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Updated: Jun 27 2023

Bunionette Deformity

Images - Richardson_moved.png photo - Richardson_moved.png
  • summary
    • Bunionette Deformities, commonly called tailor's bunion, are prominences on the lateral aspect of the 5th metatarsal head that most commonly occur as a result of compression of the forefoot.
    • Diagnosis is made clinically with presence of a prominence on the lateral aspect of the 5th metatarsal head, often associated with pain and callus formation.
    • Treatment can be nonoperative with shoe modifications for mild and minimally symptomatic cases. Surgical management is indicated for progressive deformity and difficulty with shoe wear
  • Epidemiology
    • Demographics
      • commonly seen in adolescents and adults
      • 2-4x more common in women
      • often bilateral deformities
  • Etiology
    • Pathophysiology
      • mechanism of disease
        • extrinsic causes
          • compression of forefoot (e.g. tight shoes)
          • abnormal loading on the lateral aspect of the foot
        • intrinsic causes
          • congenital deformities (e.g. splayfoot, brachymetatarsia)
          • inflammatory arthropathies
          • residual malalignments from surgery
      • pathoanatomy
        • boney prominence +/- bursitis over lateral aspect of 5th metatarsal head
        • increased 4-5 intermetatarsal angle (normal 6.5-8 degrees)
        • increased lateral deviation angle (normal 0-7 degrees)
        • increased width of MT head (normal <13mm)
        • lateral bowing of the 5th metatarsal bone
    • Associated conditions
      • varus MTP joint
      • pes planus
  • Classification
      • Bunionette Deformity Classification
      • Type I
      • Enlarged 5th MT head or lateral exostosis
      • Type II
      • Congenital bow of 5th MT, normal 4-5 IMA
      • Type III
      • Increased 4-5 IMA (most common)
  • Presentation
    • History
      • effect on activities and employment
    • Symptoms
      • cosmetic deformity
        • medial deviation of 5th toe
        • prominence of the 5th metatarsal head
      • pain
        • lateral bunion
        • plantar callus
        • worse with constrictive shoe wear
    • Physical exam
      • inspection
        • plantar or lateral hyperkeratosis
        • widened forefoot
        • erythema and swollen 5th bunion
        • check shoe wear
      • motion
        • often painless passive ROM of 5th MTP joint
  • Imaging
    • Radiographs
      • recommended views
        • standard weight-bearing films, dorsoplantar, lateral & oblique films
      • characteristic findings
        • increased 4-5 IMA (normal 6.5-8 degrees)
        • increased lateral deviation angle (normal 0-7 degrees)
        • increased width of MT head (normal <13mm)
    • CT scan
      • indications
        • ancillary studies rarely required
        • may be used if there is associated trauma or malignancy
  • Treatment
    • Nonoperative
      • NSAIDS, shoe wear modification, orthotics, keratosis padding, callous shaving
        • indications
          • indicated as first-line treatment of all types
          • asymptomatic deformities
        • techniques
          • semi-rigid shoe inserts
          • wide based shoes
          • stretching the forefoot of existing shoes
        • outcomes
          • 75-90% success rate
    • Operative
      • lateral condylectomy
        • indications
          • symptomatic Type I deformities
        • technique
          • resection of lateral third of the 5th MT head
          • combine with tightening of lateral MTP joint capsule
        • outcome
          • does not require extended period of immobilization
      • distal metatarsal osteotomy
        • indications
          • Type 2 and 3 deformities if IMA is < 12 degrees
        • technique
          • different techniques described
            • chevron-medializing osteotomy (most common)
            • distal transverse osteotomy
            • peg-and-slot type osteotomy
            • stepcut osteotomy
          • better stability of fragments with internal fixation (e.g. K-wire or screw)
          • may be combined with distal condylectomy and tightening of lateral capsule
        • outcomes
          • chevron osteotomy is biomechanically the strongest construct compared to the other proximal osteotomies
      • oblique diaphyseal rotational osteotomy
        • indications
          • symptomatic Type 2 and 3 if IMA is > 12 degrees
        • technique
          • shave plantar aspect 5th MT head if plantar callosity present
          • proximal osteotomy should be avoided due to poor blood supply in this region of the metatarsal
          • fixation achieved with screw
        • outcomes
          • may produce 5th MT shortening
      • metatarsal head resection
        • indications
          • salvage procedure only
          • leads to unacceptable instability of MTP joint
  • Complications
    • Recurrence
      • is the most common complication with condylectomy alone
    • Transfer metatarsalgia
      • seen with isolated metatarsal head resection
    • Claw toe
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