CASE 137
By: Dr. Nizar Al-Nakshabandi MD, FRCPC
HISTORY: 45-year-old female with pain in the feet and difficulty wearing shoes.
What are your findings?
What is the differential diagnosis?
What are the causes?
FINDINGS:
The AP radiograph of the weight bearing feet demonstrates a metatarsophalangeal angle more than 15° indicating hallux valgus. There is a medial deviation of the first metatarsal bone, and lateral deviation of the hallux. First to second metatarsal angle is also increased bony prominence from the inner side of the first metatarsophalangeal joint is seen [bunion]. This is associated with cystic and osteoarthritic changes of the first tarsometatarsal joint.
DIAGNOSIS:
Hallux valgus with bunion formation.
PEARLS AND DISCUSSION:
This condition can lead to painful motion of the joint and difficulty wearing shoes. Contrary to what is thought a cause high-heeled shoes and small toe box, or tightfitting shoes do not cause hallux valgus. However, if hallux valgus is present, then these shoes keep the hallux in an abduction position. This causes mechanical stretching and deviation of the soft tissue and aggravates the symptoms., in addition to making biomechanical causes dramatic and metabolic factors play a role.
Biomechanical factors include gastrocnemius or gastrocnemius soleus equinus. Pes planus valgus, forefoot varus, and hypermobility are some of the factors contributing to it.
Arthritic conditions, such as gouty arthritis and rheumatoid arthritis, can cause hallux valgus. Furthermore, psoriasis, edematous syndrome and Morphis syndrome can be due to generalized ligamentous laxity.
Neuromuscular disease such as multiple sclerosis, Charcot-Marie-Tooth disease and cerebral palsy can cause it as well.
Trauma with malunions is another culprit. Structural deformities have been associated with hallux valgus
The condition affects 1% of the population but increases proportionally with age to reach 16% those who are 60 years or older. There is a familial tendency. No racial or ethnic predispositions is seen.
Scarff osteotomy is the surgical intervention that is widely used. The surgery is done by dividing the first metatarsal in a Z-shaped fashion to allow the metatarsal to accurately be removed then fixed thus correcting the bunion.
FURTHER READING:
1. Vanore JV, Christensen JC, Kravitz SR et-al. Diagnosis and treatment of first metatarsophalangeal joint disorders. Section 6: Other disorders. J Foot Ankle Surg. 42 (3): 152-
2. Karasick D, Wapner KL. Hallux valgus deformity: preoperative radiologic assessment. AJR Am J Roentgenol. 1990;155 (1): 119-
3. George HL, Casaletto J, Unnikrishnan PN et-al. Outcome of the scarf osteotomy in adolescent hallux valgus. J Child Orthop. 2009;3 (3): 185-90. doi:10.1007/s11832-009-0177-6
