for any significant difference in the fixation type used and the overall healing time. The ANOVA was found to be nonsignificant, F(2,10) = 0.379, p < 0.05. Therefore, it can be concluded that all three types of fixation work equally well. Other analyses were performed on each of the three specific types of fractures to see if there was any difference in fixating the fracture versus no fixation and immobilization. This information was significant for only the Jones fracture, F(1,5)2.23, p < 0.05, meaning that Jones fractures heal in a significantly shorter amount of time when some type of open reduction internal fixation is used. Since there was no difference in healing time between the different types of fixation, the authors advise that the cannulated screw be strongly considered because of its efficiency of insertion. In addition, because of the vascularity, muscle insertions, and motion related to the fifth metatarsal, the authors recommend that most Jones fractures be fixated for a more rapid return to function.