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Fractured base of 5th or Os vesalianum pedis

Discussion in 'Biomechanics, Sports and Foot orthoses' started by ADuff, Oct 14, 2009.

  1. ADuff

    ADuff Member

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    I have a patient who recently presented with a painful and swollen base of 5th met head to the physio that was not present on previous consultations. He is a field hockey player but cannot remember any specific mechanism of injury. On examination a boney fragment could be felt. My physio colleagues thought this was a subluxed base of 5th met and tried to reduce it and strap into place. This did improve the pain but once the strapping was removed the displacement reoccurred.

    I requested an x-ray which showed what I thought to be a clear fracture of the base of the 5th metatarsal. However, the patient has now had a consult with an orthopedic doctor who states he believes it to be an Os vesalianum pedis (v.p.). I know the prevalence is 0.1 - 1% and that an os v.p. is found within the peroneus brevis tendon but I am still skeptical. Apart from putting the patient through an MRI does anyone have any suggestions to help get a definitive diagnosis and appropriate treatment plan?

    Thanks for reading.

    Alexandra Duff
  2. I would suggest the MRI is the best way to go. Get an exact cause of the pain and construct a treatment plan. By spending time guessing the patient will suffer more and an MRI are not that much of a big deal to be "putting the patient through"
  3. Sammo

    Sammo Active Member

    Hi Alexandra, Welcome to the Forum!

    I agree with Michael that an MRI would really help with Dx but without a little more detailed biomechanical information on the patient it will be difficult to construct an effective treatment plan even with an MRI.

    Does he have a laterally deviated STJ axis? Limited calcaneal eversion? Genu varum? What is his forefoot position like? What is his footwear like; appropriate for sport, new or old, wear patterns etc? Was it an insidious onset, or did he wake up one morning with the pain? When does he get pain.. first step/Worse with exercise? How can you be sure that the thing you are palpating is bone and not soft (hard..) tissue.. Are the peroneal muscles painful on palpation?

    Did he have the same ossicle on the other foot??

    How old is he, how much sport does he do, what does his gait look like....

    As for DDx: Per Brevis avulsion #/enthosopathy, Os V.P., dorsal compression of the Met cuboid joint.

    Tx options (depending on pathology): Aircast, ankle brace, high Dye taping, surgical repair (if #), lateral foot wedging (if laterally deviated STJ axis).

    His Biomechanics will dictate whether he is predisposed towards this injury and therefore needs some ongoing in shoe device or foot taping whenever he plays sports.

    Hope this is of some help..

    I'm sure people will be along shortly to add more suggestions!

  4. MR NAKE

    MR NAKE Active Member

    Fractures of the 5th tuberosity(stylloid process) are avulsions, possibly not all of them. Traditionally these were thought to be pulled off by peroneus brevis but biomechanical studies by Richli and Rosenthal (1984) and Theodorou et al (2003) suggest that the lateral band of the plantar fascia is more likely to be responsible, so i can imagine the O/Surg arguing differently though, so from someone who might not have the privilledges of a CT scan or MRI, i would say the x-ray can suffice and i will cast the pt and see if it unifies, then it would be a fracture to begin with and if not then an accessory bone, there is a possibility of a non union,which could be a point still ha ha ha:D.

    1)Theodorou DJ et al. Fractures of proximal portion of fifth metatarsal bone. Radiology 2003; 226:857-65

    2)Richli WR, Rosenthal DI. Avulsion fracture of the fifth metatarsal: experimental study of pathomechanics. AJR 1984; 143:889-91
  5. robert bijak

    robert bijak Banned

    bone scan
  6. jpurdydpm

    jpurdydpm Active Member

    Granted I can't see an X-ray and don't have the patient in front of me. It is characteristic of a fracture or does it have rounded edges with cortical bone at the interface?

    Is it not the short plantar ligament that pulls the base of the fifth? I believe it is.

    What would you need an MRI and / or bone scan for? Who cares if it is either?

    If it is a true avulsion Fx or a disrupted Os, then a soft cast has been shown to be just as effective as a hard cast in resolving this issue. If conservative measures do not resolve the problem then it becomes a surgical case. I still wouldn't do any further studies past an x-ray. You'll be right there so have a look.
  7. Alexandra:

    Sounds like a difficult case. Start the patient on icing therapy, 20 minutes twice a day and put him into a cam-walker style boot if has a lot of pain with walking. This may be simply nothing more than a peroneus brevis insertional tendinitis with an pre-existing os vesalianum, is the most likely case considering his sports activities and lack of history of specific traumatic injury. An MRI scan would be the diagnostic procedure of choice if money is not an object. A bone scan would be a cheaper alternative, but less specific.

    I have treated many similar problems such as this (if it is not a fracture) by using icing therapy and a valgus wedged orthosis/in-shoe insert extending from the heel to the sulcus to decrease the demand on the peroneus brevis muscle/tendon. Cortisone injections into the styloid process area can also be used judiciously if you have ruled out fracture. The lateral component of the plantar aponeurosis inserts onto the styloid process, from plantar, but is only present in about 75% of the population.

    Hope this helps.
  8. robert bijak

    robert bijak Banned

    re: tx. posts by my fellow dpm's: OMG
  9. jpurdydpm

    jpurdydpm Active Member

    Care to elaborate?
  10. ja99

    ja99 Active Member

    Last edited: Oct 24, 2009
  11. ADuff

    ADuff Member

    Dear all,
    Thanks for the responses and sorry it has taken me so long to get back to you all but life as all ways has gotten in the way; anyhow to expand to this gentleman...........

    38 year old man who plays field hockey and runs, approx 10km x 3 week presents in April 09 with LF plantar fasciitis and subluxed cuboid that had been present for 9/12. Seen by an Orthopod who ordered an MRI which indicated tendonitis and the pt was given a steroid injection. There was no evidence of os vesalianum pedis on the MRI. Pt had 1/52 relief post steroid injection but then pain returned.

    O/E inverted heel strike and minimal STJt pronation during gait, with extensor overuse noted. Limited ROM at ankle with tight gastrocs. Reduced ROM at midtarsal jt and hallux limitus. Laterally deviated STJt. Dx: cavoid foot type with secondary plantar fasciitis.

    Prescribed orthotics with additional heel pad and fascial groove for sport along with stretching programme and ultra sound from physios. Also a slimmer version for his dress shoes. No issues when fitted in office May 09.

    August 09 pt presents with pain lateral RF when wearing dress orthotics. RF base 5th met v pronounced and mobile on glide. No swelling or redness present. Deformity could be reduced which reduced the pain but this returned when the tapping removed. No history of any impact that the patient could remember (he did think it could have been a beer injury!). D/Dx subluxed or fractured base of 5th. Sent pt for x-ray and sent dress orthotics to lab for modifications.

    28/9 pt returned. X-ray showed what I believe to be a base 5th met fracture taking into account that the MRI did not show anything ‘abnormal’ in that area back in April. Oct 09 pt decided to see orthopod again who thought it was an Os Vesalianum Pedis and advised the patient not to wear the orthotics as he was told they were putting pressure on the area and contributing to the problem. Pt reported that the pain improved but did not resolve on removing the orthotics. Pt was advised to come back to Podiatry so that the dress orthotics could be modified further to accommodate the deformity.

    The patient is currently lost to follow up!

    Any thoughts????


  12. robert bijak

    robert bijak Banned

    Would expect a real fracture to be echymotic and swollen. Some radiologist will see an os vesalianum and say nothing abnormal because it's a normal variant not pathological. Did you look at the MRI yourself? Why do you think it's a fracture with no swelling of echymosis. The MD was probably correct. You need to check the MRI yourself or realy talk to the radiologist. robert bijak,dpm
  13. Sammo

    Sammo Active Member

    Possibly: due to the amount of exercise and the laterally deviated STJ the peroneus brevis is constantly pulling on the base of the 5th met which is causing the ongoing injury (whether that be a #, avulsion #, enthesopathy, or whatever). I've used small lateral heel wedges on the orthoses and high dye strapping for sport on cases similar to this to fairly good effect. (note: if it is a # he may of course need more aggressive Tx)

    30k's per week is a reasonable amount. I think it'd definitely be worth looking at his running trainers (as well as other footwear). As his foot is high arched one of two things could be happening with the footwear. If the shoes are old he could have worn down the lateral corner of the shoe leaving what is effectively a varus wedge shaped heel; or if he has a pair of running trainers with a particularly squishy (and yes that is a scientific term!) lateral heel "crash pad" or whatever the marketing people call it, this could have a similar effect. Both of these shoes could leave the foot more laterally unstable than it already is, increasing peroneal activity to counter the increased inversion forces, thus pulling more on the peroneus brevis insertion to the 5th etc etc...

    My tuppence worth (approx value: ha'penny)

  14. Hi Alex.
    Before anyone can really give you any advice you need to explain what Prescribed orthotics means in this case. What type of device what are you doing to the foot with the device. There are lots of different orthotics. If you tell us what device you are using it willbe easier to say whether this could be leading to the problem or not.

    What device are you using? ie blake medial skive lateral skive etc
    what material is it made from ? and any other info about the device then people can give you much more detailed edvice.
  15. ADuff

    ADuff Member

    In response to your questions:

    I did see the MRI and could detect nothing + ask our friendly radiologist and he agreed with me.

    Orthotic prescribed was a root device with additional heel pad and plantar fascia groove.

  16. Ok Alex so no signs of a fracture but it the patient complains of pain.

    The pain is in the area of the base of the 5th and you have prescribed a Root device previously. The patient complains of pain when wearing the slimmer dress orthotics.

    He has a lateral deviated STJ axis, which is when wearing his orthotics the STJ axis will deviate more laterally which places more load on The peroneus Brevis muscle. Then he complains that pain occurs in the dress Device which is narrower to fit his shoes. You write :

    By supinating the foot with a root device you have increased to load on the pronation muscles ( PL,PB and PT ), the patient has a laterally deviated stj axis to begin with ie the PL, PB and PT muscle work harder to pronate the foot. The dress device will be less lateral stabile because of the removed material to fit in his dress shoes. Which will load up the PB muscle which over time will lead to overuse.

    Hope that makes sense so far.

    So I recommend you to get the patient to ice the area, Wear his sport orthotics (more laterally stabile due to increased width)all the time until the pain goes away.
    I would also recommend that you make him a new device with increased lateral stibility to reduce the Load on the PB muscle. The best way to do this is with a lateral skive device but with his history of Plantar fascia problems it might be better to use a more neutral rearfoot device with an increase in lateral column support or extend a cuboid notch to under the base of the 5th. Don´t get this made slimmer for his dress shoes recommend he buy new shoes.

    Hope that helps.
  17. Rob Christman

    Rob Christman Welcome New Poster

    Alex: For educational purposes, would you be able to post the radiographs and MR images? Thanks.
    Last edited: Dec 29, 2009
  18. ADuff

    ADuff Member

    Dear All,

    Sorry for the delay in responding,

    Michael, I have checked my notes and actualy I did a neutral shell. So I give up!

    Rob, I will ask the patient and if he says yes I'll post them up here.


  19. Don´t give up try putting him in a lateral skive to reduce the pressure on the Peroneus Brevis. To try this take some 7 mm felt and stick a lateral rf wedge on top of the lateral heel, you may want to bring in forward to slightly distal to the styloid process, get the patient to ice everyday and wear better structed shoe review 2-3 weeks later. If you have good success re cast and prescribe a lateral Skrive and Bob your uncle we hope.

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