Foot and Ankle cases 10

An otherwise healthy 19-year-old female presents with a 6-week history of progressive pain over the lateral aspect of the right fifth metatarsal head. She denies a history of foot trauma. She prefers to wear high-heeled shoes at her part time job. Physical examination reveals mild swelling and a small callus over the lateral fifth metatarsal head. Passive range of motion of the fifth metatarsophalangeal (MTP) joint is painless. A weight-bearing AP x-ray of the right foot was obtained (Fig. 5–21).

 

 

Figure 5–21 Weight-bearing AP radiograph of the foot.

 

What is the most appropriate treatment at this time?

1. Conservative management including a discussion about avoiding constrictive shoe wear

2. Refer the patient to a rheumatologist for serum hematologic and immunologic testing

3. Aspirate the fifth MTP joint and evaluate for crystals and elevated white blood cell count

4. Rotational osteotomy of the fifth metatarsal

5. Lateral condylectomy of the fifth metatarsal head

 

Discussion

The correct answer is (A). The patient has a bunionette deformity. Irritation over the lateral aspect of the fifth metatarsal head results from mechanical rubbing of ill-fitting footwear against the bony prominence. Callus formation and an inflamed bursa may be noted on physical examination. Initial treatment is conservative and may include paring of the callus, orthotics, and well-fitting shoes. Rheumatology referral is not necessary as nothing in the patient history suggests a systemic inflammatory condition. Joint aspiration is not indicated in the face of painless joint range of motion and focal tenderness. Surgical measures are not indicated unless nonsurgical measures fail and symptoms are deemed unacceptable by the patient.

Despite regular callus debridement and shoe wear modification the same patient returns 1 year later with similar complaints. She is contemplating surgical intervention for symptomatic relief.

Which is the most appropriate surgical option?

1. Excision of the fifth metatarsal head

2. Lateral condylectomy of the fifth metatarsal head

3. Rotational osteotomy of the fifth metatarsal

4. Arthrodesis of the fifth MTP joint

 

Discussion

The correct answer is (C). The patient has a type 2 bunionette, characterized by a lateral curvature in the diaphysis. A type 2 bunionette is best corrected with a rotational osteotomy of the distal or midshaft region of the fifth metatarsal. Type 1 bunionette deformities are characterized by an enlarged lateral head prominence. In these cases, a simple lateral condylectomy can be performed. Type 3 bunionettes result from an increased 4–5 intermetatarsal angle. Both type 2 and 3 deformities can be treated with rotational osteotomy. There is typically not a role for excision of

the fifth metatarsal head or fifth MTP joint arthrodesis for bunionette correction.

 

Objectives: Did you learn...?

 

 

Initially manage a bunionette deformity? Classify bunionettes?

 

Identify surgical management options for a bunionette?