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Advice Needed Please, Forefoot Injury

Discussion in 'General Issues and Discussion Forum' started by ginger, Nov 20, 2013.

  1. ginger

    ginger Active Member

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    Hello, I had a 15 year old girl in today presenting with pain and swelling in her right foot focussed in the area of her metatarsophalangeal joints (2-5). She explained that the injury occured 2 weeks ago whilst climbing slatted stairs at school, her toes got caught in a slat and she fell up the stairs. She was taken to A&E where she was x-rayed, no breaks were found. Swelling and bruising appeared quickly after the injury occurred. She was advised to take anti-inflammatories and to continue walking on the foot. She did this for 1 week, the pain got continually worse to the point that she is now no longer able to weightbear on that foot. She returned to her GP who advised Paracetamol and a thicker soled shoe.
    Now, 2 weeks later, my patient has been on borrowed crutches (borrowed from a friend) for 1 week to enable her to get to school as she feels she couldn't cope otherwise.
    Her foot was extremely tender to touch in the area of the toes (2-5), 1st toe was tender but not as tender as the lateral 4 toes. The 2nd and 3rd toes were swollen with the 2nd being the most tender, most swollen and having brusing present. Pain dorsally was, as mentioned, over the metatarsophalangeal joints primarily extending to the midtarsal joint. Again, gentle palpation was extremely painful and there was swelling present over the afore mentioned areas. She also has pain in the plantar aspect of her foot extending as far as the metatarsal heads (2-5). She is unable to move her toes and any dorsal or plantar movements or inversion/eversion causes her a lot of pain.
    She has asthma but no other health complaints. I am at a loss as to what to do to help her. She feels she has been 'written off' by her GP and the fact that her foot is so tender means I was unable to do very much for her today. Has anyone seen a similar injury? What helped? Any help would be very much appreciated. I hope that all makes sense!
    ETA She has been icing twice daily for 10-15 minutes a time, resting with her foot elevated, using an anti-inflammatory gel and is keeping a tubigrip on her foot.
  2. LuckyLisfranc

    LuckyLisfranc Well-Known Member

    Acute Frieberg's? Get an MRI and fit removable cast walker for 6/52.

  3. Lab Guy

    Lab Guy Well-Known Member

    If I understand the injury correctly, my educated guess is that she abruptly and forcefully dorsiflexed her mpjs beyond their normal limit causing tearing of the plantar capsule/plantar plate/ligaments that stabilize the lesser MPJs. The forceful dorsiflexion of the digits is transmitting a great deal of force through her lesser mets from the retrograde pressure from the bases of the proximal phalanges. This is indeed a fairly serious injury that will take time to heal.

    I would wrap her foot to diminish the swelling and keep her digits from dorsiflexing. Off-load the MPJs, you do not want any weight on the ball of the foot for 4-6 weeks to expedite healing followed by physical therapy. I would re-xray in 3 weeks as well to ensure there is not a stress fracture from the impact not seen on original films. Once she is doing much better, you may wish to put her in orthotics that incorporate a met bar to off load the ball of the foot as she will still be a bit tender as complete healing will take time.

  4. ginger

    ginger Active Member

    In this case, what would you recommend as being the best method of offloading the MPJ's? Thank you both for your advice, very much appreciated.
  5. Lab Guy

    Lab Guy Well-Known Member

    Ginger, I would be inclined to keep her extremity NWB for about two weeks and apply a soft compression cast to further decrease the swelling. I would dispense a stiff post-op shoe and insert 1/4 inch felt from the heel to proximal to the MPJs to off-load but would tell her to use crutches and stay completely NWB to decrease the pain and allow the tissues to heal. After 2 weeks u can reevaluate and may try guarded WB with the post op shoe and felt or continue NWB.

    Typed from phone hope message clear
  6. ginger

    ginger Active Member

    Brilliant, thank you very much.
  7. drsarbes

    drsarbes Well-Known Member

    Agree with Steven (lab guy) although you may wish to use a CAM boot with heel OR non heel to toe gait (flat foot gait). Much easier than trying to go 2 weeks NWB.

    You may also want to consider Salter injuries since at 15 her epiphyses are most likely still open. Salter type 1 may not be well visualized on xray.

  8. ginger

    ginger Active Member

    Thank you Steve.
  9. ginger

    ginger Active Member

    Well, I wrote a letter to my patients GP for her to take in with her (I work privately and I felt it would be wise to go through her GP for the sake of getting the compression cast and subsequent physiotherapy etc). I suggested the soft compression cast as I don't think she can bear any pressure on her foot at all and I don't think she'd manage even with a CAM walker at this stage. I had an email from her mum today saying the GP had basically dismissed it all saying that the soft compression cast is old fashioned and that it would not add anything as she is using a tubigrip already? He has referred her to Orthopaedics where she has an appointment next Wednesday.

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