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Hi,
Was wondering if anyone had some recommendations for me.
A patient I am seeing sustained a 1st metatarsal communited fracture in a car accident. Initial management included casting and cam walker. He presented to me 12 months later with the following pain.
-1st metatarsal shaft pain
-2nd MTPJ pain = greatest site of pain
-1st inter metatarsal space pain
Most of this pain is during propulsion/at toe off
Recent x-rays show a shortened 1st metatarsal, dorsiflexed 1st ray and some mild spurring which seems to enter the 1st interspace.
The previous Podiatrist prescribed some custom orthotics which have helped a little. Dynamically rearfoot is overcorrected with late midtarsal joint pronation to compensate. I have tried a single wing plantar cover which increased his symptoms slightly. Now I am trying a U 2nd plantar cover. My other thought was to try a 1st met shaft pad.
Any suggestions or should he seek a surgical opinion.

thanks........

The first metatarsal shaft pain throws me. Is there some nonunion? Where are the spurs? Are there spurs in the metaphyseal webspace? Is there a post-traumatic abduction component to the first, which when shod results in impingement somewhere between the first and second or at the base? If there's nonunion, try EBI or similar. If there are spurs, they may have to be cleaned out, although if they are minor they may lessen symptomatically with the passage of time. Are the spurs likely to be causing symptoms? If there's abductoin of the distal aspect of the first met head, obviously bunion-last shoes would help. If there is no symptom-producing osteophytosis and no non-union, your chances of success with the following are considerable, if you act soon enough to forestall insufficiency in the second plantar plate:

If the first met was shortened and dorsiflexed, you have to afford it ground contact at the met head to off-load the acute transfer lesion at the second met head. Your gut about a first met pad is a good one. Dont be afraid to make the shim beneath the first mtp-j a whopper, if a whopper is necessary to act as a prosthesis for a really short and dorsiflexed first met head. Continue the met pad flush to a full-contact LA, but don't do the rote 3-degree varus rearfoot post, unless the patient had preexisting the trauma orthoses which did that and which helped something. Supinating the foot with the varus rearfoot will off-load the first met pad and perpetuate the transfer lesion.

Don't extend the distal terminus of the shell of the orthosis into the mtp joints. It should be proximal to the met heads, at condylar level. Ideally the patient should have a full-contact accomodative, not functional orthosis. Avoid met pads to off-load the 2d transfer if possible. If they are given, and are quasi-"successful", I can almost guarantee this patient will wind up with an apropulsive gait.

If the patient is young enough to look forward to athletics, this gait would easily lead to shin splints (the calf will not want to propel off of the met pads and punish the second met, so the person will extensor substitute and not push-off) and heel pain (the calf eccentric parachute will weaken due to not pushing-off).

No, don't use met pads, just try to get the patient to propel again via extrinsically lengthening the first met. Also, once the orthoses are afforded the patient, if they do relieve symptoms, start him/her on a toe strengthening, calf strengthening, peroneal strengthening (in plantarflexion, as tolerated, depending on age and past Hx) and proprioceptive-training regime of physiotherapy, with gait reeducation to facilitate propulsive gait, as indicated and tolerated.

Let me know.

TMN

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A pain-free foot is a beautiful foot

I had one of these a few months ago, although it was not from a car accident, it was from a work related injury. I had the initial presentation, and opted for ORIF with dorsal DCP plating. The patient did very will with excellent toe purchase and no residual problems.

I would suggest surgical intervention for your patient. First and foremost, consider MRI evaluation to ascertain whether or not the bone is viable. Psuedarthroses, AVN or similar. Assuming all is well, A long shaft osteotomy in the saggital plane performed obliquely should bring the metatarsal into correct alignment and diminish the lesser metatarsal problems.

This is a similar problem which I have seen all to often recently due to iatrogenic elevatus problems from another surgeon (of a different specialty) who has recently left our area. I have addressed them all the same way, with good results. Use 2 - 3 2.7 mm cortical screws. If you are unable to do this, I suggest the appropriate referral.