Osteochondral defect 3rd metatarsal head

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I saw 24 yrs old male last week with two year history of metatarsalgia, acute onset following dorsal/medial dislocation of 3rd metatarso-phalangeal joint during barefoot beach volleyball. Radiographic exam at injury date was read as normal. Chronic, partially disabling ambulatory metatarsalgia since with no further imaging or treatment.
PE: pain to palpation at distal 3rd metatarsal head, provocative testing with single limb stance heel raise duplicated ambulatory pain. No pain with passive metatarso-phalangeal joint range of motion or active resisted plantarflexion. Diagnostic ultrasound exam was suggestive for osteochondral defect. Attached video showing passive dorsiflexion of metatarso-phalangeal joint, proximal phalanx is screen right, arrow to what I assume to be displaced but attached fragment which appears within distal section of plantar plate.
Initial treatment plan is mechanical offloading with foot orthoses.
If this is inadequate any suggestions for surgical management?
The axial view suggests a linear lesion parallel to metaphysis and almost width of joint surface.
Thanks

Martin
The St. James Foot Clinic
1749 Portage Ave.
Winnipeg
Manitoba
R3J 0E6
phone [204] 837 FOOT (3668)
fax [204] 774 9918
www.winnipegfootclinic.com

 

Hello Martin

I note your request for surgical management in this case.
However since you are considering a conservative approach; why not consider a below knee cast for three weeks at least. Then perform an ultrasound examination to note if there is any resorption of the fragment and also resolution of symptoms. If this is not the case; then perhaps consider surgical intervention which the colleagues on this forum will no doubt suggest.

Cheers

 

OK, I'll take the bait.
Open it up and debride this!!!!
Nice US Mart. Fairly hyperechoic, are you thinking bone or cartilage........ or something else?

PodGov: I don't see how three weeks in a BK cast will do anything other than making the patient's life miserable for 3 weeks. Plus, why a BK cast rather than a short leg cam walker if you'd like to immobilize this?

Steve

 

Hi Drummond and Steve

Thanks for replies.

I agree with Steve regarding immobilisation, I doubt this would have any sustained benefit and cannot see how the fragment could be physiologically remodelled.

My guess is that this represents the result of avulsion of the surface of the metatarsal head. There was no pain to joint motion only metatarsal head compression. This implies that pain is likely result of soft tissue impingement or torsion of fragment.

I have tried offloading with foot orthoses and waiting to review progress in a week or so.

What surprised me from US was the apparent disruption within the plantar plate which was not painful with passive or active range of motion.Because the fragment is hyperechoic it is likely bone.

My reasoning is that if it were calcification within plantar plate it would not likely be so firmly attached to the metatarsal head as seen in video, but I may be wrong.

Hyaline Cartilage is normally hypoechoic because of the nature of the ECM and lack of Hydroxylapatite.

So . . . .. if offloading with foot orthoses not adequate I am wondering about value of radiographic exam to get better idea of the lesion.

I doubt lateral view will be much use.

I was thinking of trying a “sesamoid” type of position. Has anyone tried using a kind of plate with a gap which weight-bearing would dorsiflex the adjacent metatarsals allowing decent lateral view?

Any suggestions for radiographic exam of this lesion?

Steve would you want more imaging before exploring this surgically or is the US enough?

Cheers

Martin

The St. James Foot Clinic
1749 Portage Ave.
Winnipeg
Manitoba
R3J 0E6
phone [204] 837 FOOT (3668)
fax [204] 774 9918
www.winnipegfootclinic.com

 

"Steve would you want more imaging before exploring this surgically or is the US enough?"

Hi Mart:
In my routine, I would have taken the radiograph first, then if needed, the MSK US.

Cleaning these up is fairly simple, some synovitis needs to be resected, smooth any osteophytes and loose cartilage, drill some holes through the defect and keep your fingers crossed. I have found that early ROM exercises (2 weeks post op) help to increase success percentage.

Good luck

Steve

 

Although I have not seen the film, the radiology report at time of injury was "no abnormality". I would imagine AP and lateral, even oblique views might be insensitive to picking up this lesion. Would you agree? What might be optimal view then?

cheers

Martin

The St. James Foot Clinic
1749 Portage Ave.
Winnipeg
Manitoba
R3J 0E6
phone [204] 837 FOOT (3668)
fax [204] 774 9918
www.winnipegfootclinic.com

 

Hi Mart:
IF YOU ARE LOOKING FOR IT, you can pick up OCD on the AP and oblique films. There is often a slight semicircular sclerotic ring at the subchondral margin of the metahead. Often the metahead is slightly flattened as well.

It seems to show up better on lesser metatarsals. I think on the first, since it's larger you get more superimposition masking the changes.

I wouldn't blame the radiologist reading this. Like I said, unless you are looking for it it is very difficult to appreciate.

If you are wondering; we do the plain films first basically to rule out obvious pathology and because it's quick, cheap and easy and............. I don't need to get involved time-wise.

Steve

 

,

Fair comment, thanks Steve.

cheers

Martin

The St. James Foot Clinic
1749 Portage Ave.
Winnipeg
Manitoba
R3J 0E6
phone [204] 837 FOOT (3668)
fax [204] 774 9918
www.winnipegfootclinic.com

 

Hi Martin:
I have some pictures I think you'll like.
I was doing a 2nd met osteotomy and the patient's metahead had a small OCD with what appeared as a small piece of cartilage/bone slightly loose on the dorsal surface. I thought of your US image that was on your initial post here, I THINK this might have looked the same on US.
Let me know what you think (the pics may not be great since the nurse took them with my iPhone!)

 

Thanks Steve; that is how I would imagine the US image I posted might look in real life.

How is your US use currently?

Correlation of intrasurgical photos with preop US images could be so useful.

With enough variation in cases I think it could make great publishable Atlas.

Cheers

Martin

The St. James Foot Clinic
1749 Portage Ave.
Winnipeg
Manitoba
R3J 0E6
phone [204] 837 FOOT (3668)
fax [204] 774 9918
www.winnipegfootclinic.com

 

"With enough variation in cases I think it could make great publishable Atlas."

Send me an UltraSound you want an anatomical representation of and I'll pull out my #10 blade and my Sony Camera and click away!!!!
Sounds like fun.
I'm doing OK with it. My learning curve has flattened out a bit.

Glad you liked the pics. It was pretty strange when I opened the joint and saw that and immediately thought of you. My iPhone was in my back pocket so I had to have the circulating nurse go and get it.
It was the highlight of my day!!!!!!!!!

Steve

 

Hi MArt:
Thought you'd like to see this.
Saw this 54 Y/O M Pt. yesterday.
I Dx Freiberg's / OCD.

Steve

 

Thanks Steve that is a nice clear example.
For anyone interested I saw the patient who was subject of intial post yesterday four weeks after using foot orthoses he is pain free but not returned to sports. Will introduce running gradually and see if see if this is tolerated.
Cheers
Martin

 

Hello Martin

Will you be looking at doing a follow-up x-ray for the patient?
Also do you not perhaps think that there may have been resolution through physiological resorption. The orthoses may have helped but I think it could also be attributed by in large to resting of the injury by the patient.

 

Hi Drummond

Currently patient is pain free with normal day to day activities with foot orthoses protection which was not the case prior to foot orthoses use and is encouraging. It is uncertain if he will be able to return to running and remain pain free which is his goal. If running is poorly tolerated and he wishes to consider surgical option then I will request a radiographic exam. Evidence suggests that foot orthoses are signifcant factor rather than rest and that the efficacy of the foot orthoses is most likely explained as reducing the local soft tissue trauma and I am not expecting to significantly modify the bone lesion. The foot orthoses design involved "pressure mapping" with compliant overlay, then subsequently offloading metatarsal head. Prior to modification to foot orthoses contour there was little reduction in pain, following this the pain resolved quickly. If he is able to function at desired capacity he may prefer to avoid the uncertainty of surgical outcome in which case the ongoing presence of the bone lesion may be mute.

Regards

Martin


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