Hallux Valgus Flashcards
What is hallux valgus?
Hallux valgus (also commonly termed a “bunion”) is a deformity at the first metatarsophalangeal joint (MTPJ).
It is characterised by medial deviation of the first metatarsal and lateral deviation +/- rotation of the hallux, with associated joint subluxation.
Who is commonly affected by hallux valgus?
This condition is one of the most common foot problems in the adult population, with a prevalence of around 35% in those aged >65yrs and more common in women.
Briefly describe the pathophysiology of hallux valgus
During the gait cycle, the digits should remain parallel to the long axis of the foot. This is made possible by a balance between static stabilisers (bones and ligaments) and dynamic stabilisers (muscles and tendons). Due to the gross anatomy of the foot, the first metatarsal remains inherently unstable, heavily relying on these stabilising structures. There is therefore a greater risk of disturbing the fine balance.
Once the metatarsal head escapes the intrinsic anatomical control, the extrinsic tendons become a deforming force, causing the first metatarsal head to drift medially. This medial joint tension causes the bone to proliferate on the dorsomedial aspect of the head of the first metatarsal and the cartilage is affected by the subsequent remodelling.
Anatomical variants, genetic predisposition, and environmental factors can all further contribute. In predisposed individuals, wearing high-heeled or narrow-fitting footwear can aggravate the condition by keeping the hallux in a valgus position.
What are the risk factors for hallux valgus?
The main risk factors for developing hallux valgus include:
- Female
- Connective tissue disorders
- Hypermobility syndromes
Anatomical variants that predispose to the condition include a long first metatarsal bone, mal-alignment of the first MTP joint, and flat feet
What are the clinical features of hallux valgus?
Hallux valgus typically presents with a painful medial prominence, likely aggravated by walking, weight-bearing activities, or wearing narrow toed shoes. Symptoms have often been present for some time before presentation, however have worsened in frequency and intensity
On examination, assess position and lateral deviation of the hallux and check for evidence of inflammation or skin breakdown over the prominence at the base of the hallux. Check for worsening of the prominence in the weight-bearing position.
Ensure the foot is assessed in both a non-weightbearing position and weightbearing position.
Assess range of movement (active and passive) and crepitus, as the presence of associated pain and crepitation is indicative of cartilage degeneration
Contracture of the extensor hallucis longus tendon may be visible in longstanding joint subluxation and any excessive keratosis on the foot may indicate signs of abnormal weight distribution from an altered gait.
What investigations should be ordered for hallux valgus?
The main investigation is radiographic imaging, used to assess hallux valgux; it is often useful for the degree of lateral deviation and signs of joint subluxation.
This is measured as the angle between the first metatarsal and the first proximal phalanx; hallux valgus is diagnosed if the angle to be corrected is greater than 15 degrees (mild 15-20°, moderate 21–39°, and severe >40°).
Briefly describe the conservative management of hallux valgus
All patients should be prescribed sufficient analgesia, limiting the effects of the condition on quality of life.
Advise on adjusting footwear to prevent the deformity from worsening and preventing irritation of the skin over the medial eminence. If the patient has flat feet, then an orthosis may help to prevent the progression of the condition.
Physiotherapy can provide stretching exercises and gait re-education as indicated.
Briefly describe the surgical management of hallux valgus
For those whose quality of life is significantly impacted by the condition can be considered for surgical intervention, for which there are a variety of procedures possible:
- Chevron procedure
- Scarf procedure
- Lapidus procedure
- Keller procedure
What are the surgical complications of hallux valgus?
Surgical complications for all the aforementioned procedures include wound infection, delayed healing, nerve injury and osteomyelitis. Recurrence is not uncommon.
Briefly describe Chevron procedure
A ‘V shaped’ osteotomy of the distal first metatarsal is created, allowing the first metatarsal to be shifted laterally back into a normal alignment, then fixed by pins and screws.
Commonly used for mild deformities.
What are the complications of hallux valgus?
Complications of hallux valgus include avascular necrosis, non-union, displacement and reduced ROM.
Prognosis is variable in this condition as the deformity may remain stable or progress rapidly. Conservative management can help to alleviate symptoms but will never correct the deformity.
What differentials should be considered for hallux valgus?
- Gout
- Septic arthritis
- Hallux rigidus
- Osteoarthritis
- Rheumatoid arthritis
