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Remote Fellowship – Foot & Ankle Fundamentals – 11/2/2020

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Patient History

49-year-old woman with second metatarsophalangeal pain in the left foot for 3 months and no known injury. 

Findings

Skeletal/osseous and articulations:

Minimal medial subluxation of the proximal phalanx at the 2nd metatarsophalangeal joint. Mild degenerative arthrosis involving the 1st metatarsophalangeal joint and tibial sesamoid articulations. Mild 1st metatarsophalangeal joint capsulitis associated with a small effusion. Mild to moderate reactive 2nd metatarsophalangeal joint capsulitis associated with a small effusion.

Otherwise preserved metatarsophalangeal joints, proximal interphalangeal joints and distal interphalangeal joints. Preserved interphalangeal joint.

No micro- or macro-trabecular fracture. No stress fracture. No reactive pattern of marrow edema.

Lisfranc joint:

Not imaged.

Tendons:

Intact and unremarkable in appearance.

Ligaments:

Axial and coronal water-weighted sequences demonstrate complete or near complete rupture of the distal phalangeal portion of the lateral collateral ligament at the 2nd MTPJ associated with surrounding soft tissue/periligamentous edema. Medial collateral ligament at the 2nd MTPJ remains intact. Other ligaments intact and unremarkable in appearance.

Plantar plates:

Moderate in severity capsular synovitis at the 2nd metatarsophalangeal joint associated with a small effusion. Evident on both axial and sagittal sequences is a high-grade partial tear involving the 2nd metatarsophalangeal joint plantar plate laterally and in the midline, sparing only a small portion of the medial-most aspect of the plantar plate capsuloligamentous complex. Signal alteration consistent with edema/inflammation surrounding the plantar plate.

Soft tissues:

Focal area of soft tissue thickening/fibrosis adjacent to the 2nd metatarsophalangeal joint suggests a chronic pressure related soft tissue change related to altered biomechanics of weight-bearing. Very small/minimal fluid collection centrally within this area (best appreciated on the short axis PD fat saturated and short axis T2-weighted sequences), suggesting minimal adventitial bursal formation/bursitis.

Minimal 1st, 2nd and 3rd intermetatarsal space bursal thickening. 4th and 5th intermetatarsal space unremarkable

No well-defined Morton neuroma. A small Morton neuroma may be obscured by the inflammation adjacent to the plantar plate tear.

Prominent soft tissue thickening/fibrosis/callus formation involving the plantar aspect of the 5th metatarsal head, related to altered biomechanics of weight-bearing.

Other:

None.

Impressions

  1. High-grade partial or near complete rupture of the 2nd metatarsophalangeal joint plantar plate, primarily laterally and midline, with sparing of a small portion of the medial-most aspect.
  2. Associated complete or near complete rupture of the lateral collateral ligament of the 2nd metatarsophalangeal joint. Minimal medial subluxation.
  3. Associated reactive moderate grade 2nd metatarsophalangeal joint capsulosynovitis.
  4. No discrete Morton neuroma, however the 2nd interspace is obscured by inflammation related to the adjacent plantar plate tear.
  5. Minimal adventitial bursitis adjacent to the plantar aspect of the 2nd metatarsal head.