19 Jan Tailor’s Bunion
The tailor’s bunion (also known as bunionette) is a painful bony prominence on the lateral aspect of the fifth metatarsophalangeal joint. It occurs in many individuals and is usually painless. It is seen most commonly in adolescents and adults (mean age 28 years) with women more than twice as likely to develop it.
There are various factors that contribute to the development of a tailor’s bunion. These include structural causes, such as a prominent lateral condyle, a plantarflexed fifth metatarsal, a splay foot deformity, lateral bowing of the fifth metatarsal, or a combination of these deformities. There may be hypertrophy of the soft tissues over the lateral aspect of the metatarsal head as well. Other factors that may contribute to its development include m a varus fifth toe, hallux valgus with abnormal pronation of the fifth metatarsal, hindfoot varus, and flatfoot.
The tailor’s bunion may or may not be painful. When pain is a symptom, it tends to be exacerbated by footwear as the prominence of the fifth metatarsal head results in increased pressure from shoes. There may be localized swelling and/or callus formation as well. On examination, it appears as a lateral or plantar-lateral prominence of the fifth metatarsal head. It may be tender to touch and there may be an overlying adventitial bursa or hyperkeratotic lesion. There may also be adduction deformity of the fifth toe.
X-ray imaging may be performed, which reveals an increase in the fourth and fifth intermetatarsal angle. There may be bowing of the fifth metatarsal on x-ray images as well. The lateral deviation angle at the distal third of the shaft of the fifth metatarsal may be increased as well. Furthermore, there may be a lateral exostosis of the fifth metatarsal head.
The management of the tailor’s bunion varies based on the clinical picture. If asymptomatic, then the focus should be on patient education especially regarding footwear. If the condition is symptomatic with pain, nonsurgical treatment of tailor’s bunion deformity is focused on alleviating pressure and irritation over the fifth metatarsal head and includes footwear modifications and debridement of associated hyperkeratotic lesions. Orthotics may be useful if asymptomatic tailor’s bunion results from excessive subtalar joint pronation. If there is associated bursitis, injection therapy may be considered. Orthoses and padded insoles may be considered if there is associated hindfoot varus or flatfoot deformity. NSAIDs are often taken to control pain and inflammation.
Surgery may have to be considered for patients who have failed conservative management. The goal of surgical treatment is to decrease the lateral prominence of the fifth metatarsal, and there are multiple approaches that can be taken based on physical evaluation and x-ray findings. These include exostectomy and osteotomies. Proximal osteotomy can be considered for large deformities. In cases where the deformity is unresectable, resection of the fifth metatarsal head has to be performed. If the condition recurs, especially due to undercorrection from the initial procedure, then revision surgery may be considered.