1. Metatarsalgia—third and fourth rays Case for small group discussion
AOTrauma—Foot & Ankle
Module 15: The lesser toes
Les Grujic, AU

2. Case description 14-year-old boy
Severe bilateral hand and foot deformities
Severe metatarsalgia third and fourth rays
Footwear fitting problems

3. Clinical pictures

4. Preoperative x-rays

5. Treatment planning What are the problems?
What are the goals of treatment?
Metatarsalgia 3–4
Nonfitting foot—forefoot is too large
Syndactily 3–4—is it a problem? And mallet toes 3–4?

6. Postoperative x-rays Valgus first metatarsal osteotomy
Shortening third and fourth metatarasals oteotomy
What are the correct lengths?
Discuss other options—first ray shortening, second ray resection in order to narrow the forefoot, third and fourth toes resection arthroplasty/arthrodesis to correct mallet deformity

7. Take-home messages
In congenital deformities the treatment goal is a painless foot that fits into shoes
The restoration of appropriate metatarsal length and height is effective in the control of metatarsalgia