Ultrasound-guided Treatment of Morton's Syndrome: comparison among three different injection techniques
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1 Ultrasound-guided Treatment of Morton's Syndrome: comparison among three different injection techniques Poster No.: C-1701 Congress: ECR 2015 Type: Scientific Exhibit Authors: D. Orlandi, C. Messina, A. Corazza, G. Serafini, E. Silvestri, L M. Sconfienza ; Genoa/IT, Milan/IT, Pietra Ligure/IT, milano/it Keywords: Musculoskeletal soft tissue, Ultrasound, Puncture DOI: /ecr2015/C-1701 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 30
2 Aims and objectives METATARSALGIA Common clinical condition Acute sharp pain worsening during weight bearing / running Frequently associated with parahestesia and numbness of toes the pain often occurs in the area where the second, third and fourth toes meet the ball of the foot. Causes: Traumatic and degenerative changes of the I MTPJ (hallux valgus, stiffness) Intermetatarsal bursitis Morton's neuroma Sesamoid affections (sesamoiditis, dislocations, oveload, fractures) Metatarsal stress fractures nd 2 ray syndrome MORTON'S SYNDROME Described for the first time by Durlacher in 1845, Morton's syndrome is a neurophatic metatarsalgia caused by entrapment of the common plantar digital nerve between the metatarsal heads just distal to the intermetatarsal ligament. T. Morton in 1876 mistakenly attributed the characteristic symptoms of this condition to a subluxation of the metatarsophalangeal joint. The real "Morton's neuroma" is actually histologically characterized by an endo-perineural fibrosis and hyaline degeneration of interdigital nerve endonevrium The diagnosis is basically clinical: Burning pain at the level of a intermetatarsal web space that may radiate to the fingers or back along the midfoot / leg ± Associated with paresthesias F >>> M ( 78 % ), mean age 46 aa Overweight, use of narrow shoes or high heels are the main risk factors Particular clinical importance covers the Mulder maneuver (palpable click squeezing the metatarsal heads ) that reproduces the pain. Page 2 of 30
3 DYNAMIC US SCAN Patient prone or supine Axial dorsal and plantar scan on metatarsal heads Digital compression on the opposite site of the scan in order to enlarge the metatarsal space. Mulder manouvre (metatarsal Squeezing). Fig. 11 References: Department of Radiodiagnostic, University of Medicine Genova, San Martino University Interdigital scan Steroid injection, alchoolization and surgery are currently considered the standard of treatment. Recently, ultrasound-guided treatment has been described as more effective Page 3 of 30
4 than blind injections. Our aim was to compare three different US-guided injection techniques for Morton's syndrome. Page 4 of 30
5 Images for this section: Fig. 1 Page 5 of 30
6 Fig. 2 Page 6 of 30
7 Fig. 3 Page 7 of 30
8 Fig. 4 Page 8 of 30
9 Fig. 5 Page 9 of 30
10 Fig. 6 Page 10 of 30
11 Fig. 7 Page 11 of 30
12 Fig. 8 Page 12 of 30
13 Fig. 9 Page 13 of 30
14 Fig. 21 Page 14 of 30
15 Fig. 10 Page 15 of 30
16 Methods and materials Thirty patients (23 females; mean age 47±7.6 years) who presented at our department to be treated for Morton's syndrome were included in our study. They were treated by US-guided injection of steroid and local anhestetic in the affected web space. Patients were priory randomized into three homogeneous groups. Group A was treated using a co-axial plantar approach Fig. 20 References: Department of Radiodiagnostic, University of Medicine Genova, San Martino University Group B was treated using a interdigital US scan and a plantar approach Group C was treated using a longitudinal plantar US scan and a interdigital approach. Page 16 of 30
17 For each patient, we noted the efficacy of the treatment at 15,30, 60 days by a semiquantitative scale (from 0 to 3), pain during procedure evaluated using a VAS scale (pain score from 0 to 10), complication rate and procedure time. K and U Mann-Whitney statistics were used. Page 17 of 30
18 Images for this section: Fig. 12 Page 18 of 30
19 Fig. 13 Page 19 of 30
20 Fig. 14 Page 20 of 30
21 Fig. 15 Page 21 of 30
22 Fig. 16 Page 22 of 30
23 Fig. 17 Page 23 of 30
24 Fig. 18 Page 24 of 30
25 Fig. 20 Page 25 of 30
26 Results No immediate or delayed complication were observed in group A and B. One minor complication occurs in group C (haematoma). Group A shows a lower treatment efficacy than other groups. No differences were observed in terms of treatment efficacy between groups B and C at all time-points (median value=3 for both groups, p=n.s.). Pain during procedure was significantly lower in group C (mean VAS score=5.8±2.2) than in group B and C (7.2±2.4; p<.012). Procedure time was significantly lower in group A (mean time= 84±24 s) than in group B and C (122±32 s; p<.021). Page 26 of 30
27 Images for this section: Fig. 19 Page 27 of 30
28 Conclusion Conclusion US-guided treatment of trigger finger is more effective using a longitudinal US guidance that allows for a more precise injection in the site of pathology. Interdigital injection allows a significant reduction of pain perceived by patients during the procedure compared to plantar injection. Clinical relevance Normal 0 14 false false false IT JA X-NONE Perpendicular approach when performing an US-guided treatment of trigger finger allows for procedure time and pain reduction. Page 28 of 30
29 Images for this section: Fig. 22 Page 29 of 30
30 References Ultrasound-guided interventions of the foot and ankle. Yablon CM. Semin Musculoskelet Radiol Feb;17(1):60-8. Ultrasound-guided procedures around the wrist and hand: how to do. Orlandi D, Corazza A, Silvestri E, Serafini G, Savarino EV, Garlaschi G, Mauri G, Cimmino MA, Sconfienza LM. Eur J Radiol Jul;83(7): An injection of corticosteroid plus anesthetic was more effective than anesthetic alone for Morton neuroma. Schon L. J Bone Joint Surg Am Feb 19;96(4):334. Plantar approach for excision of a Morton neuroma: a long-term follow-up study.nery C, Raduan F, Del Buono A, Asaumi ID, Maffulli N. J Bone Joint Surg Am Apr 4;94(7): Morton neuroma: evaluated with ultrasonography and MR imaging. Lee MJ, Kim S, Huh YM, Song HT, Lee SA, Lee JW, Suh JS. Korean J Radiol Mar-Apr;8(2): Musculoskeletal ultrasound: how to evaluate for Morton's neuroma. Lee KS. AJR Am J Roentgenol Sep;193(3):W172. Page 30 of 30
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