Stress fractures of the lateral metatarsal bones in metatarsus adductus foot deformity: a previously unrecognized association

Review of Current Concepts in Metatarsus Adductus

Metatarsus adductus (MA), the most common congenital foot deformity, involves adduction of the forefoot at the tarsometatarsal joint, with normal hindfoot alignment. Early diagnosis is important because treatment is more successful if initiated before age 9 months. Treatment of MA depends on deformity severity, in which mild to moderate deformity can be treated conservatively. Current standard of care for severe or rigid deformity involves referral by primary care physicians to specialists for management by casting and splinting. Recently, several orthoses have demonstrated equal effectiveness to casting and may allow for primary care physicians to treat MA without the need for referral. In this review article, we provide an overview of MA and discuss diagnosis and treatment. We also discuss novel devices and suggest how they may affect the future management of severe and rigid MA. [Pediatr Ann. 2024;53(4):e152-e156.].

The painful lateral column of the foot: from back to front

The purpose of this article is to focus attention on the abnormalities which the radiologist may encounter in patients presenting with lateral ankle or foot pain outside of the context of acute trauma. These include anterolateral impingement, subfibular impingement, subtalar instability and tarsal sinus syndrome, tarsal coalition, sural neuromas, peroneal tendon abnormalities, calcaneocuboid instability and occult cuboid fractures, and painful accessory ossicles. The expected and unexpected findings on radiographs, CT, US, and MRI are discussed.

Forefoot Adduction, Hindfoot Varus or Pes Cavus: Risk Factors for Fifth Metatarsal Fractures and Jones Fractures? A Systematic Review and Meta-Analysis

The origin of fractures of the fifth metatarsus and Jones fracture is not clear. The goal of this study was to investigate the evidence of anatomical deformities such as metatarsus adductus, hindfoot varus, or pes cavus as risk factors for this pathology. A literature search of records related to the review question was performed screening PubMed/Medline, Embase and Cochrane library databases (last update: May 2020) according to PRISMA guidelines. A meta-analysis was performed using the mean difference of the assessed angles (in patients with the fractures vs controls) as outcome measure to summarize literature findings about metatarsus adductus angle (MAA) indicating forefoot adduction, calcaneal pitch angle (CP) indicating hindfoot cavus and varus deformity and Talo-1^st metatarsus angle/Meary's angle (T1^stMA) for varus alignment. Eight studies were included in the qualitative analysis (296 patients), 5 in the quantitative synthesis (132 patients). The pooled mean difference of MAA between fracture versus control group on a per patient-based analysis was 4.62 (95% CI 1.31-7.92). Statistical heterogeneity among studies was detected (I-Square: 76.1%), likely due to different patient groups and low number of studies. The pooled mean differences of CP and T1^stMA among fracture group versus controls did not show statistical significance. Despite limited literature data, metatarsus adductus deformity seems to be correlated with higher risk of proximal metatarsal fractures and Jones fracture. A significant relationship between hindfoot varus or pes cavus and these fractures was not demonstrated. Further studies and trials are warranted to shed more lights on this topic.

Intra and Inter-Observer Reliability and Repeatability of Metatarsus Adductus Angle in Recreational Football Players: A Concordance Study

Metatarsus adductus (MA) is a congenital foot deformity often unrecognized at birth. There is adduction of the metatarsals, supination of the subtalar joint, and plantarflexion of the first ray. The aims of this study were to assess the intra and inter-reader reliability of the radiographic MA measurement angles used in the literature. Methods: All consecutive recreational football players who practice activity more than 5 h/week over 21 years of age with MA by roentgenographic evaluation on weight-bearing dorsoplantar images were included in a cross-sectional study. Controls were matched to cases according to age and gender. We assess all radiographic measurements to evaluate metatarsus adductus with the different measurements frequently used in the literature: Sgarlato, modified Sgarlato, Rearfoot, Root, Engel, modified Engel, Kite, Kilmartin, modified Kilmartin, Simons, and Laaveg & Ponseti. Results: The variables measured in 80 weight-bearing dorsoplantar foot radiographs show excellent reliability ranging p > 0.900 in Sgarlato and modified Sgarlato with low SEM, CV, and MCD. Rearfoot, Root, Engel, modified Engel, Kite, Kilmartin, Simons, Laaveg & Ponseti, and modified Kilmartin’s angles showed intra or inter reliability with ICC lower than <0.900, systematic differences between intersession or inter observers, or high MCD value. Conclusion: It is more suitable to measure the MA angle with the Sgarlato and modified Sgarlato techniques to show higher reliability and repeatability for intra and inter-observer.

Novel device for nonsurgical correction of rigid forefoot adduction in children

Forefoot adduction deformity (FAD) (commonly called metatarsus adductus) is reported as the most common congenital foot deformity in newborns. Early diagnosis and treatment are important in rigid cases, as better outcomes have been reported if treatment was initiated before 9 months of age. While casting and splinting is the current standard of care for nonsurgical management of rigid FAD (RFAD), several orthoses have demonstrated equal benefit. The Universal Neonatal Foot Orthotic (UNFO) brace is below ankle orthosis that provides continuous pressure, thereby correcting the deformity without casting. To the best of our knowledge, UNFO is the first brace that operates below the ankle. The aim of this study was to compare the effectiveness of UNFO shoe to standard serial casting in the treatment of RFAD in infants. Between the years 2012 and 2019 we treated 147 feet (94 patients): 52 using the UNFO shoes and 95 by standard casting and splinting protocol. The treatment groups were compared based on treatment duration, complications, and recurrence of deformity. Mean full-time treatment duration was significantly shorter in the UNFO group, while no significant difference in the total duration of treatment was observed. Similar complication and recurrence rates were demonstrated. In conclusion, treatment with UNFO is equally effective to serial casting. The use of UNFO increases convenience and diminishes social burden, thus providing a distinct advantage over other treatment modalities.

Jones Fracture: A Late Sequelae of Undercorrected or Recurrent Congenital Talipes Equinovarus: A Report of 2 Cases

CASE

We present 2 cases in which patients previously treated for congenital talipes equinovarus (CTEV) presented with residual cavovarus deformity and lateral foot pain and were found to have Jones fractures. Both patients were indicated for surgical correction of their residual cavovarus deformity, although neither elected to proceed. These 2 patients were treated conservatively for their fractures with cast immobilization. At the final follow-up, both were clinically and radiographically healed.

CONCLUSION

Residual cavovarus foot deformities after the treatment of CTEV are at risk for proximal fifth metatarsal or Jones fractures. Although conservative management may lead to healing of these fractures, the underlying stresses persist after conservative management increasing the risk for recurrent fracture. Correction of the residual deformity should be the main goal.

Risk Factors Associated With Foot and Ankle Insufficiency Fractures in Postmenopausal Sedentary Women

BACKGROUND

Insufficiency fractures occur in bones with low elastic resistance. In contrast to stress fractures, which affect normal bones and have been extensively studied, insufficiency fractures of the foot and ankle have been the subject of little research. The objective of this study was to identify risk factors associated with the development of foot and ankle insufficiency fractures.

METHODS

The study included 55 postmenopausal sedentary women with foot and ankle insufficiency fractures and 51 women in the control group. The data collected were the fracture site, body mass index, use of corticosteroids, T scores of the femur and lumbar spine measured by bone densitometry, and serum 25-OH vitamin D level. The calcaneal pitch (CP), talar-first metatarsal, and metatarsus adductus (MA) angles were measured on radiographs.

RESULTS

In 49 patients (89%), fractures occurred in the metatarsals. All metatarsals were affected, and the most common fracture site was the base of the fifth metatarsal, with 21 cases (33%). Twenty patients (36%) in the study group reported chronic use of corticosteroids and had lower bone mineral density levels than controls (P < .05). The factors associated with fracture development (P < .05) were the CP and MA angles and low lumbar bone mineral density.

CONCLUSION

Insufficiency fractures in this population were associated with low bone mineral density and unfavorable biomechanical characteristics such as pes cavus and metatarsus adductus.

LEVEL OF EVIDENCE

Level IIIB, case-control study.

The Windswept Foot: Dealing with Metatarsus Adductus and Toe Valgus

The windswept foot remains a reconstructive challenge. The hallux valgus associated with the medially displaced lesser metatarsal heads is hard to correct. Either the lesser metatarsal heads need to be displaced laterally or the deformity accepted. With the deformity, all the toes tend to be aligned into valgus with the position of the flexor and extensor tendons. Several treatment alternatives exist and may require a combination of open and percutaneous surgery. The authors think that, in severe metatarsus adductus, proximal correction of the first, second, and third metatarsals is required.

Accelerated Cortical Osteolysis of Metatarsals in Charcot Neuroarthropathy: A Cross-Sectional Observational Study

Metatarsals are frequent sites of stress and fragility fractures in younger athletic populations and aging older adults. Metatarsal fractures are particularly common in Charcot neuroarthropathy (CN), a complication of diabetes mellitus (DM) and peripheral neuropathy (PN). Neuropathic metatarsal fractures may be caused by an accelerated cortical bone osteolysis and may be reflected as geometric-derived strength estimates from standard foot radiographs. The purpose of this cross-sectional study was to determine geometry and strength-derived estimates of the metatarsals in individuals with DM, PN, and CN compared with younger and older adult controls who were nondiabetic and nonneuropathic. We studied 62 participants: 20 young adult controls (YACs), 22 older adult controls (OACs), and 20 diagnosed with DMPN&CN. From weight-bearing radiographs, we measured the outer diaphysis diameter and inner marrow diameter at the distal, middle, and proximal diaphysis sites of the second and fifth metatarsal. From these diameters, we derived strength estimates of combined cortical width (CCt.Wi), percent cortical area (%Ct.rA), buckling ratio (BR), moment of inertia (MOI), and section modulus (SM) at each site in both metatarsals. DMPN&CN participants had an accelerated cortical thinning, decreased %Ct.Ar, increased BR, and lower MOI and SM compared with OACs and YACs. The OACs showed age-related decreases in CCt.Wi and % Ct.Ar, and increased BR. The BR demonstrated significant group × bone × site interaction with the distal fifth metatarsal in the DMPN&CN group having the lowest bone strength. The BR in the distal fifth metatarsal of DMPN&CN participants was 36% and 49% greater than in the OAC and YAC groups, respectively. DMPN&CN participants have lower metatarsal bone strength estimates compared with younger and older adult controls. Standard foot radiographs demonstrate an accelerated cortical osteolysis in DMPN&CN individuals, particularly in the distal fifth metatarsal diaphysis. © 2019 The Authors. JBMR Plus published by Wiley Periodicals, Inc. on behalf of American Society for Bone and Mineral Research © 2019 The Authors. JBMR Plus published by Wiley Periodicals, Inc. on behalf of American Society for Bone and Mineral Research.

Hallux valgus and metatarsus adductus measurements: inter-reader reliability and correlations on radiographs and MRI

AIM

To assess inter-reader reliability of metatarsus adductus (MA) using the traditional method and Engel's angle (EA) on radiography and magnetic resonance imaging (MRI) and assess correlations with hallux valgus (HV).

METHODS AND MATERIALS

Ninety consecutive patients with radiographs and MRI of the foot were included. Two readers measured HV angle (HVA), traditional metatarsus adductus angle (MAA), and EA on radiographs and HVA and EA on MRI. Three- and two-way mixed model analyses were used for reader agreements. Ninety-five percent bootstrap confidence intervals were calculated. The linear mixed model was used for association between HVA and EA/MAA.

RESULTS

Mean age and male to female ratio was 54.2±15.4 and 0.4:1, respectively. Mean HVA and EA were 20.6±9.4 and 21.2±8, 21.2±8.3 and 22.4±7.5 on radiographs and MRI, respectively. Mean MAA was 18.5±5.7 on radiographs. Inter-reader agreement was good for EA (ICC=0.73, 0.6) and moderate for MAA (ICC=0.41). Positive correlations between HVA, MAA, and EA on radiographs and MRI were found, but none were statistically significant (p=0.44 and 0.87).

CONCLUSION

Engel's angle is more reproducible. Although positive correlations exist between the degrees of HV and MA, they are not statistically significant.

Plate Fixation With Autogenous Calcaneal Dowel Grafting Proximal Fourth and Fifth Metatarsal Fractures: Technique and Case Series

Metaphyseal and proximal diaphyseal fractures of the lateral column metatarsals can have problems with healing. In particular, those involving the fifth metatarsal have been associated with a high nonunion rate with nonoperative treatment. Although intramedullary screw fixation results in a high union rate, delayed healing and complications can occur. We describe an innovative technique to treat both acute and chronic injuries involving the metatarsal base from the metaphysis to the proximal diaphyseal bone of the fourth and fifth metatarsals. The surgical technique involves evacuation of sclerotic bone at the fracture site, packing the fracture site with compact cancellous bone, and plate fixation. In our preliminary results, 4 patients displayed 100% radiographic union at a mean of 4.75 (range 4 to 6) weeks with no incidence of refracture, at a mean follow-up point of 3.5 (range 1 to 5) years. The early results with our small series suggest that this technique is a useful treatment choice for metaphyseal and proximal diaphyseal fractures of the fourth and fifth metatarsals.

The identification and appraisal of assessment tools used to evaluate metatarsus adductus: a systematic review of their measurement properties

Background

Metatarsus adductus is the most common congenital foot deformity in newborns. It involves adduction of the metatarsals at the Lisfranc joint. A systematic literature review was conducted to investigate the following question: What tools are used to identify and quantify metatarsus adductus and how reliable, valid and responsive are they?

Methods

The following electronic databases were searched for studies describing tools for the identification and quantification of metatarsus adductus in adults and children published from inception to June 2016: Ovid MEDLINE, Embase, CINAHL, Scopus, Web of Science and AMED. Two researchers initially searched all articles by screening titles and abstracts. If there was any doubt as to an article’s eligibility, the full text paper was retrieved. Reference lists and citations of all retained studies were examined in an attempt to locate further studies. Articles were excluded if they were not in English or described other congenital foot conditions that did not include metatarsus adductus. Studies included in the review reporting measurement properties of measurement tools were critically appraised using the Consensus-based Standards for the selection of health Measurement Instruments (COSMIN) critical appraisal tool.

Results

There were 282 articles screened by title and abstract and 28 articles screened from full text. Fifteen articles were included and nine had data that were extractable for appraisal using the COSMIN critical appraisal tool. Techniques to measure metatarsus adductus included the heel bisector method, photocopies, ultrasound, footprints, dynamic foot pressure and radiographs. There was a paucity of quality data reporting the reliability, validity or responsiveness for measuring metatarsus adductus. Several radiographic angles showed good reliability (intraclass correlation (ICC) – 0.84, 0.97) in adults during pre-operative planning.

Conclusion

There have been multiple assessment techniques proposed for quantification of metatarsus adductus, but there is paucity of reliability, validity or responsiveness to measurement data about these techniques, especially in relation to the paediatric population. Further consideration of measurement testing is required to determine if the most common non-radiographic measures of metatarsus adductus are acceptable for clinical use.

Electronic supplementary material

The online version of this article (10.1186/s13047-018-0268-z) contains supplementary material, which is available to authorized users.

Foot scan assessment of metatarsus adductus: A useful adjunct to Bleck's classification

To determine the severity of metatarsus adductus (MA) comparing with Bleck's classification as a commonly acceptable method for assessing MA, static foot scan has been used. In this cross-sectional descriptive research study, 100 subjects were equally divided into four groups according to Bleck's classification. The feet were scanned and MA severity (MAS) index was measured on the obtained foot scan images. The MAS index was the ratio of the transverse deviation of the forefoot from the lateral border heel line to the width of the ball of the foot. The mean of the MAS index in normal, mild, moderate, and severe MA was 0.02±0.02, 0.1±0.01, 0.159±0.03, and 0.216±0.025, respectively. The difference of MAS index between each group was significant (p<0.001). The mean of MAS index in 4 groups was consistent with Bleck's classification, with a significant increase from normal to severe MA (p<0.05). Since the results of this method are consistent with Bleck's classification and this novel foot scan assessment appears to be more objective than Bleck's classification, the authors recommend this method to be used in examination of patients with MA. However, further studies should be conducted to define interobserver and intraobserver reliability.

LEVEL OF EVIDENCE

III.

Operative Treatment of Fifth Metatarsal Jones Fractures (Zones II and III) in the NBA

BACKGROUND

Proximal fractures of the fifth metatarsal (zone II and III) are common in the elite athlete and can be difficult to treat because of a tendency toward delayed union, nonunion, or refracture. The purpose of this case series was to report our experience in treating 10 NBA players, determine the healing rate, return to play, refracture rate, and role of foot type in these athletes.

METHODS

The records of 10 professional basketball players were retrospectively reviewed. Seven athletes underwent standard percutaneous internal fixation with bone marrow aspirate concentrate (BMAC) whereas the other 3 had open bone grafting primarily in addition to fixation and BMAC. Radiographic features evaluated included fourth-fifth intermetatarsal, fifth metatarsal lateral deviation, calcaneal pitch, and metatarsus adductus angles.

RESULTS

Radiographic healing was observed at an overall average of 7.5 weeks and return to play was 9.8 weeks. Three athletes experienced refractures. There were no significant differences in clinical features or radiographic measurements except that the refracture group had the highest metatatarsus adductus angles. Most athletes were pes planus and 9 of 10 had a bony prominence under the fifth metatarsal styloid.

CONCLUSION

This is the largest published series of operatively treated professional basketball players who exemplify a specific patient population at high risk for fifth metatarsal fracture. These players were large and possessed a unique foot type that seemed to be associated with increased risk of fifth metatarsal fracture and refracture. This foot type had forefoot metatarsus adductus and a fifth metatarsal that was curved with a prominent base. We continue to use standard internal fixation with bone marrow aspirate but advocate additional prophylactic open bone grafting in patients with high fourth-to-fifth intermetatarsal, fifth metatarsal lateral deviation, and metatarsus adductus angles as well as prominent fifth metatarsal styloids in order to improve fracture healing and potentially decrease the risk of refracture.

LEVEL OF EVIDENCE

Level IV, case series.

Rare Proximal Diaphyseal Stress Fractures of the Fifth Metatarsal Associated With Metatarsus Adductus

Before the report of English surgeon Robert Jones, who sustained a fracture to his fifth metatarsal while dancing around a tent pole, metatarsal fractures were thought to be the result of direct trauma to the foot. The mechanism of metatarsal fractures, in particular, those involving the fifth metatarsal, is now well understood. Patients with an adducted alignment of their forefoot can overload the fifth metatarsal base, putting them at an increased risk of fractures of this bone. Studies have reported that 2 distinct types of proximal diaphyseal or junctional fractures of the fifth metatarsal occur: the acute proximal diaphyseal or transverse proximal diaphyseal fracture and the proximal diaphyseal stress fracture. The radiographic characteristics associated with proximal diaphyseal stress fractures of the fifth metatarsal can vary by the chronicity; however, the findings typically entail a radiolucent fracture line with surrounding reactive sclerosis. In addition, a reduced medullary canal width can be appreciated. In the present retrospective analysis of patients with stress-related trauma to the fifth metatarsal base with an adducted forefoot, 2012 foot trauma cases were reviewed at 3 separate institutions. Of the 2012 cases, 22 (1.11%) met the outlined criteria of stress fractures of the fifth metatarsal base and underlying metatarsus adductus.

A retrospective review of the effect of metatarsus adductus on healing time in the fifth metatarsal jones fracture

PURPOSE

The fifth metatarsal Jones fracture is a unique injury. Previous studies have identified possible biomechanical risk factors related to this fracture, as well as potential subsequent effects on bone healing complications. The purpose of this retrospective study was to determine the effect of metatarsus adductus (MAA) on bone healing in patients following intramedullary screw fixation of the Jones fracture.

METHODS

This study reviewed 14 Jones fractures that underwent intramedullary screw fixation. Serial radiographs taken approximately every two weeks were evaluated to determine bone healing time (BHT). Weight-bearing antero-posterior radiographs were used to determine the MAA using standard osseous landmarks.

RESULTS

There was a strong positive correlation between MAA and BHT. Moderate correlations were also found between age and BHT and between age and MAA. A prediction algorithm derived from the regression model shows that 63.2% of the variability in the Jones fracture healing time (BHT) can be predicted by a minimum of 22.7 days increased by an average of 1.23 days for each degree of MAA.

CONCLUSION

This study suggests healing time in Jones fractures to be highly related to the MAA following intramedullary screw fixation. The ability to predict osseous union of Jones fracture offers advantages such as patient expectations as well as individualized rehabilitation programs.

Multiple simultaneous metatarsal stress fractures in the same foot

Metatarsal stress fractures are common overuse injuries in athletes, military recruits, and ballet dancers, usually occurring in the second, third, and fourth metatarsals, respectively. Such fractures may also occur in a variety of other individuals, regardless of demographic characteristics, sex, or profession, and they are highly associated with excessive activity. Moreover, these types of fractures are usually diagnosed late and have poor outcomes. To our knowledge, there has been only one case report of an individual with stress fractures of all three central metatarsals in the same foot. We describe herein a racehorse training jockey who presented with multiple simultaneous metatarsal stress fractures in the same foot. We also discuss the possible mechanisms by which this entity occurred, as well as its management and outcome.

Pedal bone density, strength, orientation, and plantar loads preceding incipient metatarsal fracture after charcot neuroarthropathy: 2 case reports

STUDY DESIGN

Case report.

BACKGROUND

Charcot neuroarthropathy is a progressive, noninfective, inflammatory destruction of bones and joints leading to foot deformities and plantar ulceration. Though individuals with Charcot neuroarthropathy typically have low areal bone mineral density, little is known regarding changes in volumetric bone mineral density (vBMD), bone geometry, joint malalignment, and biomechanical loads preceding fracture.

CASE DESCRIPTION

Two women, aged 45 and 54 years at the onset of an acute, nonfracture Charcot neuroarthropathy event, received regular physical therapy with wound care and total-contact casting. Both enrolled in a larger research study that included plantar pressure assessment and quantitative computed tomography at enrollment and 3, 6, and 12 months later. The women sustained mid-diaphyseal fifth metatarsal fracture 10 to 11 months after enrollment. Quantitative computed tomography image-analysis techniques were used to measure vBMD; bone geometric indices reflecting strength in compression, bending, and cortical buckling; and 3-D bone-to-bone orientation angles reflecting foot deformity.

OUTCOMES

Fifth metatarsal mid-diaphyseal vBMD decreased during offloading treatment from 0 to 3 months, then increased to above baseline levels by 6 months. All geometric strength indices improved from baseline through 6 months. Plantar loading in the lateral midfoot increased preceding fracture, concomitant with alterations in bone orientation angles, which suggest progressive development of metatarsus adductus and equinovarus foot deformity.

DISCUSSION

Fractures may occur when bone strength decreases or when biomechanical loading increases. Incipient fracture was preceded by increased loading in the lateral midfoot but not by reductions in vBMD or geometric strength indices, suggesting that loading played a greater role in fracture. Moreover, the progression of foot deformities may be causally linked to the increased plantar loading.

LEVEL OF EVIDENCE

Prognosis, level 4.

Fourth metatarsal base stress fractures in athletes: a case series

BACKGROUND

Metatarsal stress fractures account for approximately 28% of all stress fractures reported in the literature. Second and third metatarsal stress fractures are most common, followed by fractures of the fourth and fifth metatarsal. Reports in the literature suggest that proximal fourth metatarsal stress fractures have the same propensity for delayed healing and nonunion as do fifth metatarsal stress fractures. There is a paucity of literature on operative management of fourth metatarsal fractures. This study reports the results of operative management of fourth metatarsal stress fractures in athletes.

METHODS

A retrospective review with prospectively collected data was undertaken to evaluate utility of operative care of fourth metatarsal stress fractures in an athletic population desiring early return to sports. Eleven athletes over a 13-year period were enrolled with proximal fourth metatarsal stress fractures. The American Orthopaedic Foot & Ankle Society (AOFAS) Midfoot scores were obtained pre- and postoperatively. Midfoot alignment, including the presence or absence of metatarsus adductus, radiographic time to healing, and time to return to sports were also recorded.

RESULTS

All patients were treated with operative open reduction and internal plate fixation with calcaneal autograft. Four of the 11 patients had metatarsus adductus. All had evidence of radiographic healing prior to return to activity, all returned to sports at an average of 12 weeks post surgery, and all would choose surgery again given the same injury. The AOFAS Midfoot scale improved from an average of 55 preoperatively to 94 postoperatively (P < .001) CONCLUSION: Our study suggests that operative repair of fourth metatarsal stress fractures hastens time of healing and return to sports in athletes. It also supports the theory that there is a correlation between metatarsus adductus lateral metatarsal stress fractures.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

The association of metatarsus adductus to the proximal fifth metatarsal Jones fracture

This retrospective study aimed to determine if a transverse plane forefoot relationship exists in patients with Jones fractures. Anteroposterior radiographs of 30 acute Jones fractures were compared with radiographs of 30 asymptomatic control subjects. Radiographic metatarsus adductus angle measurements were analyzed with a digital software program. The reliability of the measurements was evaluated with an intra-rater study. An independent t test was used to compare the metatarsus adductus angle between the Jones fracture group and the control group. Radiographic analysis revealed the mean metatarsus adductus angle for the Jones fracture group to be 20.22° (± 6.79°) compared with a mean of 14.27° (± 4.60°) for the control group. This difference between the groups was found to be statistically significant (p < .005). The intraclass reliability coefficient (ICC = 0.9396) confirmed there was no bias in the radiographic measurements. The metatarsus adductus angle in this group of patients with Jones fractures was increased compared with the nonpathologic control group. The Jones fracture mechanism of injury and resultant lateral column overload may be intensified with an increased metatarsus adductus. This relationship should be considered a risk factor for Jones fractures and taken into consideration with respect to bone healing, treatment, and prevention.

Reliability of metatarsus adductus angle and correlation with hallux valgus

BACKGROUND

Metatarsus adductus is a common congenital foot deformity. Variable prevalence values were reported using different techniques in different populations. Numerous radiological measurements have been proposed to assess this deformity with a paucity of studies reporting the reliability of these methods. The metatarsus adductus angle was shown to correlate with the severity of hallux abductovalgus in normal feet and preselected populations of juvenile hallux valgus.

MATERIALS AND METHODS

Weight bearing dorsoplantar radiographs of 150 feet were examined for 5 angles commonly used in assessing metatarsus adductus: angle between the second metatarsus and the longitudinal axis of the lesser tarsus (using the 4th or 5th metatarso-cuboid joint as a reference), Engel's angle and modified Engle's angle. The prevalence of metatarsus adductus was assessed according to published criteria for different techniques. Inter and intra-observer reliabilities of these angles were evaluated on 50 X-rays. Linear regression tests were used to assess the correlation between hallux valgus and different angles used in assessing metatarsus adductus.

RESULTS

Intraclass correlation coefficients were high for intra- as well as inter-observer reliability for the 5 angles tested. Prevalence of metatarsus adductus ranged (45-70%) depending on the angle used in the same population. Only the metatarsus adductus angle using the 4th metatarso-cuboid joint as a reference demonstrated significant correlation between metatarsus adductus and hallux abductovalgus angles.

CONCLUSION

Five techniques commonly used in assessing metatarsus adductus demonstrated high inter and intra-observer reliability values. Prevalence of metatarsus adductus and the correlation between the severity of this deformity and hallux valgus angle is sensitive to the assessment method.

Stress fracture of the fourth metatarsal in a relapsed clubfoot of a 5.5-year-old child

Stress fractures are uncommon in skeletally immature patients and usually affect adolescents involved in competitive sports, whereas they are very rare in young children. Involvement of the fourth metatarsal is very infrequent and has been associated with metatarsus adductus deformities. The authors describe a stress fracture of the proximal fourth metatarsal occurred in a 5.5-year-old child with a relapsed clubfoot. Operative correction of the deformity and cast immobilization provided consolidation of the fracture. Stress fractures of lateral metatarsals may represent a possible source of pain in recurrent clubfeet, even in young children. In these cases, early correction of the deformity is required.

Radiological assessment of metatarsus adductus

Metatarsus adductus is the most common congenital foot abnormality. Whilst there is a growing body of evidence describing many aspects of this condition, basic questions regarding aetiology, management and treatment remain controversial. Diagnosis is achieved with clinical and radiological examination. The latter is particularly important for the diagnosis of mild cases. An extensive literature review is presented outlining the development of various radiological methods of angular measurement used in the diagnosis and classification of metatarsus adductus. In addition, the review highlights a spectrum of values obtained for each angle and the validity were reported.

Hallux valgus correction in a patient with metatarsus adductus with multiple distal oblique osteotomies

Metatarsus adductus is a structural foot deformity that is rarely associated with hallux valgus deformity. Surgical treatment is challenging, and multiple osteotomies are often required to correct both deformities. However, surgical impact must be considered, especially in elderly patients. We present a clinical case of a 76-year-old woman affected by hallux valgus and metatarsus adductus deformity. Multiple distal oblique osteotomies were performed on the first, second, and third metatarsals, coupled with Z-lengthening of the extensor digitorum longus tendons.

Stress fracture of the fourth metatarsal in a child: a case report and review of the literature

Metatarsal stress fractures are uncommon in the children. They usually occur in the distal part of the metatarsal and common in second and third metatarsals. Stress fracture in the proximal fourth metatarsal in a child is very rare. We report a stress fracture in the proximal fourth metatarsal in an 8-year-old boy, which was successfully treated with non-operative management.

ACQUIRED PES CAVUS IN CHARCOT-MARIE-TOOTH DISEASE

Hereditary motor and sensory neuropathies, especially Charcot-Marie-Tooth disease, are frequently expressed with an acquired cavusvarus foot which is characterized by a fixed increase of the plantar arch and hindfoot inversion. Diagnosis of the underlying condition achieved through careful patient assessment and local evaluations is the keystone for decision-making about the adequate treatment. The cavus may present as an isolated deformity of the forefoot, hindfoot or it may be a combination of both locations. Related deformities, mainly the varus and toe clawing require appropriate evaluation; clinical characteristics such as severity of the deformity, impairment of the muscular power, flexibility and patient's age are important characteristics in the treatment decision. Conservative treatment of the cavusvarus foot with physiotherapy, insoles and shoe modifications are reserved to young patients and mild deformities. However, there is a tendency of the deformity to become more severe over time because of the progressive feature of the underlying neurological condition. So, the surgical treatment by using classical techniques is performed in early stages. Most importantly is the identification of the primary and main components of each deformity to properly correct them, if possible. Muscular transfers are used to treat the dynamic unbalance, retracted structures should be either divided or lengthened and localized osteotomies should be preferred over arthrodeses, which are reserved for stiff and severely deformed feet in adults.

Significant forefoot varus deformity resulting in progressive stress fractures of all lesser metatarsal bones

Stress fractures may occur in any bone, but appear most frequently in the metatarsal bones. Consecutive stress fractures of all lesser metatarsals in a short period are rare, and only a few cases have been described in the literature. We report an unusual case of a young man with consecutive stress fractures of four adjacent lesser metatarsal bones. The etiology was in all probability the fixed forefoot varus deformity. This foot deformity may impose increased mechanical loads across the lateral aspect of the foot that, in turn, may result in stress fractures involving the lesser metatarsals. In our patient conservative treatment finally resulted in a satisfactory outcome.

Fractures of proximal portion of fifth metatarsal bone: anatomic and imaging evidence of a pathogenesis of avulsion of the plantar aponeurosis and the short peroneal muscle tendon

PURPOSE

To evaluate the normal anatomy of the structures supporting the proximal portion of the fifth metatarsal bone and investigate the pathogenesis of fractures in this region.

MATERIALS AND METHODS

In two cadaveric feet, the region of the lateral component of the plantar aponeurosis (PAL), short peroneal muscle (SPM) tendon, and third peroneal muscle (TPM) tendon was dissected. These two foot specimens and four nondissected foot specimens were studied at magnetic resonance (MR) imaging. Two of the six specimens were studied at computed tomography (CT). Sectioning the nondissected foot specimens enabled anatomic correlation. In two additional specimens, simulation of the presumed mechanism of fifth metatarsal bone fracture was attempted. The radiographic, CT, and MR images obtained in 13 patients with fractures of the proximal portion of the fifth metatarsal bone were evaluated.

RESULTS

Anatomic, CT, and MR imaging studies revealed broad insertion of the PAL into the plantar aspect of the proximal portion of the fifth metatarsal bone in all specimens. The SPM tendon was consistently attached more distally and to the lateral side of the tuberosity, blending with the PAL fibers. The TPM tendon was inconsistently identified inserting anteriorly to the SPM tendon. No fracture was created in the specimens subjected to attempted injury. Frequent attachment of the PAL and the SPM tendon to the avulsed fragment was confirmed in clinical cases.

CONCLUSION

The pathogenesis of fractures of the proximal portion of the fifth metatarsal bone appears to be related to avulsion injury of PAL and SPM tendon fibers.

Stress fractures of the ankle and forefoot in patients with inflammatory arthritides

Twenty-four stress fractures occurring in the metatarsal bones and ankle region were examined in 17 patients with inflammatory arthritides. There were 16 metatarsal, four distal fibular, two distal tibial, and two calcaneus fractures. Radiographic analyses were performed to determine the presence of possible predisposing factors for stress fractures. Metatarsal and ankle region stress fractures were analyzed separately. Stress fractures occurred most frequently in the second and third metatarsals. In metatarsal fractures, there was a trend for varus alignment of the ankle to cause fractures of the lateral metatarsal bones and valgus alignment of the medial metatarsal bones. Valgus deformity of the ankle was present in patients with distal fibular fractures in the ankle region group. Calcaneus fractures showed neutral ankle alignment. Malalignment of the ankle and hindfoot is often present in distal tibial, fibular, and metatarsal stress fractures. Additionally, patients tend to have long disease histories with diverse medication, reconstructive surgery and osteoporosis. If such patients experience sudden pain, tenderness, or swelling in the ankle region, stress fractures should be suspected and necessary examinations performed.

Proximal fourth metatarsal injuries in athletes: similarity to proximal fifth metatarsal injury

Proximal fourth metatarsal injuries are rarely reported. We present five case histories in which athletic patients sustained injuries at the shaft-base junction of the fourth metatarsal. Similar to proximal fifth metatarsal injuries, adduction of the forefoot appears to be associated. Our patients returned to their activities in two to eight months. These patients injuries tended to take longer to heal than other lesser metatarsal fractures and stress fractures (which are typically more distal). Some patients were continually symptomatic, even after three months of rest and immobilization. This coincides with proximal fifth metatarsal injuries and stress fractures. For treatment of proximal fourth metatarsal injuries to be successful, ideal treatment appears to involve nonweightbearing below-knee cast/boot immobilization for three weeks. This is followed by an additional three or more weeks of weightbearing immobilization. Healing may still be prolonged.