48/49: Metatarsalgia I/II - Frush

Question 1

metatarsalgia =

Answer 1

forefoot pain under metatarsal heads

Question 2

bony causes metatarsalgia

Answer 2

• ¨Long metatarsal
• ¨Plantarflexed metatarsal
• ¨Hammer toe
• ¨Enlarged metatarsal head
• ¨Arthritis
• ¨Freiberg’s infarction
• ¨Stress fracture

Question 3

soft tissue causes metatarsalgia

Answer 3

• ¨Calluses
• ¨Neuroma
• ¨Capsulitis
• ¨Plantar plate pathology
• ¨Hypermobile 1st ray
• ¨Equinus

Question 4

Answer 4

retrograde buckling

Question 5

indications for metatarsal osteotomies

Answer 5

• ¨Long metatarsal
• ¨Plantarflexed metatarsal
• ¨Contracted digit that cannot be reduced without decreasing metatarsal length
• ¨Angular deformity of metatarsal

Question 6

Answer 6

budin splint

Question 7

contraindicatons for metatarsal osteotomies

Answer 7

• ¨Pain of unknown etiology
• ¨Parabola correction without underlying pain or symptoms
• ¨Severe osteopenia

Question 8

describe weil osteotomy

Answer 8

• ¨Shortening osteotomy
• ¨Usually fixated with 1.5 or 2.0 screw
• ¨Try to make parallel to WB surface
• ¨Will shorten to its own level

Question 9

describe plantar condylectomy (duvries)

Answer 9

• ¨Used generally for older patients
• ¨Can lead to arthritis because it cuts into joint
• ¨Can lead to floating toe due to relaxation of plantar plate
• ¨Diabetic patient with chronic callus/ulcer

Question 10

describe V metatarsal osteotomy (jacoby)

Answer 10

• Dorsiflexory osteotomy with little shortening
  
  • Can create shortening by taking making parallel v cut
• Can be allowed to float
  
  • Seek its own level
  • May lead to delayed healing
• Can do offset V to help with fixation

Question 11

describe dorsiflexory wedge osteotomy

Answer 11

• ¨Can do proximal or distal
• ¨Need less wedge if proximal
• ¨Leave plantar cortex intact

Question 12

complications for metatarsal osteotomy

Answer 12

• may lead to floating toe
• transfer lesions
• delayed or nonunions w/o fixation

Question 13

postop for osteotomies distal vs. proximal

Answer 13

• Distal procedures
  
  • WB in postop shoe for 6 weeks if fixated
  • If not fixated may consider NWB
• Proximal procedures
  
  • NWB for 6-8 weeks

Question 14

what is freiberg’s infarction?

Answer 14

• Osteochondrosis
• Avascular necrosis (AVN) of bone
  
  • Usually involves 2nd metatarsal head
• Excessive loading of metatarsal head compromises circulation to subchondral bone resulting in AVN and collapse of articular surface
• Tenderness and edema with activity
• Radiographs show nothing early in disease
  
  • Late stage shows flattening of met head, spurring, sclerosis

Question 15

tx for freiberg’s infarction

Answer 15

• Initial treatment
  
  • Immobilization
• Chronic treatment
  
  • Steroid injection
  • Rocker bottom shoes
  • Carbon plate
• Sugical Treatment
  
  • Metatarsal head resection
  • Graft (orthobiologics [scaffold] or fresh frozen cadaveric [replaces] graft)
  • Implant

Question 16

stress fracture vs other metatarsalgias

Answer 16

pain with palpation dorsally (plantar in other etiologies)

Question 17

s/s stress fracture

Answer 17

• pain with palpation dorsally
• pain with tuning fork application
• may be edema
• x rays negative up to 3 wks
• bone scan show uptake in 3rd phase

Question 18

tx stress fracture

Answer 18

• conservative
  
  • Immobilize in boot or postop shoe 4-6 weeks
• surgical
  
  • Done only if goes to full fracture or excessive callus formation

Question 19

s/s neuroma

Answer 19

• Burning pain
• Tingling/numbness
• “wrinkled-sock” sensation
• Sharp and/or radiating pain
• Symptoms worse with shoes (particularly tight fitting)
• Most frequently in the 3rd interspace

Question 20

PE findings neuroma

Answer 20

• Pain direct palpation to the interspace
• “Mulder’s sign”
  
  • Squeeze forefoot while applying plantar and dorsal pressure
  • Palpable click
• Gauthier test
  
  • Pain with just squeezing foot
• Usually no edema noted

Question 21

sullivan’s sign on xray

Answer 21

splaying of toes where the neuroma is located

Question 22

what would a neuroma look like on ultrasound?

Answer 22

ovoid mass with hypoechoic signal

Question 23

tx neuroma

Answer 23

• Conservative treatment
  
  • Wider shoes
  • Metatarsal pad
  • Steroid injection
    
    • Usually 1-2 mL of fluid total
    • 11-47% success rate
    • Avoid doing too much
  • Sclerosing injection (4% alcohol) repeat injections
  • Vit B12 injection
  • Phenol
• Surgical Excision
• Endoscopic Neuroma Surgery
  
  • percutaneous release deep transverse intermetatarsal ligament
• Cryogenic Denervation
  
  • helps prevent stump neuroma (wallerian degeneration with intact peri and epineurium)
  • can’t use on large neuromas
  • not permanent

Question 24

dorsal vs. plantar incision for neuroma

Answer 24

• dorsal
  
  • • immediate WB
  • • no plantar scar
  • • need meticulous dissesction (hematoma formation, hammertoes)
• plantar
  
  • • better visualization
  • • less incidence of hematoma and hammertoe formation
  • • need to be NWB 3 wks
  • • potential plantar scar

Question 25

most common site plantar plate pathology

Answer 25

2nd MPJ

Question 26

s/s plantar plate pathology

Answer 26

• pain worse with walking, better with rest
• feels like wlking on “stone bruise” or “lump”
• pt may note change in position (drifted to one side)

Question 27

etiology plantar plate pathology

Answer 27

• Long second/short first
• Trauma
  
  • Not common
• 1st ray hypermobility
• Hypermobility disorders
  
  • Marfans or Ehlers-Danlos
• Overloading
  
  • Equinus
  • High heels

Question 28

PE plantar plate pathology

Answer 28

• Pain with palpation directly plantar at joint line
  
  • More pain at base
• Focal edema over the joint
• Possible loss of purchase of toe
• Vertical stress test
  
  • Positive with 2 mm or more displacement
• Always do exams bilaterally

Question 29

Yu and Judge Predislocation Staging

Answer 29

• Stage I
• Subtle, mild edema dorsal and plantar to lesser MPJ
• Exquisite tenderness plantar and distal to joint
• Alignment of the digit clinically and radiographically appears unchanged compared to contralateral digit
• Stage II
• Moderate Edema
• Noticeable deviation of the digit both clinically and radiographically
• Loss of toe purchase, noticeable in weight bearing
• Stage III
• Moderate edema
• Clinically, the deviation (subluxation or dislocation) is more pronounced
• Subluxation or dislocation radiographically

Question 30

bone scan plantar plate tear vs. stress fracture

Answer 30

Question 31

direct vs. indirect surgical treatment for plantar plate tear

Answer 31

direct

• plantar approach usually
• tear usually off of phalanx side
• suture end-to-end or use anchor in proximal phalanx base
• NWB 3 wks, stabilize with k wire 4 wks

indirect

• flexor digitorum longus tendon transfer
• dorsal (WB) or plantar (NWB)
• Isolate tendon and split in half, bring up over toe and suture to itself and periosteum dorsally OR isolate tendon and insert into bone and secure to itself, periosteum or use anchor
• do with or w/o plantar plate repair