48/49: Metatarsalgia I/II - Frush Flashcards Preview

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Flashcards in 48/49: Metatarsalgia I/II - Frush Deck (31)

metatarsalgia =

forefoot pain under metatarsal heads


bony causes metatarsalgia

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


soft tissue causes metatarsalgia

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


retrograde buckling


indications for metatarsal osteotomies

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


budin splint


contraindicatons for metatarsal osteotomies

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


describe weil osteotomy

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


describe plantar condylectomy (duvries)

  • ¨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


describe V metatarsal osteotomy (jacoby)

  • 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


describe dorsiflexory wedge osteotomy

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


complications for metatarsal osteotomy

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


postop for osteotomies distal vs. proximal

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


what is freiberg's infarction?

  • 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


tx for freiberg's infarction

  • 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


stress fracture vs other metatarsalgias

pain with palpation dorsally (plantar in other etiologies)


s/s stress fracture

  • 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


tx stress fracture

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


s/s neuroma

  • 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


PE findings neuroma

  • 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


sullivan's sign on xray

splaying of toes where the neuroma is located


what would a neuroma look like on ultrasound?

ovoid mass with hypoechoic signal


tx neuroma

  • 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


dorsal vs. plantar incision for neuroma

  • 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


most common site plantar plate pathology

2nd MPJ


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)


etiology plantar plate pathology

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


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


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


bone scan plantar plate tear vs. stress fracture


direct vs. indirect surgical treatment for plantar plate tear


  • 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


  • 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

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