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•Metatarsal coalition is rare.
•This is the second reported case occurring at the level of distal metatarsal.
•Timing of ossification of coalition varies from one anatomical site to another.
•Surgery performed before complete ossification of the coalition risks recurrence.
•Conservative management should be persevered until skeletal maturity.
Metatarsal coalition is an extremely rare condition. We report the second documented case of 4th and 5th distal metatarsal coalition in the literature.
PRESENTATION OF CASE:
An eight year old girl was referred to an orthopaedic clinic with a four-month history of forefoot pain and swelling on the plantar aspect of the right little toe. Radiograph and clinical examination confirmed distal metatarsal coalition between the 4th and 5th metatarsals. Following a period of conservative treatment, excision was eventually performed due to worsening symptoms. Patient re-attended two years later with a recurrence of the coalition confirmed by computed tomography (CT) scan. The case was discussed at a tertiary paediatric orthopaedic insititution. Decision was made to manage patient conservatively with insole and physiotherapy until skeletal maturity. A year later, patient's symptoms did not worsen, and her foot displayed no evidence of change in the arch and shape.
The timing of ossification of coalition varies from one anatomical site to another. Surgery when performed before ossification is complete runs the risk of recurrence.
Our case report illustrates the importance of restoring normal weight bearing dynamics and pain relief when managing metatarsal coalition, or synostosis in skeletally immature patients. We recommend persevering with conservative treatment, with operative treatment reserved only as a later option, and ideally, until skeletal maturity is achieved.
An intermetatarsal coalition is an uncommon pathologic entity, previously reported in published studies as being primarily unilateral, most commonly between the first and second metatarsals and less so between the third and fourth metatarsals. We report an unusual case of a bilateral coalition of the third and fourth metatarsals in a 43-year-old male who presented with nonspecific dorsolateral foot pain. Conservative therapy initially failed, and resolution of pain was noted bilaterally after coalition resection.