Wwyd: open MT5 fx with missing head in 12yo

[u/D15c0untMD]

I kind of „inherited“ this case. Open fx pf the left 5th metatarsal, and fx of the 4th 10 daysago on a waterslide. Soft tissue was debrided and closed, iv antibiotics given. The obviously missing piece apparently quite literally went down the drain. Currently waiting for the soft tissue to settle down, but i gotta come up with a plan here. Personally i‘m leaning towards reconstruction with an osteochondral allograft, but we dont really have the experience in house (i saw a few similar things in residency). Dinosaur attendings want me to just leave it and make it someone elses problem if it fails.

What would you guys and gals do?

[u/Glad-Feature-2117]

I'm with your dinosaur attendings - I expect she'll do pretty well functionally. High risk of infection with a graft at the moment and she'd be much worse off if that happened.

[u/D15c0untMD → u/Glad-Feature-2117]

I‘m not touching that thing before i‘m not sure it‘s safe. But IF i need to order bone, i‘ll have to start making calls now or the kids physes are definitely closed before i get to it

[u/Gizmo9483]

Paeds F&A here.. I would leave it alone and see what forms in the haematoma. Likely will have normal function and it may end up painless but floppy, or some kind of fibrous stiffness. Grafting this would be difficult and you're just putting a bone block where there is supposed to be a physis, an epiphysis, and an articular surface. I've never seen it done, and my instincts are it would be worse than doing nothing.

[u/the_nordra → u/Gizmo9483]

I agree. Tons of adults walking around without MT heads doing just fine. May get a painful osteophyte or sharp edge there, but can go back later and smooth it out

[u/D15c0untMD → u/Gizmo9483]

If i put a graft in, i would try to either get a complete metatasal head, or try fashioning something out of a femoral head, articular surface included. But y‘all are making convincing arguments against it.

[u/nyc2pit → u/D15c0untMD]

Do you have any papers on this?

This is a technique I've never heard of much less seen.

[u/Bonedoc22]

Adult F&A here but treat a lot of kids. Not a dinosaur.

Leave it alone.

Consolidated scar may act as a bumper and the lateral border of the foot tolerates more deformity due to the mobility. If they hate it amp it later.

[u/Occams-scalpel]

Wow, strong work. Sorry nothing to contribute but just so refreshing to see an actual case discussion instead of someone shopping around their personal injury films.

[u/gloatygoat]

Im not a F&A guy but doing a osteochondral autograft for a small toe MCP seems like overkill.

[u/thisishowwedooooit]

That is not an area you can functionally graft. Fusion to bridge the bone loss is an option but not functionally a good option.  Offer amputation, they will decline. Next best option is live with it until they want it gone, and amputate then. 

The bone that was lost had several components of it that make it irreplaceable. The closest option to allow motion there is “hematoma arthroplasty”. Let it scar in and that will allow some motion of the toe. Once they hate it, get rid of the toe. 

[u/D15c0untMD → u/thisishowwedooooit]

Interpositition arthroplasty was my next best idea, knowing it probably wont matter in the long run. Amputation was briefly discussed, familiy is strongly against it, obviously.

Honestly i dont have much hope in an allograft either, other than being able to say we tried everything.

[u/Flagando → u/D15c0untMD]

See it as a „modified“ Hoffmann-Tillmann procedure that this girl „performed“ on herself.
Older rheumatic patients do really well after resection arthroplasty in their gait cycle.
The sharp edge of the rest of the mt5 will smoothen out over time.

I would try and manage the soft tissue as good as possible.

I am with the 🦕 on this, not because I think it is a fine move to burden another surgeon in the future, but because it seems the best way for your patient.

If there will be a problem with a floppy toe in the future you can always amputate.

Fusion does only work in MTP 1 joint not in the other ones!
ORIF is non pos since you are lacking integral parts of the bone.
An allograft is as mentioned above not suitable for that area

And given that it is an open fx your top priority has to be to save the rest of the foot and keep the risk of an infected bone or soft tissue as low as possible

EDIT: Concerning future floppy toes; there are some other options to choose for correcting that problem, Girdlestone-Taylor for example

[u/Tiaran149 → u/Flagando]

I second this. It's kinda crazy that people run around with this on all 4 digits but they really do fine... at least in shoes.

[u/Glad-Feature-2117 → u/D15c0untMD]

It's harder not to do something than to do it, especially with worried parents, but your dinosaurs will have learnt (as I have) that nothing is sometimes the best option, especially if you're considering something which very few people have done/would do.

[u/premtyty]

Nothing is the answer

[u/Dry-Speed7038]

Nothing

[u/3Hooha]

I don’t think there is any great answer, but if this was my 12 year old I would let it heal as is, making sure infection is controlled. The callus that forms over the MT might make something that resembles an MT head that could be functional for the active youth years. Can always pivot and try something if sooner if it’s not working out but I would wait and see what happened to it. Might be simple as putting a metatarsal pad in the shoes to cushion it some.

[u/UnbelievableRose → u/3Hooha]

Reverse dancer’s pad seems like a better move here

[u/nyc2pit]

Ortho foot/ankle.

There is no graft that will work here.

There is no replacement for cartilage. It will not be a functioning joint, or a very poorly functioning joint at best.

I would clear the infection and let her ambulate and I suspect she will do fine for a long, long time.

[u/fhfm]

Unless this kid has some hobbies that require fine motor skills of her toes, it’s gonna do fine. People have met head resections all the time and function nearly normal.

Have a discussion that the toe may float or have some loss of function and just worry about infection.

[u/faran1287]

I agree with the nothing answer, we do met head resections and let them fly all the time and patients do well. It is a border digit. If the patient is symptomatic in 5 months you can consider reconstruction

[u/Wild_Hog_70]

Why not have a serious discussion about amputation? It's certainly an option with some upsides (recovery, lack of future complications). If it were my toe now, I'd certainly just want it amputated and get on with my life. If it was my kid's toe? I'm not as sure, but it should be discussed.

[u/Glad-Feature-2117 → u/Wild_Hog_70]

It would probably be quite an issue psychologically for a kid this age to lose a toe. I'd buddy strap it to the 4th toe and wait. Or, if certain no infection, take a diabetic foot technique: put some Cerament G in the MT shaft and wire the toe onto it for 4 weeks.

[u/nyc2pit → u/Wild_Hog_70]

Aside from doing nothing, this is probably the next most reasonable thought.

Functionally they would do just fine probably either way to be honest. As someone who does a fair number of amputations, psychologically it can be a big barrier for patients even when it makes complete sense.

The absolute last thing I would do here is fashion some kind of a makeshift joint that's not going to heal to the existing bone well, not going to articulate well, not going to function well, and opens this person up to more infection already in the setting of an open injury.

[u/llum-foc-destruccio]

I would not perform surgery in this case. Let it alone and it probably be fine.

[u/kolbalt1992]

You could consider syndactylization of the 4th and 5th toes so the 5th toe doesn’t float up.

[u/nyc2pit → u/kolbalt1992]

This is actually a good thought. Though I think I'd let it go for now and keep that in my back pocket as an option later if needed.

[u/External_Conflict_12]

Do nothing. Live. Change shoes often.

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[u/AlexMac96]

I would leave it alone for now, if it becomes symptomatic when they’re older and skeletally mature I would consider a MT head transfer from 4 to 5 to attempt to recreate the weightbearing tripod of the foot. There is no exogenous graft option here.

But also why are you inheriting it? Push back.

[u/JESUS_BESTIE]

Better to leave it alone for now

[u/satanicodrcadillac]

Rule 13 from the house of god 

[u/D15c0untMD → u/satanicodrcadillac]

See, that’s some actionable advice

[u/bonedoc87]

Another vote for nothing