48/49: Metatarsalgia I/II - Frush Flashcards
1
Q
metatarsalgia =
A
forefoot pain under metatarsal heads
2
Q
bony causes metatarsalgia
A
- ¨Long metatarsal
- ¨Plantarflexed metatarsal
- ¨Hammer toe
- ¨Enlarged metatarsal head
- ¨Arthritis
- ¨Freiberg’s infarction
- ¨Stress fracture
3
Q
soft tissue causes metatarsalgia
A
- ¨Calluses
- ¨Neuroma
- ¨Capsulitis
- ¨Plantar plate pathology
- ¨Hypermobile 1st ray
- ¨Equinus
4
Q
A
retrograde buckling
5
Q
indications for metatarsal osteotomies
A
- ¨Long metatarsal
- ¨Plantarflexed metatarsal
- ¨Contracted digit that cannot be reduced without decreasing metatarsal length
- ¨Angular deformity of metatarsal
6
Q
A
budin splint
7
Q
contraindicatons for metatarsal osteotomies
A
- ¨Pain of unknown etiology
- ¨Parabola correction without underlying pain or symptoms
- ¨Severe osteopenia
8
Q
describe weil osteotomy
A
- ¨Shortening osteotomy
- ¨Usually fixated with 1.5 or 2.0 screw
- ¨Try to make parallel to WB surface
- ¨Will shorten to its own level
9
Q
describe plantar condylectomy (duvries)
A
- ¨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
10
Q
describe V metatarsal osteotomy (jacoby)
A
- 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
11
Q
describe dorsiflexory wedge osteotomy
A
- ¨Can do proximal or distal
- ¨Need less wedge if proximal
- ¨Leave plantar cortex intact
12
Q
complications for metatarsal osteotomy
A
- may lead to floating toe
- transfer lesions
- delayed or nonunions w/o fixation
13
Q
postop for osteotomies distal vs. proximal
A
- Distal procedures
- WB in postop shoe for 6 weeks if fixated
- If not fixated may consider NWB
- Proximal procedures
- NWB for 6-8 weeks
14
Q
what is freiberg’s infarction?
A
- 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
15
Q
tx for freiberg’s infarction
A
- 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
16
Q
stress fracture vs other metatarsalgias
A
pain with palpation dorsally (plantar in other etiologies)
17
Q
s/s stress fracture
A
- 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
18
Q
tx stress fracture
A
- conservative
- Immobilize in boot or postop shoe 4-6 weeks
- surgical
- Done only if goes to full fracture or excessive callus formation
19
Q
s/s neuroma
A
- 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
20
Q
PE findings neuroma
A
- 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
21
Q
sullivan’s sign on xray
A
splaying of toes where the neuroma is located
22
Q
what would a neuroma look like on ultrasound?
A
ovoid mass with hypoechoic signal
23
Q
tx neuroma
A
- 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
24
Q
dorsal vs. plantar incision for neuroma
A
- 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
25
most common site plantar plate pathology
2nd MPJ
26
s/s plantar plate pathology
* 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)
27
etiology plantar plate pathology
* Long second/short first
* Trauma
* Not common
* 1st ray hypermobility
* Hypermobility disorders
* Marfans or Ehlers-Danlos
* Overloading
* Equinus
* High heels
28
PE plantar plate pathology
* 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
29
Yu and Judge Predislocation Staging
* **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
30
bone scan plantar plate tear vs. stress fracture
31
direct vs. indirect surgical treatment for plantar plate tear
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
