Juvenile Bunions

COMMONLY ASKED QUESTIONS ABOUT BUNIONS IN CHILDREN AND TEENAGERS
By:  Robert H. Sheinberg, D.P.M., D.A.B.F.A.S., F.A.C.F.A.S. 

Bunions are hereditary conditions that can occur at a very early age.  We have seen in our office the presence of bunions as early as age one.  An abnormal drifting of the big toe starts to take place.  It starts moving towards the second toe causing a bone on the inside of the foot (first metatarsal, bunion) to become prominent.  These deformities are hereditary and when seen in early childhood have a great propensity for getting worse during the teenage years.  These juvenile bunions are often worse than their parents’ or grandparents’. 

They are often associated with flatfeet in young children.  Flatfeet cause instability of the foot creating loose ligament structures and splaying of the foot.  Abnormal bone structure (cuneiform) in the middle portion of the foot is also commonly seen on x-rays with this early deformity.  The earlier the deformity is seen, the worse the deformity develops over time. 

Treatment of bunions in a juvenile are directed at wearing comfortable shoes with a wide toe box that accommodate the width of the forefoot.  This takes pressure off of the bone and allows the bunion to be pain free.  Orthotics are of benefit in reducing the flatfoot deformity and the abnormal forces that take place in the big toe joint.  They help to lessen the progression of the deformity but have no chance in eliminating the problem.  Stretching the big toe joint towards the inner foot (away from its abnormal position) and night splinting may be of limited benefit.

Due to the nature of the child’s foot and the growth plate centers that are present, bunion surgery should be delayed until about the age of twelve.  The area of most bunion corrections is away from the primary growth center in the first metatarsal bone.  If the deformity is severe the growth plate in the back portion of the first metatarsal may need to close (age 12-14) before surgery is performed.

More mild to moderate deformities are corrected via a Chevron osteotomy.  The first metatarsal bone is cut and the bunion is pushed back into the foot.  More severe deformities require movement of the entire first metatarsal bone into its proper position and fusing the first metatarsal to the cuneiform to correct the deformity and the instability that has developed in the foot. 

Complications following bunion surgery are uncommon.  If a flatfoot deformity is present and the bone is corrected on the bunion itself (Chevron) there is a small chance for recurrence.  If the deformity is corrected by fusing the first metatarsal cuneiform joint (Lapidus) the recurrence rate is extremely low. 

Commonly Asked Questions:

  1. What is this large bump on the inside of my foot?  It is called a bunion.  A bone is becoming more prominent on the inside of the foot.  It is part of your normal foot and not a growth of new bone.  The foot bones are starting to spread out, making the bone (bunion)  more prominent.

  2. What is the cause of bunions?  Most commonly bunions are hereditary.  Tight shoes will often bring out the problem sooner.  Poor foot structure (i.e. flatfeet) may also contribute to the bunion deformity.

  3. Can I avoid getting bunions if my mother and grandmother have them?  Generally not.  You may wear shoes that are wider in the toe box.  This may delay the onset of bunions and prevent them from getting very painful.  Eventually, a bunion will usually appear.

  4. Will exercises of the toe or wearing of pad between my toes help to lessen the bunion deformity?  Pulling the big toe away from the second toe and wearing a toe spacer will be of limited benefit in the long term prevention of bunions.

  5. Do bunions get worse?  Over time the bones in the feet spread out further making a bunion appear larger.  It may take months to many years, but bunions  will almost always get worse over time.

  6. Will I develop arthritis in the area?  Over the years the big toe joint will become affected by the bones in the foot separating.  Cartilage will start to wear thin and some degree of arthritis will develop.  It may be mild causing pain occasionally with movement of the toe or severe, causing pain with every step.  The arthritis that may develop is different from the pain directly on the bunion. 

  7. What causes the pain over the bunion?  Shoes that are narrow put pressure on the skin, nerves and bone (bunion).  Numbness or tingling may also develop over the bunion as the nerve gets compressed against the bunion by tight shoes.

  8. What can be done to help this condition?  Wider shoes are the first step in the treatment process.  This will take pressure off of the skin, nerves and bunion.  If the foot is functioning poorly, an orthotic (custom-molded inserts into the shoes) will help.  Occasionally medication and physical therapy will be of some short-term benefit in lessening the pain on the bunion.

  9. Can the bunion be corrected?  Bunions can be corrected surgically if the bunion is painful and it is unresponsive to conservative care.  In some cases small bunions hurt much more than large bunions.  It has to do more with the bone structure of the metatarsal.

  10. What is the process of getting it corrected?  Surgical correction may take place after a thorough history and physical examination.  X-rays are performed to see the degree of bunion deformity.  A treatment plan is then formulated based on the physical findings and lifestyle of the patient.  Surgery to correct bunions is done on an outpatient basis and patients choose the type of anesthesia they prefer.  Some choose to go completely to sleep and others to be minimally sedated.  Surgical procedures to correct bunions take less than one hour to perform and they are done in an outpatient surgery center.

  11. How is the bunion corrected?  There are tight tendons and ligaments in the foot that need to be loosened and loose tendons and ligaments that need to be tightened during the surgical procedure.  A small sliver of bone is taken off of the bunion.  The bone that is sticking out is then precisely cut with a special saw and positioned back into the foot.  This allows the big toe to be straightened and the bunion to be completely eliminated.  The position is held by a small pin or screw that can be removed at a later time if painful.

  12. Is it painful to have bunion surgery?  When done correctly by an experienced surgeon minimal pain is involved in correction bunions.

  13. Can I walk on my foot immediately after bunion surgery?  We advise people to stay off their foot for two or three days. 

  14. How quickly can I return to work after bunion surgery?  Usually requires four days of rest at home before returning to work.  A special surgical shoe or boot is given to take stress off the area and prevent problems from developing postoperatively. 

  15. How long will it take to get back into normal shoes?  For everyone it is different.  It will usually take four to six weeks to get back into sandals, flat shoes or sneakers.  Small heels may take 2-3 months.  High heels can usually be worn after three months. 

  16. Will I be able to resume sports after bunion surgery?  Stationery bicycles may be used 1-2 weeks after surgery.  Running sports and activities may require six or more weeks.

  17. Would I be able to wear high-heeled shoes after the bunion is corrected?  In almost all cases, yes. 

  18. Will the bunion recur?  In most cases it will not if the surgery is done properly.  Patients with flatfeet are more susceptible to recurrence many years later.  Orthotics are often used to help prevent recurrence of bunion deformities. 

  19. I had bunion surgery many years ago and it has come back.  Can I do something about it?  Yes.  If the surgical procedure is done correctly a second time, the results may be outstanding provided that there are no arthritic changes in the joint.

  20. I have heard terrible things about bunion surgery.  Why?  Techniques have changed dramatically over the last 20 years.  Bunions used to be shaved off, leaving the joint uncorrected.  Pain and recurrence were common.  When performed by an experienced Board Certified Podiatric Surgeon results are usually excellent.  The doctors at Foot, Ankle & Leg Specialists of South Florida have performed thousands of bunion surgeries with great success and minimal complications.

  21. Are there any risks in doing bunion surgery? Any operation carries some risk.  These can include infection (less than 1%), excessive scarring (rare and can be treated if present), delay in healing (more common in smokers), overcorrection (less than 5%. where the big toe drifts excessively to the inside of the foot), joint stiffness (normal after surgery and restored with time and physical therapy), swelling (common after any bone or soft tissue surgery), numbness along the incision (usually temporary) and recurrence of the deformity (more common in flatfooted people.

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Anterior posterier view of the foot demonstrates a Hallux Valgus (bunion) deformity in a young teenager. The closing growth plate of the 1st metatarsal can be seen at the base of the metatarsa (left). Post-surgical correction of the bunion (right) eliminated the pain from the bunion bump and corrects the great toe into straight position.

 

Pre and Postop Juvenile Bunion and Flaftfoot Correction Together

This is another case of pre and post-surgical correction of bunion deformity with pin fixation of the osteotomy to the distal 1st metatarsal.

 

Pics Pre and Post Bunionectomy and hammertoe correction on young  girl

This is a series of pic of a 4 year old girl with a juvenile bunion and flatfeet

Intraop pic of the deviated first metatarsal head and the medial incision prior to osteotomy

The V osteotomy (Chevron) of the first metatarsal and sliding of the head to correct the bunion

The osteotomy after the medial excess bone is removed and prior to pin fixation

First metatarsal osteotomy with pin fixation

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