Bilateral cleft epiphysis of the first metatarsophalangeal joint
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CASE REPORT An athletic 12-year-old girl presented with increasing pain on exercise localized to the first metatarsopha- langeal joint (MTPJ) of the right foot. She gave no history of trauma. X-ray performed after one month revealed an apparent intra-articular fracture of the base of the proximal phalanx with minimal displace- ment (Fig. 1). After 6 weeks rest from sporting activities she was still complaining of pain localized to right first MTPJ brought on by both walking and passive motion. Repeat X-ray still showed an apparent fracture with increased sclerosis of the epiphysis also notable. X- ray of the left MTPJ was normal at that time. Six months after initial presentation she was still com- plaining of a dull ache around the right first MTPJ and gradually increasing discomfort around the left first MTPJ. Despite this she was managing limited sport. On examination she walked normally but com- plained of left-sided pain. The right MTPJ was virtu- ally pain free but noted to be stiff compared with the left MTPJ which was painful on all passive move- ments but fully mobile. X-rays revealed a virtually resolved lesion in the right proximal phalanx base and an obvious identical but a new lesion in the base of the left proximal phalanx. Prior to her presentation her usual footwear was soft, well-fitting, training shoes. She was supplied with stiffened shoes and kept under review. Over the next 18 months she had a remitting and relapsing course with symptoms bilaterally until at her last review, 2 years after the initial onset of symp- toms, she was pain free and returned to full sporting activities. She had dispensed with the use of the stiff- ened shoes after 6 months. On examination she was noted to have a degree of hallux rigidus bilaterally with compensatory hyperextension of both distal interphalangeal joints (DIPJs). X-rays revealed fully united lesions at the bases of both proximal pha- langes with small dorsal osteophytes (Fig. 2). She is still under observation. DISCUSSION Epiphyseal clefts have been observed in many loca- tions around the time of puberty 1 but they have been noted to affect the basal epiphysis of the great toe most commonly. They may be unilateral or bilateral and can occur near the centre or the margin of the epiphysis. 2,3 Marginal clefts, such as our case, are best seen on oblique radiographs. The clefts may have irregular margins and there may be spreading of the fragments around the cleft. These clefts are of unknown aetiology; it has been suggested they may represent areas of secondary ossification, however, they have been observed in previously normal epiphyses. 4 We think aseptic necrosis is an unlikely explanation, as we have not seen any fragmentation of the epiphysis in our patient. It has been thought that fracture is an unlikely explanation as healing has not been observed at 4 months; 1 no associated damage to the epiphyseal line has been observed 1 and previous cases have been asymptomatic. 1 Our patient clearly had disabling symptoms and despite the lack of specific trauma was engaged in regular athletic activities. It is a possibility that these clefts are in fact stress fractures of the Salter-Harris III configuration. 1 CASE REPORT Bilateral cleft epiphysis of the first metatarsophalangeal joint A. L. Smith, P. W. Laing Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry, Shropshire, UK SUMMARY. We report the case of a young patient who presented with symptomatic bilateral cleft epiphyses of the first metatarsophalangeal joint. She has become asymptomatic with radiological union of the clefts after prolonged follow-up, but is left with moderate hallux rigidus. This condition was thought previously only to be a radiological variant, with no documentation of symptomatic presentation or radiological resolution of the cleft. Correspondence to A. L. Smith, Specialist Registrar, Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry, Shropshire SY10 7AG, UK. Tel: +44 (0) 1691 404000; Fax: +44 (0) 1691 404050. The Foot (1999) 9, 47–48 © 1999 Harcourt Brace & Co. Ltd
Transcript of Bilateral cleft epiphysis of the first metatarsophalangeal joint
CASE REPORT
Bilateral cleft epiphysis of the first metatarsophalangeal joint
A. L. Smith, P. W. LaingRobert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry, Shropshire, UK
SUMMARY. We report the case of a young patient who presented with symptomatic bilateral cleft epiphyses ofthe first metatarsophalangeal joint. She has become asymptomatic with radiological union of the clefts afterprolonged follow-up, but is left with moderate hallux rigidus. This condition was thought previously only to be aradiological variant, with no documentation of symptomatic presentation or radiological resolution of the cleft.
The Foot (1999) 9, 47–48© 1999 Harcourt Brace & Co. Ltd
CASE REPORT
An athletic 12-year-old girl presented with increasingpain on exercise localized to the first metatarsopha-langeal joint (MTPJ) of the right foot. She gave nohistory of trauma. X-ray performed after one monthrevealed an apparent intra-articular fracture of thebase of the proximal phalanx with minimal displace-ment (Fig. 1).
After 6 weeks rest from sporting activities she wasstill complaining of pain localized to right first MTPJbrought on by both walking and passive motion.Repeat X-ray still showed an apparent fracture withincreased sclerosis of the epiphysis also notable. X-ray of the left MTPJ was normal at that time. Sixmonths after initial presentation she was still com-plaining of a dull ache around the right first MTPJand gradually increasing discomfort around the leftfirst MTPJ. Despite this she was managing limitedsport.
On examination she walked normally but com-plained of left-sided pain. The right MTPJ was virtu-ally pain free but noted to be stiff compared with theleft MTPJ which was painful on all passive move-ments but fully mobile.
X-rays revealed a virtually resolved lesion in theright proximal phalanx base and an obvious identicalbut a new lesion in the base of the left proximalphalanx.
Prior to her presentation her usual footwear wassoft, well-fitting, training shoes. She was suppliedwith stiffened shoes and kept under review.
Over the next 18 months she had a remitting andrelapsing course with symptoms bilaterally until at
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Correspondence to A. L. Smith, Specialist Registrar, Robert Jonesand Agnes Hunt Orthopaedic Hospital, Oswestry, ShropshireSY10 7AG, UK. Tel: +44 (0) 1691 404000; Fax: +44 (0) 1691404050.
her last review, 2 years after the initial onset of symp-toms, she was pain free and returned to full sportingactivities. She had dispensed with the use of the stiff-ened shoes after 6 months. On examination she wasnoted to have a degree of hallux rigidus bilaterallywith compensatory hyperextension of both distalinterphalangeal joints (DIPJs). X-rays revealed fullyunited lesions at the bases of both proximal pha-langes with small dorsal osteophytes (Fig. 2). She isstill under observation.
DISCUSSION
Epiphyseal clefts have been observed in many loca-tions around the time of puberty1 but they have beennoted to affect the basal epiphysis of the great toemost commonly. They may be unilateral or bilateraland can occur near the centre or the margin of theepiphysis.2,3 Marginal clefts, such as our case, are bestseen on oblique radiographs. The clefts may haveirregular margins and there may be spreading of thefragments around the cleft.
These clefts are of unknown aetiology; it has beensuggested they may represent areas of secondaryossification, however, they have been observed inpreviously normal epiphyses.4 We think asepticnecrosis is an unlikely explanation, as we have notseen any fragmentation of the epiphysis in ourpatient. It has been thought that fracture is anunlikely explanation as healing has not been observedat 4 months;1 no associated damage to the epiphysealline has been observed1 and previous cases have beenasymptomatic.1
Our patient clearly had disabling symptoms anddespite the lack of specific trauma was engaged inregular athletic activities. It is a possibility that theseclefts are in fact stress fractures of the Salter-HarrisIII configuration.
2 The Foot
Fig. 1—Oblique X-ray of the right first MTPJ demonstrating an apparent intra-articular fracture at the base of the proximal phalanx.
Fig. 2—Complete resolution of the proximal phalanx lesion with dorsal osteophyte formation 2 years after initial presentation.
Over the 2 year period of review we have observedsymptomatic and radiological resolution of ourpatients problem. This is the longest follow-up to dateof an unusual condition previously only described asan asymptomatic radiological variant and is the firstreported case of radiological resolution.
We plan to keep this patient under review to moni-tor the progress of her hallux rigidus.
The Foot (1999) 9, 47–48
REFERENCES
1. Harrison R B, Keats T E. Epiphyseal clefts. SkeletalRadiology 1980; 5: 23–27.
2. Birkner R. Normal radiologic patterns and variances of thehuman skeleton. Munich: Urban and Schwarzenberg, 1978; 519.
3. Koller A, Zimmer E A. Borderlands of the normal and earlypathologic in skeletal roentgenology. New York: Grune andStratton, 1968; 536.
4. Caffey J. Paediatric X-ray diagnosis. Chicago: Year BookMedical Publishers, 1973; 914.
© 1999 Harcourt Brace & Co. Ltd
