Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

#4 Surg > 48 and 49 - Metatarsalgia I and II > Flashcards

48 and 49 - Metatarsalgia I and II Flashcards

1
Q

Metatarsalgia

A
  • Forefoot pain under metatarsal heads
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Reasons for metatarsalgia

A

o Soft tissue
o Bone abnormalities
o Biomechanical abnormalities

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Bone abnormalities leading to metatarsalgia

A 
o	Long metatarsal  (commonly the 2nd)
o	Plantarflexed metatarsal
o	Hammer toe 
o	Enlarged metatarsal head
o	Arthritis
o	Freiberg’s infarction
o	Stress fracture
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Soft tissue abnormalities leading to metatarsalgia

A 
o	Calluses (secondary to bony abnormalities) 
o	Neuroma 
o	Capsulitis
o	Plantar plate pathology
o	Hypermobile 1st ray
o	Equinus
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Plantar calluses

A
  • Most plantar calluses are due to a biomechanical over-load
  • You have increased pressure and the callus is the body’s way of trying to protect itself
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Hypermobile first ray

A
  • Rays 2 and 3 have little motion (relatively static)
  • 1st and 5th rays have own axis
  • If 1st or 5th hypermobility is present, it can place increase stress on adjacent metatarsal
  • Pronated foot type can also lead to this
  • If the 1st ray elevates (in diagram), you can see how the 2nd and 3rd metatarsals are taking on an additional load
  • This can occur in pronation as well
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Retrograde buckling

A
  • Normal (dashed line): the toe is straight
  • Buckling (solid line): proximal phalanx dorsiflexes, causing
    the metatarsal to plantarflex, making it more prominent
    and high pressure, so calluses commonly form
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Metatarsal length

A

Metatarsal parabola
o Nice even arc is present here
o 2nd metatarsal is supposed to be slightly longer
(peak of arc), but not sticking way out
o Overloading can also occur with a short 1st met

Metatarsal tangent angles
o 2nd metatarsal is not part of a nice arc
o Longer and sticking out too far

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Gait cycle

A
  • The stance phase is more where we run into problems
  • If the 2nd metatarsal is a lot longer than the rest of the metatarsals, it will have contact for much longer than the other metatarsals, leading to increased pressure and pain
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Now we are moving on to BONE pathology

A

FYI

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Long metatarsal

A
  • Usually 2nd or 3rd metatarsal (Congenital or iatrogenic)
  • May get hammering of digit due to elongation (Retrograde buckling due to tendon imbalance (tendons need to reach too far))
  • May get plantar callus
  • Chronic overloading can lead to capsulitis/plantar plate tears (remember the plantar plate is just the thickening in the capsular structure)
  • Excess length can indirectly cause it to be plantarflexed
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Conservative treatment of long metatarsal

A

o Metatarsal pad (placed proximal to metatarsal head to relieve pressure from head)
o Callus debridement (try to keep callus down to further reduce pressure)
o Budin splint (toe goes through elastic strap which pulls the toe down flat in the shoe)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Surgical treatment of long metatarsal

A

o Metatarsal osteotomy

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Indications for metatarsal osteotomies

A
  • Long metatarsal
  • Plantarflexed metatarsal
  • Contracted digit that cannot be reduced without decreasing metatarsal length
  • Angular deformity of metatarsal
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Contraindications for metatarsal osteotomies

A
  • Pain of unknown etiology
  • Parabola correction without underlying pain or symptoms
  • Severe osteopenia (really soft bone – difficulty with healing)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Most common type of metatarsal osteotomy done

A

Weil osteotomy

Other types

  • Plantar condylectomy
  • V metatarsal osteotomy
  • Dorsiflexory wedge osteotomy
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Weil osteotomy

A
  • Shortening osteotomy which involves a dorsal incision
  • Make cut through metatarsal head, parallel to WB surface
  • If you have a long metatarsal, it will retract back to the appropriate length
  • The head of the metatarsal is usually fixated with 1.5 or 2.0 screw
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Plantar condylectomy

A
  • DuVries initially descripted this procedure
  • You shave off the bottom of the condyle on the metatarsal head
  • Can lead to arthritis because it cuts into the joint
  • Can lead to floating toe due to relaxation of plantar plate
  • Used generally for older patients – NOT for active patients
  • Good option for diabetic patient with chronic callus/ulcer because
    it prevents you from having to remove entire metatarsal head
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

V metatarsal osteotomy

A
  • Jacoby initially described this procedure which helps to dorsiflex the metatarsal
  • Dorsiflexory osteotomy with little shortening (can create shortening by taking making parallel V cut)
  • The toe can be allowed to float (no fixation) - The metatarsal will then seek its own level (a potential complication is delayed healing)
  • Can do offset V to help with fixation – You would make one side of the V longer than the other so you have a good spot to place a screw for fixation (an even V is difficult for screw placement)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Dorsiflexory wedge osteotomy

A
  • Similar concept to Weil, but opposite side of metatarsal (leave the plantar cortex intact)
  • Can do proximal or distal (need less wedge if proximal)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Metatarsal osteotomy post op protocol

A

General rule of thumb
o If it is a forefoot procedure (distal), you will be WB
o If it is a rearfoot procedure (proximal), you will be NWB

Distal procedures
o WB in postop shoe for 6 weeks if fixated
o If not fixated may consider NWB (don’t want bone floating too much, very large callus)

Proximal procedures
o NWB for 6-8 weeks (how long bone healing takes)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

Metatarsal osteotomy complications

A
  • May lead to “floating toe” (due to tendon/capsule relaxation)
  • Transfer lesions (now get problems with the next met down)
  • Delayed or nonunions without fixation (uncommon w/ fixation)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

Freiberg’s infarction

A
  • Osteochondrosis or 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
  • This means the bone dies and the metatarsal head collapses
  • Patient experiences tenderness and edema with activity
  • Radiographs show nothing early in disease process
  • Late stage radiographs show flattening of met head, spurring, sclerosis
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

Radiographs of Freiberg’s infarction

A
  • Top left: area of darkness on 2nd metatarsal head
  • Top right: area of black at arrow tip, where it should be all bright
  • Bottom left and right: after healing has occurred, the entire metatarsal head has flattened out, no cartilage remains
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

Conservative treatment

A 
Initial treatment
o	Immobilization (boot or cast to prevent pressure with toe-off)

Chronic treatment
o Steroid injection
o Rocker bottom shoes (shoe does the work for you, not a lot of pressure with toe off)
o Carbon plate (stiffen shoe, prevents toes from bending or flexing while walking)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

Surgical treatment of Freiberg’s infarction

A
  • Metatarsal head resection (a lot of floating of toe will occur)
  • Graft (prevents floating)
  • Implant (to resurface metatarsal head)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

Freiberg’s infarction graft

A
  • First remove spurring and contour joint, make room for the graft
  • Use orthobiologics or fresh frozen graft
  • Orthobiologics provides scaffold for fibrocartilage
  • Fresh frozen replaces cartilage
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

Stress fracture

A
  • Pain with palpation dorsally (usually pain plantar in other etiologies)
  • Pain with tuning fork application
  • May have edema
  • X-rays initially negative (may take up to 3 weeks)
  • Bone scan (will see uptake in 3rd phase)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

Stress fracture treatment

A
  • Conservative = Immobilize in boot or postop shoe for 4-6 weeks
  • Surgical = Done only if goes to full fracture or excessive callus formation
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

CASE STUDY I

A
  • Biomechanical issues (metatarsus adductus)
  • Still a very active person and was in a lto of pain
  • Initially had a stress fracture which went onto become a full fracture and non-union
  • Took him to surgery
  • 3rd metatarsal base was uneven and enlarged, so smoothed it out and removed excess bone
  • Place a locking plate to correct fracture site
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

Now we are moving on to soft tissue pathology

A

FYI

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q

Neuroma

A
  • Burning pain
  • Tingling/numbness
  • “Wrinkled-sock” sensation (something under there)
  • Sharp and/or radiating pain
  • Symptoms worse with shoes (particularly tight fitting)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q

Diagram of neuroma anatomy

A
  • Medial and lateral plantar nerves branch in the plantar foot
  • Come together in 3rd intermetatarsal space, so there is a little bit extra nerve here
  • If this gets irritated or becomes enlarged, it can start to cause problems for people
  • If you are going to go in and surgically excise it, need to know the anatomy in the area
  • The deep transverse intermetatarsal ligament runs across entire ball of the foot and nerves sit right underneath that
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
34
Q

Intermetatarsal neuroma frequency of interspace involvement

A
  • This chart combines 4 different studies regarding the interspace most commonly involved in neuroma formation
  • The third interspace is by far the most common location of a neuroma (64-91%)
  • If someone has these symptoms in the 1st or 4th interspace, be cautious of calling it a neuroma because it is so rare
  • If someone has these symptoms in the 2nd interspace, thing about a plantar plate tear because that is much more common in that location
  • NOTE: 3rd interspace (between 3rd and 4th metatarsal)

Chart is included in handout

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
35
Q

Neuroma exam

A
  • Pain will be present on direct palpation to the interspace
  • Usually NO edema is present
  • “Mulder’s sign”: squeeze forefoot while applying plantar and dorsal pressure, palpable click
  • Gauthier test: pain with just squeezing foot
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
36
Q

Neuroma diagnostic testing

A
  • Usually not necessary
  • X-rays – to look for stress fracture or Sullivan’s sign (splaying of the toes where the neuroma is)
  • Ultrasound – ovoid mass with hypoechoic signal (can actually see the neuroma)
  • MRI – best seen on T1 (such a small structure, so may not be able to see it)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
37
Q

Neuroma conservative treatment

A
  • Wider shoes
  • Metatarsal pad
  • Steroid injection – usually inject only 1-2 mL of fluid total since it is a small space, only an 11-47% success rate, avoid doing too much due to risk of atrophy of soft tissue structures
  • Sclerosing injection
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
38
Q

4% alcohol sclerosing injections - solution

A

Solution: prepare in office
o 48ml of 0.5% bupivacaine HCl with EPI (1:200,000)
o 2mL of dehydrated alcohol for injection

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
39
Q

4% alcohol sclerosing injections - injection

A

o Inject just proximal to the “bulb”
o Repeat every 5-10 days – TIME COMMITMENT
o Up to 7-9 injections
o Dockery had 89% success rate (usually around 60-70% success rate)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
40
Q

4% alcohol sclerosing injections - Notes

A
  • Not a lot of long-term follow-up regarding recurrence

- Essentially you are trying to kill the nerve so you don’t have to go in and surgically remove it

41
Q

Other conservative treatment options for neuroma

A
  • Vitamin B12 injection (calms down nerve)
  • Phenol (more caustic, meaning able to burn or corrode organic tissue by chemical reaction, but has the same effect as alcohol sclerosing)
42
Q

Morton’s neuroma surgical incisions

A
  • A = Plantar approach, straight linear
  • B = Plantar approach, transverse (avoid WB surface)
  • C = Dorsal approach, distally
  • D = Dorsal approach, overtop nerve
43
Q

Morton’s neuroma surgery

A
  • The nerve branches to the toes are clamped and severed

- The abnormal nerve is dissected free

44
Q

Advantages and disadvantages of dorsal incision

A

Advantages
o Immediate weightbearing
o No plantar scar

Disadvantages
o Need meticulous dissection (hematoma formation or hammertoes if not careful)

45
Q

Advantages and disadvantages of plantar incision

A

Advantages
o Better visualization
o Less incidence of hematoma and hammertoe formation

Disadvantages
o Need to be NWB 3 weeks
o Potential plantar scar

46
Q

Metatarsal osteotomy complications

A
  • May lead to “floating toe” (due to tendon/capsule relaxation)
  • Transfer lesions (now get problems with the next met down)
  • Delayed or nonunions without fixation (uncommon w/ fixation)
47
Q

Freiberg’s infarction

A
  • Osteochondrosis or 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
  • This means the bone dies and the metatarsal head collapses
  • Patient experiences tenderness and edema with activity
  • Radiographs show nothing early in disease process
  • Late stage radiographs show flattening of met head, spurring, sclerosis
48
Q

Radiographs of Freiberg’s infarction

A
  • Top left: area of darkness on 2nd metatarsal head
  • Top right: area of black at arrow tip, where it should be all bright
  • Bottom left and right: after healing has occurred, the entire metatarsal head has flattened out, no cartilage remains
49
Q

Conservative treatment

A 
Initial treatment
o	Immobilization (boot or cast to prevent pressure with toe-off)

Chronic treatment
o Steroid injection
o Rocker bottom shoes (shoe does the work for you, not a lot of pressure with toe off)
o Carbon plate (stiffen shoe, prevents toes from bending or flexing while walking)

50
Q

Surgical treatment of Freiberg’s infarction

A
  • Metatarsal head resection (a lot of floating of toe will occur)
  • Graft (prevents floating)
  • Implant (to resurface metatarsal head)
51
Q

CASE STUDY surgery

A

o Went in surgically, had very large neuroma – 3 cm in length
o Following surgery, foot looks relatively normal, splaying decreased

52
Q

Stress fracture

A
  • Pain with palpation dorsally (usually pain plantar in other etiologies)
  • Pain with tuning fork application
  • May have edema
  • X-rays initially negative (may take up to 3 weeks)
  • Bone scan (will see uptake in 3rd phase)
53
Q

Stress fracture treatment

A
  • Conservative = Immobilize in boot or postop shoe for 4-6 weeks
  • Surgical = Done only if goes to full fracture or excessive callus formation
54
Q

CASE STUDY I

A
  • Biomechanical issues (metatarsus adductus)
  • Still a very active person and was in a lto of pain
  • Initially had a stress fracture which went onto become a full fracture and non-union
  • Took him to surgery
  • 3rd metatarsal base was uneven and enlarged, so smoothed it out and removed excess bone
  • Place a locking plate to correct fracture site
55
Q

Now we are moving on to soft tissue pathology

A

FYI

56
Q

Neuroma

A
  • Burning pain
  • Tingling/numbness
  • “Wrinkled-sock” sensation (something under there)
  • Sharp and/or radiating pain
  • Symptoms worse with shoes (particularly tight fitting)
57
Q

Diagram of neuroma anatomy

A
  • Medial and lateral plantar nerves branch in the plantar foot
  • Come together in 3rd intermetatarsal space, so there is a little bit extra nerve here
  • If this gets irritated or becomes enlarged, it can start to cause problems for people
  • If you are going to go in and surgically excise it, need to know the anatomy in the area
  • The deep transverse intermetatarsal ligament runs across entire ball of the foot and nerves sit right underneath that
58
Q

Intermetatarsal neuroma frequency of interspace involvement

A
  • This chart combines 4 different studies regarding the interspace most commonly involved in neuroma formation
  • The third interspace is by far the most common location of a neuroma (64-91%)
  • If someone has these symptoms in the 1st or 4th interspace, be cautious of calling it a neuroma because it is so rare
  • If someone has these symptoms in the 2nd interspace, thing about a plantar plate tear because that is much more common in that location
  • NOTE: 3rd interspace (between 3rd and 4th metatarsal)

Chart is included in handout

59
Q

Neuroma exam

A
  • Pain will be present on direct palpation to the interspace
  • Usually NO edema is present
  • “Mulder’s sign”: squeeze forefoot while applying plantar and dorsal pressure, palpable click
  • Gauthier test: pain with just squeezing foot
60
Q

Neuroma diagnostic testing

A
  • Usually not necessary
  • X-rays – to look for stress fracture or Sullivan’s sign (splaying of the toes where the neuroma is)
  • Ultrasound – ovoid mass with hypoechoic signal (can actually see the neuroma)
  • MRI – best seen on T1 (such a small structure, so may not be able to see it)
61
Q

Neuroma conservative treatment

A
  • Wider shoes
  • Metatarsal pad
  • Steroid injection – usually inject only 1-2 mL of fluid total since it is a small space, only an 11-47% success rate, avoid doing too much due to risk of atrophy of soft tissue structures
  • Sclerosing injection
62
Q

4% alcohol sclerosing injections - solution

A

Solution: prepare in office
o 48ml of 0.5% bupivacaine HCl with EPI (1:200,000)
o 2mL of dehydrated alcohol for injection

63
Q

4% alcohol sclerosing injections - injection

A

o Inject just proximal to the “bulb”
o Repeat every 5-10 days – TIME COMMITMENT
o Up to 7-9 injections
o Dockery had 89% success rate (usually around 60-70% success rate)

64
Q

4% alcohol sclerosing injections - Notes

A
  • Not a lot of long-term follow-up regarding recurrence

- Essentially you are trying to kill the nerve so you don’t have to go in and surgically remove it

65
Q

Other conservative treatment options for neuroma

A
  • Vitamin B12 injection (calms down nerve)
  • Phenol (more caustic, meaning able to burn or corrode organic tissue by chemical reaction, but has the same effect as alcohol sclerosing)
66
Q

Morton’s neuroma surgical incisions

A
  • A = Plantar approach, straight linear
  • B = Plantar approach, transverse (avoid WB surface)
  • C = Dorsal approach, distally
  • D = Dorsal approach, overtop nerve
67
Q

Morton’s neuroma surgery

A
  • The nerve branches to the toes are clamped and severed

- The abnormal nerve is dissected free

68
Q

Advantages and disadvantages of dorsal incision

A

Advantages
o Immediate weightbearing
o No plantar scar

Disadvantages
o Need meticulous dissection (hematoma formation or hammertoes if not careful)

69
Q

Advantages and disadvantages of plantar incision

A

Advantages
o Better visualization
o Less incidence of hematoma and hammertoe formation

Disadvantages
o Need to be NWB 3 weeks
o Potential plantar scar

70
Q

Images of procedure

A

Image 1
o Traditional technique of flexor digitorum longus tendon transfer
o Tendon has been harvested at the proximal interphalangeal joint level,
split and brough around the diaphysis of the proximal phalanx
o A simultaneous arthrodesis of the proximal IPJ will further facilitate
plantar stabilization of the digit via flexor digitorum longus and brevis

Image 3
o At the top you can see the flexor tendons running along the toe
o In the middle you can see that you drill a hole, take you longus
and pass it up through the proximal phalanx then suture it down
on the dorsal aspect to pull the toe down

71
Q

Cryogenic denervation

A
  • Minimally invasive
  • Temp -50°C to -70°C
  • Get Wallerian degeneration of axons and myelin, leaving perineurium and epineurium intact (helps prevent stump neuroma)
  • Results not permanent
  • Can’t use on large neuromas
72
Q

Post-surgical sensory deficit

A
  • You are removing the nerve, so the patient can get
    numbness instead of pain in that area
  • Sometimes the numbness can go away after time
    (other nerves pick up the slack)
  • Half of one toe and half of the neighboring toe will lose
    sensation
73
Q

CASE STUDY

A
  • 60 year old female
  • History of mass left 3rd interspace
  • PMH: lupus, Raynaud’s
  • Was told by others is was a rheumatoid nodule
  • Patient having pain and would like it removed
74
Q

CASE STUDY MRI results

A

o Dark signal between 3rd and 4th digits
o Large gray mass
o Monochromatic and uniform, so not
concerned about malignancy

75
Q

CASESTUDY surgery

A

o Went in surgically, had very large neuroma – 3 cm in length
o Following surgery, foot looks relatively normal, splaying decreased

76
Q

Plantar plate pathology

A
  • 2nd MPJ most common site
  • Pain worse with walking, better with rest
  • Feels like walking on “stone bruise” or “lump”
  • Patient may note change in position
77
Q

Etiology of plantar plate pathology

A
  • Long second/short first
  • Trauma (not common)
  • 1st ray hypermobility (COMMON)
  • Hypermobility disorders (i.e. Marfan’s or Ehlers-Danlos) – COMMON
  • Overloading (equinus, high heels)
78
Q

Physical exam for plantar plate pathology

A
  • 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
    when stabilizing metatarsal head and moving base of proximal phalanx)
  • Always do exams bilaterally
79
Q

Positive vertical stress test

A
  • Positive vertical stress test results with dorsal translocation of the proximal phalanx
  • Note maintenance of the toe parallel to the plantar aspect of the foot while the maneuver is performed – examiner must be careful not to confuse dorsal translocation with dorsiflexion
80
Q

YU AND JUDGE CLASSIFICATION OF PLANTAR PLATE PATHOLOGY

A

This is what we are moving onto now… Stages I, II and III of predislocation

81
Q

Predislocation stage I (Yu and Judge)

A
  • 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
82
Q

Predislocation stage II (Yu and Judge)

A
  • Moderate Edema
  • Noticeable deviation of the digit both clinically and radiographically
  • Loss of toe purchase, noticeable in weight bearing
83
Q

Predislocation stage III (Yu and Judge)

A
  • Moderate Edema
  • Noticeable deviation of the digit both clinically and radiographically
  • Loss of toe purchase, noticeable in weight bearing
84
Q

Plantar plate – Diagnostic studies

A
  • X-rays
  • Arthrogram
  • Bone scan
  • MRI
85
Q

Arthrogram

A

.5-1mL of iodinated contrast injected into joint under fluoroscopy

  • With tear or rupture will see contrast tracking up flexor tendons
  • Not a common test – mostly for academic study
86
Q

Bone scan

A

Plantar plate tear

  • Positive for phase II (blood pool phase)
  • Negative for phase III (bony phase)

Stress fracture

  • Can be +/- for phase II (blood pool phase)
  • Positive for phase III (bony phase)
87
Q

Notes on bone scan

A
  • If you have a plantar plate tear, it is only a soft tissue abnormality, so you will only see uptake on phase II, nothing on phase III
  • For stress fracture, you see some uptake on phase II due to swelling, but full uptake on phase III
88
Q

MRI results

A
  • Lateral aspect of plate of the 2nd MPJ can be disrupted with edema
  • Flexor tendon can be disrupted with edema
  • White areas where it should just be black
89
Q

Conservative treatment for plantar plate tears

A
  • Metatarsal pads
  • Budin splint
  • Cross over taping
  • NSAIDs
  • Ice
  • Stiff soled shoes
  • CAM boot immobilization (if severe)
90
Q

Surgical treatment for plantar plate tears

A
  • Direct repair or indirect stabilization (flexor tendon transfer)
  • PIPJ fusion often done with above procedures to enhance stabilization
  • May also need to do metatarsal osteotomy if metatarsal is long
  • Limited studies done on 2nd MPJ fusion
91
Q

Direct repair

A
  • Usually done through plantar approach
  • Tear is usually off of phalanx side
  • You can suture end-to-end or use an anchor into the proximal phalanx base
  • If done plantarly, you will need to be NWB for 3 weeks
  • Stabilized with K-wire for 4 weeks
  • Can also go through dorsal approach if metatarsal osteotomy performed
92
Q

Indirect repair - flexor tendon transfer

A
  • Can do with or without plantar plate repair

- Can be dorsal or plantar - If dorsal can WB in postop shoe, If plantar NWB for 3 weeks

93
Q

Technique for flexor tendon transfer - indirect repair

A

Several techniques
o Isolate tendon and split in half, bring up over toe and suture to itself and periosteum dorsally
o Isolate tendon and insert into bone and secure to itself, periosteum or use anchor

94
Q

Images of procedure

A

Image 1
o Traditional technique of flexor digitorum longus tendon transfer
o Tendon has been harvested at the proximal interphalangeal joint level,
split and brough around the diaphysis of the proximal phalanx
o A simultaneous arthrodesis of the proximal IPJ will further facilitate
plantar stabilization of the digit via flexor digitorum longus and brevis

Image 3
o At the top you can see the flexor tendons running along the toe
o In the middle you can see that you drill a hole, take you longus
and pass it up through the proximal phalanx then suture it down
on the dorsal aspect to pull the toe down

95
Q

CASE STUDY III

A
  • 41 year old female who is a runner presents with burning pain between 2nd and 3rd toe, says it feels like balled up sock under her foot

Previous treatment
o Steroid injection
o Custom orthotics
o Little relief with either

96
Q

CASE STUDY III physical exam

A

o Positive vertical stress test
o Negative Mulder’s sign
o Pain with direct palpation of plantar 2nd MPJ
o Swelling around MPJ
o Functional hallux limitus present (when I moved her MPJ, her hallux moved fine during NWB, but if you tried it during WB, it just locked up)

MRI – plantar plate tear on lateral part of joint

97
Q

CASE STUDY III treatment

A

o Dancer’s pad added to orthotic (metatarsal pad with cut out for 1st ray – helps to bring the 1st metatarsal down to avoid the limitus)
o Mobic 7.5 mg
o Discussed possible surgical options
o Flexor tendon transfer with possible plantar plate repair, PIPJ fusion, shortening metatarsal osteotomy

98
Q

CASE STUDY III follow up

A

4 moths post-op
o Pain resolved plantar PIPJ
o 2nd toe floating
o Pain under 3rd metatarsal head when barefoot

#4 Surg (14 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions