summary Bunionette Deformities, commonly called tailor's bunion, are prominences on the lateral aspect of the 5th metatarsal head that most commonly occur as a result of compression of the forefoot. Diagnosis is made clinically with presence of a prominence on the lateral aspect of the 5th metatarsal head, often associated with pain and callus formation. Treatment can be nonoperative with shoe modifications for mild and minimally symptomatic cases. Surgical management is indicated for progressive deformity and difficulty with shoe wear Epidemiology Demographics commonly seen in adolescents and adults 2-4x more common in women often bilateral deformities Etiology Pathophysiology mechanism of disease extrinsic causes compression of forefoot (e.g. tight shoes) abnormal loading on the lateral aspect of the foot intrinsic causes congenital deformities (e.g. splayfoot, brachymetatarsia) inflammatory arthropathies residual malalignments from surgery pathoanatomy boney prominence +/- bursitis over lateral aspect of 5th metatarsal head increased 4-5 intermetatarsal angle (normal 6.5-8 degrees) increased lateral deviation angle (normal 0-7 degrees) increased width of MT head (normal <13mm) lateral bowing of the 5th metatarsal bone Associated conditions varus MTP joint pes planus Classification Bunionette Deformity Classification Type I Enlarged 5th MT head or lateral exostosis Type II Congenital bow of 5th MT, normal 4-5 IMA Type III Increased 4-5 IMA (most common) Presentation History effect on activities and employment Symptoms cosmetic deformity medial deviation of 5th toe prominence of the 5th metatarsal head pain lateral bunion plantar callus worse with constrictive shoe wear Physical exam inspection plantar or lateral hyperkeratosis widened forefoot erythema and swollen 5th bunion check shoe wear motion often painless passive ROM of 5th MTP joint Imaging Radiographs recommended views standard weight-bearing films, dorsoplantar, lateral & oblique films characteristic findings increased 4-5 IMA (normal 6.5-8 degrees) increased lateral deviation angle (normal 0-7 degrees) increased width of MT head (normal <13mm) CT scan indications ancillary studies rarely required may be used if there is associated trauma or malignancy Treatment Nonoperative NSAIDS, shoe wear modification, orthotics, keratosis padding, callous shaving indications indicated as first-line treatment of all types asymptomatic deformities techniques semi-rigid shoe inserts wide based shoes stretching the forefoot of existing shoes outcomes 75-90% success rate Operative lateral condylectomy indications symptomatic Type I deformities technique resection of lateral third of the 5th MT head combine with tightening of lateral MTP joint capsule outcome does not require extended period of immobilization distal metatarsal osteotomy indications Type 2 and 3 deformities if IMA is < 12 degrees technique different techniques described chevron-medializing osteotomy (most common) distal transverse osteotomy peg-and-slot type osteotomy stepcut osteotomy better stability of fragments with internal fixation (e.g. K-wire or screw) may be combined with distal condylectomy and tightening of lateral capsule outcomes chevron osteotomy is biomechanically the strongest construct compared to the other proximal osteotomies oblique diaphyseal rotational osteotomy indications symptomatic Type 2 and 3 if IMA is > 12 degrees technique shave plantar aspect 5th MT head if plantar callosity present proximal osteotomy should be avoided due to poor blood supply in this region of the metatarsal fixation achieved with screw outcomes may produce 5th MT shortening metatarsal head resection indications salvage procedure only leads to unacceptable instability of MTP joint Complications Recurrence is the most common complication with condylectomy alone Transfer metatarsalgia seen with isolated metatarsal head resection Claw toe