fifthmetatarsalTreatmentOptionsNonsurgicalmanagementConservativetreatmentshouldbeaimedtowardpatienteducationofthedeformityinordertoincreasecomplianceProperfittingshoegearisessentialbecausemanyofth ID: 336236
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secondarytoanexostosis;aprominentlateralcondyle;oraround,ordumbbell- fifthmetatarsal.TreatmentOptionsNonsurgicalmanagementConservativetreatmentshouldbeaimedtowardpatienteducationofthedeformityinordertoincreasecompliance.Proper-fittingshoegearisessential,becausemanyofthepatientÕssymptomscanarisefromplacingincreasedpressureonthelateralfootandfifthmetatarsalhead,thusirritatingtheoverlyingskinandcapsule;swellingofthefifthmetatarsalbursamayalsooccur.2,5Extradepthshoesortennisshoeswithawidertoeboxcandecreasedirectpressureandimprovesymptoms.Inaddition,leather-styleshoesmaybestretchedoverthepainfulprominencebyapodorthist.1,2,4,5,16,17Theuseoforalantiinflammatorymedicationandlocalcorticosteroidinjectionsinaninflamedbursamayreducelocaltissueinflammation.4,17Incasesinwhichtheprominentmetatarsalheadisaccompaniedbyhyperkeratoticlesion,debridementandpaddingshouldbeperformed.Whenpainoverthefifthmeta-tarsalheadiscausedbyabnormalfootmechanics,prefabricatedorcustomorthoticsmaybeusedtoalleviatesymptomsanddecreasepronationofthesubtalarjoint.SurgicalmanagementOperativemanagementiswarrantedinpatientswithsymptomaticbunionettedefor-mitywhohavenotrespondedtononsurgicaltreatment.Thismanagementmayalsobethelineofapproachforpatientswithspecialdemands,suchashigh-performingathletes.Theprocedureperformedisdictatedbytheanatomicandbiomechanicalfindingsmadeduringthepreoperativeevaluation.Thegoalsofsurgicalinterventionaretodecreasethewidthoftheforefootaswellastheprominenceofthebunionette.Correctionoftheunderlyingdiseaseisnecessarytopreventarecurrenceofthedeformity.Likewise,preservationoffunctionofthefifthMTPjointmaypreventsuchcomplicationsasrecurrence,subluxation,dislocation,orthedevelopmentofatransferlesion. allelandthemetatarsalphalangealjointiswellaligned.Next,temporaryfixationisapplied,andamultiple-holelockingplateisappliedlaterally,withinterfragmentary ensureasuccessfuloutcomewithminimalcomplications,ifallowedbythelevelandfixationtechniques.6Ð8ADDUCTOVARUSFIFTHDIGITIntroductionThecontractureofthedigitsisknownashammertoedeformityorhammerdigitsyn-drome.32,33Thesedigitaldeformitiescanbedividedinto3types:hammertoe,clawtoe,andmallettoe.17,32,34CauseThehammertoedeformityisthemostcommontypeofdigitaldeformity.Itoccursmostlyinthesagittalplane,wheretheMTPjointisextended,theproximalinterphalan-gealjointisflexed,andthedistalinterphalangealjointisextended.32,33Clawtoedefor-mityissimilarinappearancetohammertoe,withtheexceptionoftheflexioncontractureofthedistalinterphalangealjoint,andmallettoedeformityisidentifiedbyflexioncontractureofthedistalinterphalangealjointalone.32,33The3maincausesofhammertoesyndromeareflexorstabilization,flexorsubstitu-tion,andextensorsubstitution.Flexorstabilizationisconsideredthemostcommoncauseofhammertoedeformityandoccursmainlyinflexibleflatfootdeformity,inwhichthereisabnormalsubtalarjointpronation.32,35,36Itleadstounlockingofthemidtarsaljoint,allowingittobecomehypermobile.Thiseventallowstheflexorstogainmechanicaladvantageovertheinterosseousmusclesattemptingtostabilizethehypermobilefoot,causingreversebucklingofthedigitsandresultinginacontrac-turedeformity.36,37Throughtheseevents,thequadratusplantaemusclebecomeslesseffectivebecauseofthechangeindirectionofforcecausedbytheflexordigito-rumlongus.37Thepulloftheflexordigitorumlongusisnowmoreproximalandmedial,creatingafrontalplanerotationofthedigits,whichgivesrisetotheadductovarusdeformity.Thefifthdigitisaffectedmorethanthefourthandeventhethirddigitsbecauseofincreaseinmedialpulloftheflexordigitorumlongustendononthefifthdigitversusthethird.Peripheralneuropathyisanotherreasonwhyinterosseousmus-clescanbecomeweakened,leadingtosimilardigitalcontractures.32,38Flexorsubstitutionistheleastcommoncauseofahammertoedeformity.Itisobservedmostlyinthesupinatedfoottype,inwhichthereisaweaktricepssuraemuscle.Thelongflexorsaidinplantarflexionoftheankle,producingdigitalcontrac-turebecauseofitsmechanicaladvantageovertheinterosseimuscles.Asthisoccurs,adductovaruscontractureisunlikelycomparedwithflexorstabilization,becauseofitssupinatedfoottype.32Extensorsubstitutionalsocausesdigitalcontractures,althoughtheymainlyoccurintheswingphaseofgait.Extensorsubstitutionmostlyoccursinthecavusorsupinatedfoottype,inwhichtheextensordigitorumlongustendongainsmechanicaladvantageoverthelumbricales.32,36Ð38Clinically,bowstringingoftheextensortendonsandclawtoedigitalcontracturesarecommonlyseen.ClinicalpresentationPatientsmostlypresentwiththemaincomplaintofpainfuldigitaldeformity.39Frontalplanerotationandadductionofthedigitcanbeseeninadditiontothecontractureoftheinterphalangealjoints.MTPjointextensionisnotuncommonwithadductovarushammertoedeformity(Fig.16TailorÕsBunionandAdductovarusDeformity GerbertJ,SgarlatoTE,SubotnickSI.Preliminarystudyofaclosingwedgeosteot-omyofthefifthmetatarsalforcorrectionofatailorÕsbuniondeformity.JAmPo-diatrAssoc1972;62(6):212Ð8.27.DieboldPF,BejjaniFJ.Basalosteotomyofthefifthmetatarsalwithintermetatarsalpinning:anewapproachtothetailorÕsbunion.FootAnkle1987;8(1):40Ð5.28.LaVelleDG.Delayedunionandnonunionoffractures.In:CanaleST,editor.CampbellÕsOperativeOrthopedics.10thedition.Vol.3.Philadelphia,PA:Mosby;2003.p.3125Ð65.29.DolceM,AdamovDJ.Postoperativecomplicationinpodiatricsurgery.In:LevyLA,HetheringtonVJ,editors.Principlesandpracticeofpodiatricmedicine,vol.51.Brooklandville(MD):DataTrace;2006.p.1Ð14.30.BellacosaRA,PollakRA.Complicationsoflessermetatarsalsurgery.ClinPodiatrMedSurg1991;8(2):383Ð97.31.CoughlinMJ.Bunionettes.In:CoughlinMJ,MannRA,SaltzmanCL,editors.Sur-geryofthefootandankle.8thedition.Philadelphia:Mosby-Elsevier;2007.p.491Ð530.32.McGlamryED,JimenezAL,GreenDR.Part1:deformitiesoftheintermediatedigitsandthemetatarsophalangealjoint.In:BanksAS,DowneyMS,MartinDE,etal,editors.McGlamryÕscomprehensivetextbookoffootandanklesurgery.Philadelphia:Lippincott,Williams&Wilkins;2001.p.253Ð304.33.MandracchiaVJ,MandiDM,HaverstockBD,etal.Lessermetatarsalanddigital