Lesser Metatarsal 2-4 Pathology

Related radiographic pathology may include:

  • CRPS (complex regional pain syndrome, aka reflex sympathetic dystrophy or RSD)
  • arthritis, including rheumatoid , seronegative, and gout
  • metatarsal length abnormality, including brachymetatarsia
  • Freiberg's disease
  • trauma, including stress fracture
  • joint subluxation and dislocation

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Here are some examples of pathology followed by interpretations (*):

  • Case 1
  • *Case 1
  • Case 2
  • *Case 2
  • Case 3a
  • *Case 3a
  • *Case 3b
  • Case 4a
  • *Case 4a
  • *Case 4b
  • Case 5
  • *Case 5
  • Case 6
  • *Case 6
  • Case 7
  • *Case 7
  • Case 8
  • *Case 8
  • *Case 8b
  • Case 9
  • *Case 9
  • Case 10
  • *Case 10
  • Case 11
  • *Case 11
  • Case 12
  • *Case 12
  • Case 13
  • *Case 13
spotty osteopenia
spotty osteopenia marked

Dorsoplantar view. Spotty osteopenia (loss of bone density, arrowheads) is seen at all lesser MPJ's, more pronounced in the metatarsal heads.
Diagnosis: Acute osteoporosis, seen with disuse and CRPS (complex regional pain syndrome, aka reflex sympathetic dystrophy or RSD).

permeative osteopenia
permeative osteopenia marked

Dorsoplantar view. Permeative osteopenia (loss of bone density, arrowheads) is seen in all lesser metatarsal diaphyses.
Diagnosis: Acute osteoporosis, seen with disuse and CRPS (complex regional pain syndrome, aka reflex sympathetic dystrophy or RSD).

rheumatoid arthritis
rhematoid arthritis marked

Dorsoplantar view.
There are erosions (black arrowheads) along the medial aspects of all lesser metatarsal heads as well as along the lateral aspect of the fifth metatarsal head. (The white arrowheads identify the normal concavity along the lateral aspects of lesser metatarsal heads that mimic erosion.) Even joint space narrowing is seen at all lesser metatarsophalangeal joints. The second through fourth toes angulate laterally relative to their respective metatarsals. Geographic decreased densities (black arrows) are seen in the second toe proximal phalanx base and second metatarsal head (sometimes referred to as "pseudocysts").
Diagnosis: rheumatoid arthritis.

rheumatoid arthritis bilateral

Dorsoplantar views, same patient.
A well-defined erosion presents along the medial aspect of the left first metatarsal head. There are erosions along the medial aspects of all lesser metatarsal heads as well as along the lateral aspect of the fifth metatarsal heads. Uniform (even) joint space narrowing is seen at all lesser metatarsophalangeal joints; some of these joints exhibit less than 100% apposition. The second through fourth toes angulate laterally relative to their respective metatarsals. Most findings are bilateral and relatively symmetrical.
Diagnosis: rheumatoid arthritis, including subluxation of lesser metatarsophalangeal joints.

psoriatic arthritis
psoriatic arthritis marked

Dorsoplantar view.
There are erosions along the medial and lateral aspects of the second and third metatarsal heads and probably along the medial aspect of the fourth metatarsal head. Uniform (even) joint space narrowing is seen at the third metatarsophalangeal joint.
Diagnosis: psoriatic arthritis.

psoriatic arthritis bilateral

Dorsoplantar views, different patient.
There are erosions(arrowheads) along the medial aspects of the right third through fifth metatarsal heads as well as along the lasteral aspect of the third metatarsal head. Unioform (even) joint space narrowing is seen at the third metatarsophalangeal joint. The left foot is relatively normal.
Diagnosis: psoriatic arthritis.

gout
gout marked

Dorsoplantar view.
Well-defined, C-shaped erosions (arrowheads) are seen along the medial aspects of both the first metatarsophalangeal and hallux interphalangeal joints. They are accompanied by overhanging margins of bone (arrows, aka Martel's sign).
Diagnosis: gouty arthritis.

short metatarsal
short metatarsal marked

Dorsoplantar view.
The fourth (4) metatarsal is short relative to the remaining metatarsals.
Diagnosis: brachymetatarsia.

long metatarsal
long metatarsal marked

Dorsoplantar view.
The third metatarsal is long relative to the first metatarsal and approximately at the same parabola level distally as the second metatarsal.
Diagnosis: elongated third metatarsal.

freiberg's disease
feiberg's disease marked

Medial oblique and two dorsoplantar views. This series of films were obtained over the course of two years in a 15-17 year old patient.
In the first image, there is a geographic decreased density (arrowhead) in the epiphysis that is surrounded by diffuse sclerosis (S) throughout the epiphysis and metaphysis.
In the second image, in addition to physeal closure, the third metatarsal distal head has collapsed onto the metaphysis (arrows). Diffuse scleriosis (S) is still present.
In the third image, the third metatarsal head has remodeled but is now flattened and enlarged from medial to lateral.
Diagnosis: post-traumatic (based upon history) epiphyseal osteonecrosis/Freiberg's disease.

old freiberg's disease

Dorsoplantar view, different patient from 8a.
The third metatarsal head is grossly deformed; it is flattened along its articular surface and there are osteophytes (arrows) medially and laterally. Subchondral sclerosis is also present.
Diagnosis: old, healed Freiberg's disease with secondary osteoarthritis.

impact fracture
impact fracture marked

Dorsoplantar view.
Ill-defined sclerosis (arrow) runs across the second metatarsal distal diametaphysis. The medial aspect of the head/neck is impacted upon the diaphysis (arrowheads; compare to the normal third metatarsal).
Diagnosis: impaction fracture.

stress fracture
stress fracture marked

DP view.
An ill-defined periosteal reaction (p) is seen along the medial and lateral aspects of the second metatarsal distal one-half diaphysis. There also is ill-defined increased density within the diaphysis at this location. A subtle cortical discontinuity (obliquely oriented) can be seen laterally, just medial to the letter "p".
Diagnosis: healing stress fracture (approximately three weeks old).

medial obliqu viewlateral view
a medial oblique marked blateral marked

Medial oblique (a) and lateral (b) views.
(a) The proximal phalanx base does not fully appose the metatarsal head (black arrow); there is approximately 85% apposition.
(b) Articular apposition can be viewed in the lateral view as well.
Diagnosis: subluxation of the second metatarsophalangeal joint.

DP VIEW medial obliqu viewlateral view
a dp view marked b medial oblique view marked
c lateral view marked

Dorsoplantar (a), medial oblique (b), and lateral (c) views.
(a) The base of the second toe proximal phalanx (white arrows) is fully superimposed upon the second metatarsal head (white arrowheads).
(b & c) The proximal phalanx base (arrowheads) does not appose (there is 0% apposition) the metatarsal head ("m" and outline) in either view.
Diagnosis: dislocation of the second metatarsophalangeal joint.

dp view axial view lateral view
a dp marked b axial marked
c lateral marked

Dorsoplantar (a), sesamoid axial (b), and lateral (c) views.
(a) The base of the hallux proximal phalanx and the medial eminence (e) of the first metatrsal head are absent; the remaining surfaces are well-defined and bounded by diffuse sclerosis. The second metatarsal ends more proximally relative to the first and third metarsal heads. The distal half of the second metatarsal head is absent, and an exostosis emantes lateral to that which is remaining. The first and second metatarsophalangeal joint spaces are decreased.
(b) The first and second metatarsal heads are superior to the level of the third metatarsal head (white line) in the coronal plane.
(c) Both the hallux (white arrow) and second toe (black arrow) proximal phalanges are dorsiflexed at their respective metatarsophalangeal joints.
Diagnosis: Keller bunionectomy and arthroplasty procedures have been performed on the first and second rays, respectively. Hammertoes. The metatarsal parabola is abnormal, and the third metatarsal is "plantarflexed" relative to the first and second metatarsals.

Should a radiographic study be ordered for evaluation of lesser metatarsal pathology?

Yes, if symptomatic.

What are the best views to order?

At a minimum, order dorsoplantar and lateral views. Sesamoid axial, medial oblique and/or lateral oblique views can be added when appropriate.

When should additional imaging studies be ordered?

Special studies are generally not indicated; however, ultrasound and MRI could be useful for assessing soft tissue pathology.

Related Information

Be able to distinguish between the characteristic radiographic features of rheumatoid and seronegative arthritis.

References:

  1. Christman RA: Foot and Ankle Radiology, 2nd edition, Lippincott Williams & Wilkins, 2015.