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CASE REPORT

Bilateral Idiopathic Avascular Necrosis of the Hallux Metatarsals in a Child

 Gella S*, Tulwa N**

* Clinical research fellow
** Consultant Orthopaedic Surgeon
Department  of  Orthopaedics,
Pinderfields General Hospital, Wakefield, UK

Address for Correspondence:  

Sreenadh Gella  (MRCS)
6 Riverdale crescent
Wakefield
,WF3 4JZ
United Kingdom
Tel: 01924 360735
Fax: 01709544832
Email: mrgella@hotmail.co.uk

Abstract:

We report a very rare case of bilateral idiopathic avascular necrosis (AVN) of the hallux metatarsal heads in a child. This condition is not described in any previous literature and as such presented an interesting challenge for management.  She was successfully treated conservatively and at two years of follow-up, the patient reported that her symptoms had resolved.

J.Orthopaedics 2008;5(2)e6

 Keywords:
Avascular necrosis, metatarsal head, children


Case Report:

A 13-year-old girl was referred by her general practitioner with a two-month history of pain in both big toes. This pain caused her a great deal of discomfort, was aggravated by walking and prevented her from undertaking any sporting activities. She was otherwise fit and well with no significant past medical history and no report of any similar problems in her family.           

Examination revealed hallux rigidus affecting both big toes, worse on the left. Dorsiflexion is about 15 degrees on the left and 20 degrees on the right with discomfort at the extreme range of passive movements. All other joints of the feet were normal on examination.

Radiographs of the feet showed findings consistent with avascular necrosis, namely, flattening of the metatarsal heads (being more pronounced on the left), with two small subchondral cysts and dorsal osteophytes (Figures 1a&b). Haematological investigations were normal. No further imaging was planned, as the diagnosis was conclusive on the radiographs 1,2 

Figure 1a Radiographs of both feet at presentation

Figure 1b Lateral views at presentation

She was treated conservatively with medial arch support by foot orthoses, non-steroidal anti-inflammatory drugs and was reviewed on a regular basis for two years. The symptoms gradually improved, as did the appearance of the radiographs (Figure 2). The osteophyte on the left was thought be limiting the full range of dorsiflexion and cheilectomy was offered to the patient.  However, as her symptoms had improved significantly she opted to defer surgery at that time.  

Figure 2 at six months follow up

Figure 3 at one year follow up

Figure 4a at two years follow up AP views

Figure 4b two years follow up lateral views

At one year of follow up her symptoms had improved although she had persistent limitation in dorsiflexion to about 10 degrees (Figure 3). X-rays at that time showed radiological improvement, however the osteophyte and cyst remained. At two years of follow up she is asymptomatic with minimal limitation in dorsiflexion. The osteophytes persisted but given the fact that she was asymptomatic, she declined cheilectomy (Figures 4a&b).

Discussion: 

A wide range of aetiologies including trauma, medications, iatrogenic, infection and idiopathic can cause avascular necrosis of the metatarsal heads3.  It most commonly occurs in the talus, navicular bones and also the second and third metatarsal heads.  It occurs more frequently in adults, being extremely rare in children.  It has only been described once in the first metatarsal of a child 4. A Medline search revealed no cases of bilateral avascular necrosis of the first metatarsal heads in children. 

Symptomatic AVN of the first metatarsal head is an extremely infrequent condition.  Its rarity makes standardisation of the treatment impossible.  Easley and Kelly suggested that shoe modification and change in activity may suffice, but in severe cases joint debridement and metatarsal head decompression may be indicated.  In extremis with severe head collapse, joint arthrodesis may be an option5.  Fortunately, this patient improved with medial arch support and we hypothesise that the orthoses acted by relieving pressure on the metatarsal heads, preventing further collapse and allowed bone remodelling.

Reference :

  1. Brody AS, Strong M, Babikian G, et al: Avascular necrosis: early MR imaging and histologic findings in a canine model, AJR 157:341-345, 1991. 
  2. Berquist TH,  Welch TJ,   Brown ML, et al : Bone and soft tissue ischaemia.       In Berquist TH  editor: Radilogy of the foot and ankle, New York,1989 Raven Press, pp 316-348. 
  3. Easley ME,  Kelly IP:   Avascular necrosis of the hallux metatarsal head. Foot and ankle clinics, Foot-Ankle-Clin, Sep 2000, vol. 5, no. 3, p. 591-608 
  4. Souverijns G, Peene P, Cleeren P, Raes M, Steenwerckx A: Avascular necrosis of the epiphysis of the first metatarsal bone. Skeletal Radiol (2002) 31:366-368. 
  5. Easley ME, Kelly IP Avascular necrosis of the hallux metatarsal head Foot Ankle Clin. 2000 Sep;5(3):591-608.

 

This is a peer reviewed paper 

Please cite as : Gella S: Bilateral Idiopathic Avascular Necrosis of the Hallux Metatarsals in a Child

J.Orthopaedics 2008;5(2)e6

URL: http://www.jortho.org/2008/5/2/e6

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