Bunionette

A bunionette (also known as a tailor’s bunion) is a painful bony prominence, or bump, on the outside of the little (pinky) toe. Over time, the bunionette may worsen as the little toe moves inward and the fifth metatarsal (the bone connected to it) moves outward. Rubbing between the bump and tight shoes may also cause a callus to grow over the area. All bunionettes can cause pain and pressure on the outside of the foot, though often they do not cause symptoms.

Treatments

The initial treatment of a bunionette is non-surgical. This can include wearing shoes that are roomier with a wide toe box to avoid rubbing on the bony prominence. Padding the little toe using a toe sleeve may reduce discomfort as well.

If your bunionette is painful even after wearing wide, comfortable shoes, if you cannot wear comfortable shoes because of the size of your bunionette, or if you continue to have problems after non-surgical treatment, your foot and ankle orthopedic surgeon may recommend surgery. The goals of this surgery are to remove the bony prominence and correct alignment to decrease pain. Surgery should be avoided if you have poor circulation or uncontrolled diabetes, if you are a chronic steroid user, or if you smoke cigarettes. These are risk factors for delayed healing of incision and bone.

Bunionette surgery is usually an outpatient surgery, meaning you can go home the same day as the surgery. It involves removing the bony prominence of the bunionette. In a larger bunionette that is causing an alignment problem, breaking the fifth metatarsal bone and restoring normal alignment may be necessary. Your foot and ankle orthopedic surgeon will explain what kind of surgery is needed for you and why.

Specific Techniques

The type of surgery to correct the bunionette depends on the shape of the fifth metatarsal bone, type of bunionette, and patient’s wishes.

• If you have a painful prominence without a bony growth, the surgery usually involves removing the painful soft tissue of the little toe.
• If you have a Type 1 bunionette, it means you have an enlarged bump at the outer end of the fifth metatarsal head (where the toe meets the foot). During surgery, this bony growth is removed.
• Sometimes the bony protuberance is so big that the bone of the fifth metatarsal needs an osteotomy, which is breaking the bone to realign it. The bone is cut and moved towards the fourth metatarsal to correct the alignment.
• If you have a curved shape to your little toe (Type 2 bunionette) or angle (Type 3 bunionette) between the fourth and fifth metatarsal, your surgeon will often do an osteotomy. This osteotomy is done to straighten out the fifth metatarsal.
• If a bunionette deformity is treated with an osteotomy, the bone may be held straight with a steel wire, screw, or plate and screws, depending on the surgeon’s preference.

Recovery

After the surgery, patients may need to stay off their operated foot with no weight or heel weight bearing on it for a period of weeks. Patients will need to wear a post-surgical shoe or a short CAM boot on their foot to keep it protected after surgery. You may also need to use crutches or a walker depending on your activity level and pain. In severe deformities, some surgeons will place a short leg splint to better protect the surgical correction. The specific amount of time that your foot needs to be protected after surgery depends on the type of surgery and the surgeon’s protocol. The operated foot will need to be elevated above the level of the heart as much as possible for at least the first few days. This will help to decrease swelling.

Your stitches are usually taken out 2-3 weeks after surgery. You will be asked to not soak your foot or get the surgical area wet until your stitches are out.

Your foot and ankle orthopedic surgeon may ask you to do knee and ankle exercises at home after surgery. This can help maintain your joint motion and flexibility. If your doctor thinks that you need physical therapy after the soft tissue and bone is healed, he or she will discuss that with you.

Swelling is the last thing to improve for most patients after bunionette surgery. It can take 6-12 months for your foot’s swelling to completely improve after surgery.

Risks and Complications

All surgeries come with possible complications, including the risks associated with anesthesia, infection, damage to nerves and blood vessels, and bleeding or blood clots. Potential complications after bunionette surgery are rare. Possible problems include bleeding from the wound, injured nerves around the little toe, poor wound healing or bone healing if an osteotomy is done, and the possibility of recurrence of the bunionette.

FAQs

If my bunionette deformity is treated without surgery, can I ever wear high heels and pointed shoes?

Wear pointed-toe shoes as little as possible. This does not mean that you cannot ever wear these shoes, but you should limit the time wearing them in order to decrease pain and the chance that the bunionette will get worse.

If I’m treated with surgery, will the deformity come back?

Most bunionettes do not come back after being treated with the right type of surgery. The surgery should correct the underlying cause of the problem. However, wearing shoes that are too narrow can still cause irritation and inflammation at the operated little toe.

Bunion

Bunion is the name for a prominent bump along the inside of your big toe. If you notice a swollen, painful big toe, you may have a bunion. More than one-third of women in America have bunions. Bunions often are hereditary, but they also develop from wearing tight shoes.

If you have a painful, swollen lump on the outside of your foot near the base of your little toe, it may be a bunionette (“tailor’s bunion”). Similar to a bunion, bunionettes can be caused by wearing shoes that are too tight.

Symptoms

With a bunion, the base of your big toe (metatarsophalangeal joint) gets larger and sticks out. The skin may be red and tender, and wearing any type of shoe may be painful. This joint flexes with every step you take, so the bigger your bunion gets, the more it may hurt to walk. Bursitis (painful swelling with inflammation) may set in. Your big toe may tilt toward your second toe or move all the way under it.

In addition, the skin on the bottom of your foot may become thicker and painful. Pressure from your big toe may force your second toe out of alignment, sometimes overlapping your third toe or the big toe. An advanced bunion may make your foot look deformed. If your bunion gets too severe, it may be difficult to walk. Your pain may become chronic and you may develop arthritis.

Prevention

Most bunions are treatable without surgery. Prevention is always best. To minimize your chances of developing a bunion, never force your foot into tight shoes that don’t fit or that crowd your toes. Choose shoes that conform to the shape of your feet and ones with wide insteps, broad toe boxes, and soft soles. Avoid shoes that are short, tight, or sharply pointed, and those with heels higher than 2 1/4 inches.

If you already have a bunion, wear shoes that are roomy enough to avoid putting pressure on the big toe. This should relieve most of your pain. You may want to have your shoes stretched out professionally. You also may use protective pads to cushion the painful area, or a spacer to maintain the gap between the big toe and the second toe.

Treatments

If your bunion has progressed to the point where you have difficulty walking or experience pain despite changing shoes, you may be a candidate for surgery. Bunion surgery realigns bone, ligaments, tendons, and nerves so your big toe can be brought back to its correct position. There are several different techniques that can be performed to ease your pain; see a foot and ankle orthopedic surgeon to discuss your options.

Most bunion surgeries are outpatient procedures, meaning you can go home the same day as surgery. Recovery occurs over 3-6 months and may include persistent swelling and stiffness.

Broken Foot or Broken Toes

Nearly one-fourth of all the bones in your body are in your feet, which provide you with both support and movement. A broken (fractured) bone in your forefoot (metatarsals) or in one of your toes (phalanges) often is painful but rarely disabling. Most of the time, these injuries heal without surgery. Since a dislocation can be mistaken for a toe fracture, it is important to obtain X-rays to ensure a correct diagnosis.

Symptoms

Pain, swelling, and bruising are the most common signs of a fracture in the foot. If you have a broken toe, you may be able to walk but this usually aggravates the pain. If the pain, swelling, and discoloration continue for more than 2-3 days, or if pain interferes with walking, something could be seriously wrong; see your foot and ankle orthopedic surgeon as soon as possible. If you delay getting treatment, you could develop persistent foot pain and arthritis. Pain also can change the way you walk (your gait), which could lead to painful calluses on the bottom of your foot or other issues.

Causes

Stress fractures frequently occur in the bones that extend from your toes to the middle of your foot (metatarsals). Stress fractures are like tiny cracks in the bone surface. They can occur with sudden increases in physical activity, such as running or walking for longer distances or times, improper training techniques, or changes in training surfaces. They may be related to the shape of the foot, an overly tight calf muscle or heel cord (Achilles), or metabolic or nutritional factors.

Traumatic fractures result from a sudden force, such as a fall, dropping a heavy object on your foot, or a twisting injury. If the fractured bone does not break through the skin, it is called a closed fracture. These fractures may be stable with no shift in bone alignment or displaced with bone ends that no longer line up.

Several types of fractures can occur to the forefoot bone on the side of the little toe (fifth metatarsal). Ballet dancers may break this bone during a misstep or fall from a pointe position. An ankle-twisting injury may tear the tendon that attaches to this bone and pull a small piece of the bone away. A more serious injury in the same area is a Jones fracture, which occurs near the base of the bone and disrupts the blood supply to the bone. This injury may take longer to heal or require surgery.

Diagnosis

Your foot and ankle orthopedic surgeon will examine your foot to pinpoint the central area of tenderness and compare the injured foot to the normal foot. You should tell your surgeon when the pain started, what you were doing at the time, and if there was any injury to the foot. X-rays will show most fractures of the forefoot and should be obtained standing if possible to improve diagnostic accuracy. A CT scan or MRI may be needed if the fracture enters a joint, or if X-rays fail to reveal an injury.

Treatment

See your foot and ankle orthopedic surgeon as soon as possible if you think that you have a broken bone in your foot or toe. Until your appointment, keep weight off the painful area and apply ice to reduce swelling. Use an ice pack or wrap the ice in a towel so it does not come into direct contact with the skin. Apply the ice for no more than 20 minutes at a time. Take acetaminophen or ibuprofen to help relieve the pain. Wear a wider shoe with a stiff sole to remove stress from the injury site.

Rest is the primary treatment for stress fractures in the foot. Stay away from the activity that triggered the injury, or any activity that causes pain at the fracture site, for 3-4 weeks. Substitute another activity that puts less pressure on the foot, such as swimming. Gradually, you will be able to return to activity. Your surgeon, physical therapist, or coach may be able to help you pinpoint the training errors that caused the initial problem so you can avoid a recurrence.

If you have a displaced fracture, the bone ends must be realigned and the bone kept immobile until healed. If you have a broken toe, the doctor will “buddy tape” the broken toe to an adjacent toe, with a gauze pad between the toes to absorb moisture. You should replace the gauze and tape as often as needed. Remove or replace the tape if swelling increases and the toes feel numb or look pale. If you have diabetes with neuropathy or peripheral neuropathy (loss of sensation in the toes), do not tape the toes together. You may need to wear a rigid, flat-bottom orthopedic shoe for several weeks.

If you have a broken bone in your forefoot, you may have to wear a short-leg walking cast, a brace or a rigid, flat-bottom shoe. It could take 6-8 weeks for the bone to heal, depending on the location and extent of the injury. After a week or so, your foot and ankle orthopedic surgeon may request another set of X-rays to ensure that the bones remain properly aligned. Many of these fractures are treated successfully without surgery, although in severe injuries, pins or screws may be required to hold the bones in place while they heal. Surgery often is not needed to treat fractures in the toes or forefoot. However, when it is necessary, it has a high degree of success.

Recovery

The forefoot and toes tend to heal slowly, so it can take months for a fracture to heal. In the toes, swelling can continue for a long time even when patients are not having other symptoms.

Risks and Complications

Risks associated with these fractures are specific to the injury. If the fracture goes into a joint, it could lead to arthritis. If the skin is broken at the time of the injury, you could develop an infection.

On occasion, the bone does not heal. In other cases, pain or swelling can remain. For these reasons, it is important to have further follow up with your surgeon if you continue to have symptoms.

The ankle is made up of three bones:

• the tibia (shin bone), which forms the inside, front, and back of the ankle
• the fibula, which forms the outside of the ankle
• the talus, a small bone that sits between the tibia and fibula and the heel bone

The ends of these bones are called malleoli. The tibia has a medial (inside) malleoli and a posterior malleoli. The fibula forms the lateral (outside) malleoli.

Ankle Fracture

A fracture is a partial or complete break in a bone. In the ankle, fractures involve the far (distal) ends of the tibia and/or the fibula. Some distal tibia fractures can involve the rear (posterior) part of the bone, which also are known as posterior malleolar fractures. Ankle fractures can range from less serious avulsion injuries (small pieces of bone that have been pulled off) to severe, shattering-type breaks. Some fractures also may involve injuries to important ankle ligaments that keep the ankle in its normal position. Ankle fractures are commonly caused by the ankle twisting inward or outward.

Symptoms

One or all of these signs and symptoms may accompany an ankle fracture:

• Pain at the site of the fracture, which can extend from the foot to the knee
• Swelling, which may occur along the length of the leg or be more localized at the ankle
• Blisters, which should be treated promptly
• Bruising
• Decreased ability to walk. It is possible to walk or bear weight upon the ankle with less severe fractures. Never rely on walking as a test of whether the ankle is fractured.
• Bones protruding through the skin. This condition is known as an open ankle fracture. These types of ankle fractures require immediate treatment to avoid problems like infection.

Most patients with ankle fractures are treated in an emergency room or a doctor’s office. An X-ray of the damaged ankle may be taken to determine what the fracture looks like, which bones are broken, how separated or displaced the bones are, and the condition of the bone itself. The X-ray will help determine the proper course of treatment.

The goal of amputation is to remove unhealthy tissue and create a remaining leg that is less painful and more useful. Just like many reconstructive orthopedic surgeries, the surgical goal is to improve a patient’s pain and function. Amputation can improve quality of life for many patients.

Below-Knee Amputation

A below-knee amputation (BKA) is an amputation often performed for foot and ankle problems. The BKA often leads to the use of an artificial leg that can allow a patient to walk. A BKA is performed roughly in the area between the ankle and knee. This amputation provides good results for a wide range of patients with many different diseases and injuries.

Diagnosis

Your foot and ankle orthopedic surgeon may perform a BKA if you are severely injured or have a severe infection. After a severe injury to the lower leg, an amputation may be recommended immediately or after attempts to save the limb leaves the patient with significant pain or functional limitations. Other reasons for amputation can include non-healing ulcers, chronic pain, birth defects, and tumor. The decision to amputate involves many factors and is done after a thorough discussion between you and your orthopedic surgeon.

There are many medical reasons why a patient may not be a good candidate for a BKA. Below are some of the more common reasons.

• Poor blood flow: Patients with poor blood flow should not undergo an operation without proper evaluation before surgery. Adequate blood flow is necessary for wound healing. This may mean a referral to a vascular specialist before surgery is considered.
• Medical problems: Severe heart or lung disease, a poor immune system, or bleeding problems may be reasons to not have surgery.
• Infections or tumors that extend above the knee: In cases where an infection or tumor goes above the knee joint, a higher level of amputation may be required.
• Scar tissue or skin and muscle loss: A patient with scarring, tissue grafting, or tissue loss may not be a candidate for a BKA. Such patients may not have adequate skin or muscle to heal a wound or to use an artificial leg.
• Limited knee function or knee pain: Patients who cannot straighten their knee or have pain and giving way at the knee may find it difficult to use an artificial leg.
• Patients who already do not walk or stand due to other reasons may not benefit from a BKA.

Treatment

If amputation is being considered, a team approach should be used. This often means meeting with numerous specialists. This may include your foot and ankle orthopedic surgeon; your medical doctor, who can make sure you are healthy for surgery; a prosthetist, someone who specializes in making artificial limbs; a physical therapist; and a rehab doctor. Support groups and patients with similar problems who have undergone amputation can be excellent resources before and after surgery.

During surgery, the leg is amputated at a level that removes as much damaged tissue as possible. There is no single length of amputation that will work for all patients. In general, several inches of leg bone below the knee are required in order for an artificial leg to be properly fit. There is not an advantage to a very long residual leg as it does not improve the ability to fit and wear an artificial leg.

Specific Technique

There are many different techniques for performing a BKA. Each surgery is customized for the individual patient. Most patients are completely asleep for the procedure. On occasion, a spinal anesthetic or a nerve block with a sedative may be appropriate.

An incision is made below the desired level of the amputation. The calf muscles and skin are cut in a way that creates a “flap.” The leg bones are cut with a saw. Some surgeons may fuse the end of the two bones (tibia and fibula) together, called an Ertl technique. The calf muscle is then folded up over the ends of the bones and held with sutures. The skin is closed with sutures or staples. Some surgeons may place a temporary drain to help prevent blood from pooling under the flap. A compressive dressing or a cast is applied to minimize swelling. Sometimes a cast is applied for added protection. The surgery usually lasts two to three hours. Patients spend some time in a recovery area and are then transferred to a hospital floor.

Recovery

Most patients will be admitted to the hospital for at least one night following the procedure. Many are able to return home as long as they have help at home and are able to walk with crutches or a walker. Some patients who need more assistance with walking or have multiple medical problems may benefit from a stay in a rehabilitation facility until they are ready to return home.

The incision will heal over a period of 2-6 weeks. This can depend on patient factors such as blood flow, quality of skin and soft tissue, and medical conditions such as diabetes. Swelling is common and may last for months if not years.

Swelling often is treated with a compression stocking or “shrinker.” Decreased swelling is critical for proper use of an artificial leg. If a limb is swollen when the prosthesis is fitted, it will be loose when the swelling improves. Similarly, a swollen limb won’t fit into an artificial leg. Complete healing may take up to a year. The artificial leg is continually adjusted during that time to make sure of a proper fit.

Most surgeons will want the incision to be completely healed before allowing a patient to walk with an artificial leg. Most patients are fitted with a temporary artificial leg within the first three months. Activities are increased slowly over time. A permanent artificial leg may not be made for 6-12 months after surgery.

Risks and Complications

All surgeries come with possible complications, including the risks associated with anesthesia, infection, damage to nerves and blood vessels, and bleeding or blood clots. After amputation patients may have continued nerve pain, phantom limb pain, or bone spur overgrowth at the end of the limb (heterotopic ossification). Any of these problems may require additional operations. Disability can result from any of these problems.

FAQs

What kind of activities can I expect to be able to do after a below-knee amputation?

This depends on your level of activity before surgery. Patients often are able to return to the level of activity they had prior to amputation. An amputation may even allow a higher level of activity such as brisk walking or running. Younger patients without other medical problems or joint ailments may have the best results. Different prosthetic styles are available depending on an individual’s functional demands.

What are the keys to having a successful below-knee amputation?

Knowing what to expect is important. Even a perfectly performed surgery may be seen as a failure if a patient has the wrong expectations. This is one of the reasons why it is important to learn about the procedure and talk to as many patients and practitioners as possible before the operation. Speaking with a patient who is of similar age and has undergone an amputation for similar reasons can be extremely helpful.

What can I do before surgery to stay strong?

Prior to your operation it is important to maintain hip and knee strength. This can be accomplished with straight leg raises and knee extension exercises. These exercises should be continued during your recovery.

What kinds of things can help healing?

It is important to protect the limb and incision after surgery. If you are given a brace or cast to wear, you should wear this exactly as directed. It takes only one accidental bump to open the incision. If this happens, it could delay healing by several weeks or even months. It may even require additional surgery.

If you are a smoker, you should stop. Smoking has been associated with numerous complications. These include wound healing problems, bone healing problems, heart and lung disease, pain, and even arthritis. The risks of surgery are sometimes so high that some surgeons will hold off on performing an amputation until a patient has stopped smoking entirely. Proper nutrition and medical management of chronic disease, particularly diabetes, also is helpful.