Saturday, April 21, 2012

A Pain in the the Foot

What's the Diagnosis?
History:  A 9 year-old female presents with left foot pain and mild swelling.  This has been going on for a week or so and there's no history of trauma.  The patient is otherwise healthy and her past medical history is significant for urinary tract infections complicated by pyelonephritis secondary to vesicoureteral reflux, although this has not been a recent issue.  Physical exam reveals a well appearing, normal weight young girl whose foot demonstrates mild edema without ecchymosis and tenderness along the proximal fifth metatarsal.  The patient can bear weight but qualifies for x-ray by the Ottawa ankle rules due to tenderness along the base of the fifth metatarsal, even though some question the utilization of this rule in the under 18 year old population.

Diagnosis:



Apophysitis (Iselin's Disease)  
    • Common in young girls (9-11 years old) and boys (11-14 years old)
      • No history of acute or traumatic insult
    • Ossification of the peroneus brevis tendon parallel to the diaphysis, typically parallel to the 5th metatarsal diaphysis
    • Pain that is worsened by activity, improves with rest
    • Ecchymosis and edema may be present
    • Self-limiting, improves with temporary limitations of activity
Differential Diagnosis:
  • Avulsion Fracture of the 5th Metatarsal Tuberosity
    • Cause: Acute injury - forced inversion of the ankle with the foot and ankle in plantar flexion
    • Typically these fractures are perpendicular to the long axis of the metatarsal
  • Jones Fracture 
    • Fracture of proximal metatarsal within 1.5 cm of the tuberosity
    • Cause:  Acute injury - lateral force on the forefoot with the ankle in plantar flexion
  • Stress Fracture
    • More chronic in nature due to repetitive microtrauma
  • Accessory ossicle (os vesalianum or os peroneum) - may be confused with avulsion fracture
    • Smooth edges on x-ray when juxtaposed with avulsion fractures
Treatment for Fractures:
  • Generally conservative and symptomatic:  analgesia and solid footwear
  • Activity and weight bearing as tolerated with limitation of rigorous athletic play.  Physical therapy as needed
    • Return to play as tolerated
  • Casting may be used for pain control 
  • Follow-up x-ray at 8 weeks
  • Surgical referral for displaced or comminuted fractures, or fractures involving 30% of the articular surface
    • Diaphyseal fractures (Jones Fracture) is more likely to fail conservative management and may need surgical intervention

References:
Strayer S, Reece S, Petrizzi M.  Fractures of the Proximal Fifth Metatarsal.  Am Fam Physician  1999 May 1;59(9):2516-22.

1 comment:

  1. it is likely to crack. This normally occurs in healthy and fit individuals who subject their body to excess physical activities. This kind of fracture is normally experienced by sportspersons and military recruits who engage in physical activities for long periods of time. They develop a stress fracture that leads to foot pain. The second situation is where people have extremely weak bones. This commonly affects women with osteoporosis.

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