FASXXX10.1177/1938640017744642Foot & SpecialistFoot & Ankle Specialist case-report7446422017

vol. 11 / no. 2 & Ankle Specialist 177 〈 Case Report 〉 of the Fifth Metatarsal in Foot Deformity

Secondary to Neuromuscular Jesús Payo-Ollero, MD, Fernando Álvarez Goenaga, MD, Disease Gotzon Elorriaga, Sagarduy, MD, Alberto Ruiz Nasarre, MD, Matías Alfonso Olmos-García, MD, PhD, Experiences of Deformity and Carlos Villas Tomé, MD, PhD Correction Treatment—A Report of 3 Cases and Review of the Literature

Abstract: Fractures at the proximal to correct the foot deformity with no the fracture with no correction of the metaphyso-diaphyseal junction of direct action on the fracture. Once deformity leads to therapeutic failure. the fifth metatarsal are associated a good alignment (plantigrade foot) Levels of Evidence: Therapeutic, with high rates of delayed union. was obtained, stress causing the Level IV When these fractures are the result fracture disappeared, and union of repeated stress in patients with was achieved with equinovarus hindfoot, which in turn optimal biomechanical is caused by neurological disorders, function in all 3 Optimal treatment should address delayed union is the rule. Therefore, fractures. When stress in neurological patients with stress fracture of the fifth correction of the deformity leading to the fractures, optimal treatment would metatarsal is caused be to achieve a plantigrade foot by a secondary foot “stress fracture rather than the fracture enabling them to relieve the fifth deformity, treating metatarsal overload, which prevents the deformity can itself.” the consolidation. We report 3 cases of lead to healing the fifth metatarsal stress fracture resulting fracture efficiently from an equinovarus hindfoot and should be considered prior to Keywords: metatarsal stress fracture; deformity caused by a neuromuscular indicating surgical stabilization of the neurological foot disorders; paralytic disease. Our surgical indication was fracture itself. Primary treatment of foot; equinovarus hindfoot

DOI: 10.1177/1938640017744642. From University Clinic of Navarra, Orthopedic Surgery and Traumatology Department, Pamplona, Navarra, Spain (JP-O, MAO-G, CVT); San Rafael Hospital, Orthopedic Surgery and Traumatology Department, Barcelona, Catalunya, Spain (FAG, ARN); and University Cruces Hospital, Orthopedic Surgery and Traumatology Department, Baracaldo, Vizcaya, Spain (GES). Address correspondence to: Fernando Álvarez Goenaga, MD, San Rafael Hospital, Orthopedic Surgery and Traumatology Department, Passeig de la Vall d’Hebron, 107, Barcelona, Catalunya 08035, Spain; e-mail: [email protected]. For reprints and permissions queries, please visit SAGE’s Web site at http://www.sagepub.com/journalsPermissions.nav. Copyright © 2017 The Author(s) 178 Foot & Ankle Specialist April 2018

Introduction Figure 1. Fifth metatarsal fractures are the most common metatarsal fractures.1,2 Three Case 1: X-rays showing a stress fracture (A) that was consolidated secondary to main types of fractures may affect the the intervention 40 days postoperatively (B). After a 4-year follow-up, the stress proximal zone of the fifth metatarsal fracture remains consolidated (C). : (1) tuberosity , (2) Jones’s fracture, and (3) stress fracture. Jones’s fracture was described in 19023 as a transverse fracture at the junction of the diaphysis and the proximal metaphysis, with no extension distally beyond the fourth to fifth intermetatarsal . A stress fracture is defined as bone fatigue secondary to a repetitive load of the proximal fifth metatarsal. Both types of fractures, because of the anatomical proximity, have high rates of delayed union, nonunion,4 or refractures possibly favored by low blood supply in the proximal region.5-7 Chuckpaiwong et al8 did not consider it of interest to differentiate Jones’s fracture from the proximal metaphyso-diaphyseal the biomechanics of the foot and the X-ray studies revealed an overall stress fracture because differences, patient’s gait. alteration of the anatomical structure of sometimes subtle, may not be important the foot (corresponding well with the from a prognostic point of view. Surgical Case Reports equine and varus deformity) and a treatment usually consists of anterograde nonconsolidated transverse fracture at 9-12 intramedullary screw fixation. This Case 1 the metaphyseal-diaphyseal junction of approach reduces the rate of nonunion A 47-year-old woman was diagnosed the fifth metatarsal (Figure 1A). 13 and shortens union time. In the with a proximal metaphyseal-diaphyseal The diagnosis was pseudoarthrosis of a literature, there are currently no junction fracture of the fifth metatarsal in stress fracture secondary to a dystonic references to foot morphology, and the 2013. At consultation, she had an equine spastic equine and varus hindfoot type of fracture that is presented in this and varus spastic right foot, secondary to deformity. The patient was referred to article is very rare. Refracture has been a previous stroke (2 years previously), our center for surgical treatment of the brought on by an inadequate synthesis resulting in dystonic spastic hemiparesis. fracture, but we indicated double 14 material selection, high body mass The patient complained of pain along arthrodesis (talonavicular and subtalar index, plantar protrusion of the the lateral edge of the foot, at the joints) with a tibialis posterior transfer to metatarsal head, varus hindfoot proximal zone of the fifth metatarsal. A the dorsal aspect of the foot and an deformity,15 or premature return to sports diagnosis of fifth metatarsal stress Achilles lengthening. After the activities.16 fracture was made. Conservative operation, she continued to unload the The aim of this study is to focus on the treatment with a plaster cast for 3 extremity for 6 weeks with a subsequent therapeutic approach to foot morphology months did not procure consolidation, plaster cast. in patients with a fifth metatarsal stress and she continued to experience pain. The plaster cast was removed once a fracture and an equinovarus hindfoot Physical examination showed an bony union of the fracture was observed deformity secondary to neurological equine and varus hindfoot deformity, (Figure 1B). Weight-bearing was then disorders. In these cases, the treatment of with hyperkeratosis along the fifth allowed with a Cam Walker orthosis for a the fracture with no correction of the metatarsal lateral border and under the further 6 weeks. Three months following deformity leads to therapeutic failure, metatarsal head (second rocker zone). the operation, the evaluation of the and delayed union or nonunion of the Furthermore, there was hypertonia of the double arthrodesis was favorable, and fracture are the rule. Optimal treatment sural triceps underlying the equine normal gait was allowed. Finally, a should address correction of the deformity hypertonia of the tibialis plantigrade foot without hyperpressure deformity leading to the stress fracture posterior muscle with a relative muscular zones was obtained. After a 4-year rather than the fracture itself. Moreover, deficit of the tibialis anterior and follow-up (Figure 1C), the patient correcting the deformity would improve peroneus muscles. remains without pain at the fifth vol. 11 / no. 2 Foot & Ankle Specialist 179 metatarsal region and only reports observed consolidation of the sporadic discomfort in the foot when Figure 2. osteotomies and persistence of the hypertonia crises push her against Case 2. Lateral X-rays showing a fracture line in the fifth metatarsal. On the shoe. At the present moment, the stress fracture (A) and union of the physical examination, a plantigrade foot foot is still plantigrade with no fracture with new foot alignment was observed with a varus axis hyperpressure zones. 3 months after surgery (B). After a correction. No further treatment was 2-year follow-up, the stress fracture called for, and normal walking was Case 2 remains consolidated (C). allowed because the patient was asymptomatic. Then, 6 months after A 38-year-old man consulted for pain surgery, a new radiological control was and functional difficulties in the left foot performed, and complete healing of the throughout a period of 7 months. The fracture was observed (Figure 4B). patient had undergone multiple foot To improve dorsiflexion of the ankle, in operations owing to a deformity a subsequent step, both a transfer of the secondary to Charcot-Marie-Tooth posterior tibialis tendon to the dorsal disease. aspect of the foot as well as a flexors Physical examination revealed a tendon tenotomy were performed. Later, cavus-varus hindfoot deformity with the same treatment was conducted on selective pain on the lateral edge of the the right foot, which had never shown a foot—at the fifth metatarsal zone—where stress fracture. After a 2-year follow-up hyperkeratosis was noted. X-ray studies (2 years for the left foot and 1 year for revealed a cavus-varus foot and a the right foot), the balance had proximal transverse fracture of the fifth improved in both feet (Figure 5), and the metatarsal at the metaphyso-diaphysis resolution of the stress fracture on the proximal junction (Figure 2A). Diagnosis left foot persisted with the disappearance was fifth metatarsal stress fracture on the of the fracture line (Figure 4C). left foot secondary to cavus-varus deformity. Conservative treatment was applied, revealed a sensorimotor axonal Discussion with a plaster cast for 6 weeks and a polyneuropathy with motor involvement The present study shows 3 cases of Cam Walker orthosis for a further 6 in both feet and gastrocnemius muscles. stress fracture secondary to equinovarus weeks. The fracture did not heal. Surgical There was a previous family history of hindfoot deformities in neuromuscular treatment was then indicated and neurological diseases, but genetic studies disease, in which the fracture was consisted of correcting the mechanical did not show any abnormalities leading successfully treated by correcting the defect produced by the deformity. to a diagnosis of a specific condition. deformity instead of acting directly on Arthrodesis of the subtalar joints (with Physical examination showed an the fracture. The principle behind the screws) and the -cuboid joint equine deformity with a positive therapeutic decision was to treat the (with clamps) was then carried out; Coleman test in the left foot. Pes deformity in order to correct the stress posterior tibialis tendon transfer to the varus-cavus and equinovarus hindfoot that caused the fracture. Although 3 dorsolateral part of the third cuneiform generated high pressure around the fifth cases of any specific topic may currently was associated with fibular metatarsal and hyperkeratosis under its be considered to be a low-interest report tenodesis and elevation osteotomy on head in the left foot (Figure 3). In for expert readers and, furthermore, the the . Healing of the addition, there was hypertonia of the present topic seems to be traditionally stress fracture was procured 3 months sural triceps, leading to an equine (colloquially) well known by later (Figure 2B), leading to the patient deformity. X-ray studies revealed an experienced surgeons, the fact remains being pain free. Two years later, the unconsolidated transverse fracture in the that—in the past decades—the literature patient had a plantigrade foot and metaphyseal-diaphyseal junction at the has offered a total lack of information, remained asymptomatic (Figure 2C). base of the fifth metatarsal (Figure 4A). which may be useful for young foot Surgical treatment was carried out in 2 surgeons when having to face similar Case 3 steps. The first consisted of a Dwyer problems and decide on the best A 33-year-old man consulted with a osteotomy and calcaneal lateralization therapeutic option. proximal pseudoarthrosis of the fifth associated with elevation osteotomy on Stress fracture of the fifth metatarsal metatarsal on the left foot after failed the first metatarsal bone, Achilles tendon may result from a plantar overload in the conservative treatment with a plaster lengthening, and plantar fasciotomy. In a case of a progressive metatarsus cast. The electromyographic study postoperative control at 3 months, we adductus and equinovarus foot 180 Foot & Ankle Specialist April 2018

concluded that a plantar load increase on Figure 3. the lateral midfoot following progression Case 3: Posterior view of the ankle showing a cavus-varus hindfoot (A). The plantar of an equine and varus deformity could views show high pressure around the fifth metatarsal and hyperkeratosis under its be causally related to stress fracture of head (B). the . Treatment of an equinovarus foot deformity secondary to neurological disease should be individualized. Obtaining a plantigrade and biomechanically functioning foot would be necessary to achieve good muscular balance of the foot. Among the various technical options available, tenodesis, correction osteotomies, arthrodesis, and tendon transfer can be used alone or in combination. In all our cases, a posterior tibialis tendon transfer to the dorsolateral part of the midfoot was associated with arthrodesis and/or corrective osteotomies, allowing a diminishing of overload at any given point. Any of these procedures alone may not be efficient enough to help recover normal-like mechanics. A posterior tibialis tendon transfer would be the key to achieving the best plausible result because it Figure 4. manages the dynamic factor of inversion Case 3: Oblique X-ray showing pseudoarthrosis secondary to stress fracture (A). and plantar flexion that exists in these At 6 months after surgery, oblique X-ray showing a complete healing of the stress deformities, simultaneously enabling fracture (B). After a 2-year follow-up, the stress fracture remains consolidated (C). some dorsiflexion of the foot.18 Our patients had stress fractures secondary to equinovarus hindfoot deformity. A surgical correction of the deformity—as we did—should be prioritized over consolidation of the fracture owing to the fact that treating the cause—the deformity—and not the consequence—the fracture—may result in successful fracture healing and a better functioning of the foot. If we attempt to treat the fracture alone without attending to the deformity, refracture or pseudoarthrosis will occur. When we treat the deformity and obtain a plantigrade foot, the high pressure applied on the fifth metatarsal vanishes. Subsequently, the stress that causes the fracture and inhibits the union also disappears. Some surgeons may consider corrective surgery too aggressive to treat a fracture. Nevertheless, the relationship among a deformity. Gutekunst and Sinacore17 malalignment, and biomechanical loads foot cavovarus deformity, a stress detected changes in volumetric bone preceding fracture in 2 patients with fracture, a fracture recurrence, or mineral density, bone geometry, joint Charcot neuroarthropathy. They pseudoarthrosis has long been vol. 11 / no. 2 Foot & Ankle Specialist 181

fracture without the need for Figure 5. subsequent surgery on the fracture Case 3: Physical examination showing a plantigrade alignment on both feet after a itself. Conversely, primary treatment of 2-year follow-up for the left foot and 1 year for the right foot. the fracture without accompanying correction of the deformity will lead—as a rule—to therapeutic failure in neurological patients. Future studies are needed to establish the optimal treatment of stress fracture in the fifth metatarsal secondary to neuromuscular disease.

Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. established in the literature.15,19,20 In our refractured over the same site without opinion, stress fracture in the fifth any trauma. They, then, decided to Funding metatarsal secondary to equinovarus correct her foot deformity, and the deformity should be first treated fracture site showed a bony union 5 The author(s) received no financial conservatively with plaster allowing months later. support for the research, authorship, weight bearing, as in our cases. As a Except for the McDade et al22 case and/or publication of this article. result, if there is a refracture or report of a spastic-dystonic foot of pseudoarthrosis, it can be assumed that a different etiology and despite the fact Ethical Approval mechanical factor is preventing that experienced surgeons have classical Not applicable, because this article does consolidation, and therefore, changing concepts leading to a solution in these not contain any studies with human or the foot morphology to obtain a kinds of fractures, we have been able to animal subjects. plantigrade foot should be indicated. find 1 similar case in the reviewed Craigen and Clarke21 described the case literature. McDade et al22 did not succeed of a 3.5-year-old boy who had a bilateral in healing the fracture and did not Informed Consent “Jones” fracture secondary to congenital consider treating the consolidation failure Not applicable, because this article does varus hindfoot. He was treated or improving the biomechanical function not contain any studies with human or conservatively for 3 weeks, and union of of the neurological foot. animal subjects. the fracture was achieved. Two days later This study is limited by the nature of this same patient suffered a refracture in the case reports, which provide the the right foot, which was treated experience of particular cases. However, Trial Registration conservatively yet again. Then, 17 it may well be a useful tool for readers if Not applicable, because this article does months later, he presented with a they come across a similar pattern, not contain any clinical trials. refracture in the left foot, and fracture especially taking into account that the union was established by means of recent literature does not offer reliable conservative treatment. McDade et al22 information regarding a therapeutic References reported 1 metatarsal fracture in a orientation. 1. Petrisor BA, Ekrol I, Court-Brown C. The 45-year-old man affected by Parkinson’s The clinical relevance of our report is epidemiology of metatarsal fractures. Foot disease with related levodopa dystonia. to propose a reflection on the very Ankle Int. 2006;27:172-174. Conservative treatment failed. The likely possibility of therapeutic failure 2. Kane JM, Sandrowski K, Saffel H, authors provided no data on the ultimate when treating stress fractures occurring Albanese A, Raikin SM, Pedowitz DI. The epidemiology of fifth metatarsal fracture. clinical outcome of the patient. Chee and in patients with neurological hindfoot Foot Ankle Spec. 2015;8:354-359. 20 Walsh described a girl with an deformities. We suggest that if the 3. Jones R. Fracture of the base of the fifth equinovarus deformity secondary to fracture is caused by a secondary metatarsal bone by indirect violence. Ann cerebral palsy. Jones’s fracture was deformity, treatment of the deformity Surg. 1902;35:697-700.2. diagnosed. Initially, she was treated should be considered first because it 4. Zelko RR, Torg JS, Rachun A. Proximal conservatively. Two months later, she may result in consolidation of the diaphyseal fractures of the fifth 182 Foot & Ankle Specialist April 2018

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