RU2797314C2 - Method for determining the position of the heads of the metatarsal bones - Google Patents

Abstract

FIELD: medicine; radiology.

SUBSTANCE: invention can be used to determine the position of the heads of the metatarsal bones. Before examining the foot, a special marking is applied to the platform. Then the patient places the feet on the platform in accordance with the markup, bringing the fingers closer to the front edge of the platform and the cassette and lifts the heel onto a 4 cm high stand without tearing the forefoot from the platform. Then, on the radiograph obtained, a horizontal line of support is drawn along the lower border of the soft tissues of the foot under the heads of the metatarsal bones. On the plantar surface of the heads of the 2nd, 3rd, 4th, 5th metatarsal bones and the sesamoid bone under the head of the 1st metatarsal bone, the lower points are marked, lines parallel to the horizontal line of support of the soft tissues of the foot are drawn through the marked points. These lines determine the high or low position of the heads of the 2nd, 3rd, 4th metatarsal bones relative to the heads of adjacent metatarsal bones. The position of the heads of the 2nd, 3rd or 4th metatarsal bones above or at the level of the heads of adjacent metatarsal bones is considered a variant of the norm, the position of the heads of the 2nd, 3rd or 4th metatarsal bones below the heads of adjacent metatarsal bones is considered a variant of deviation from the norm.

EFFECT: method provides a more objective study of the position of the heads of the metatarsal bones, simplification of the technology of placing the foot before radiography for the patient and the specialist, a specific definition of tactics when planning surgical treatment of the pathology of the forefoot and elimination of pain syndrome due to the combination of techniques of the claimed invention.

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Description

The present invention relates to the field of medicine, namely to X-ray examination of the foot, to orthopedics, and can be used in the treatment of adult patients with deformity of the toes and metatarsalgia for planning surgical intervention.

A known method of x-ray examination of the foot, including performing x-rays in a standing position on a special stand that allows you to raise the back of the foot by 20 degrees and the front of the foot by 10 degrees, placing the metatarsophalangeal joint at the lowest point ([1] Suzuki J, Tanaka Y, Takaoka T, Kadono K, Takakura Y 2004. Axial radiographic evaluation in hallux valgus: evaluation of the transverse arch in the forefoot J Orthop Sci 9:446-451 DOI: 10.1007/s00776-004-0800-9). The x-ray film is placed in the forefoot perpendicular to the floor. The X-ray source is placed 1 meter from the back of the foot and focused on the base of the foot at the head of the second metatarsal bone, creating an axial radiograph of the foot under load in the posterior direction to visualize the heads of the metatarsal bones. An analysis is made of the height of the heads of the metatarsal bones and sesamoid bones relative to the base of the foot, which touched the ground, in the normal group of subjects and in the group of patients with valgus deformity of the first toe (hallux valgus). For this purpose, the lowest points of the heads of all metatarsal bones, as well as the lowest points of the sesamoid bones, were noted on the obtained radiograph. The measurement results showed that in the normal group, the heads of the second and third metatarsals were significantly lower than the heads of the first metatarsal. In the "valgus deformity" group, the heads of the second and third metatarsal bones were significantly lower compared to those in the normal group. Also, the method made it possible to determine the position of the sesamoid bones in the region of the head of the first metatarsal bone.

This method has significant disadvantages:

1. If the patient has a pronounced deformity of the small toes, accompanied by contractures of the joints of the fingers, it will be difficult to correctly place the foot on the proposed stand so that the metatarsophalangeal joints are at the lowest point. In such a situation, when performing an axial radiograph, the x-ray image of the fingers will overlap the image of the heads of the metatarsal bones, preventing them from being clearly visualized. This will not allow for sufficiently objective calculations of the position of the heads of the metatarsal bones and sesamoid bones.

2. The method for performing radiography of the foot includes focusing the x-ray beam on the base of the foot at the head of the second metatarsal bone. To determine clinically precisely this landmark - the head of the second metatarsal bone on the foot, located in a special stand, may be impossible with the severity of soft tissues on the back of the foot, with deformities of the small fingers. The consequence of this may be a different location of the foot relative to the x-ray beam in different patients, that is, different conditions for performing x-rays can lead to an erroneous interpretation of the result of the study.

3. In analogy, on the obtained radiographs, the change in the height of the heads of the 1st, 2nd, 3rd metatarsal bones and sesamoid bones in hallux valgus was considered relative to similar parameters obtained in the group of patients without foot pathology. The method does not present the determination of the normal position of the heads of the 2nd, 3rd and 4th metatarsal bones and deviations from the norm.

Voigt Μ. 2009. The transverse forefoot arch demonstrated by a novel X-ray projection. Foot Ankle Surg. 15:7-13. DOI: 10.1016/j.fas.2008.04.004). Оба рентгенологических исследования проводились в положении стоя. Испытуемому предлагалось перенести весь свой вес на одну ногу, наклониться вперед и максимально нагрузить переднюю часть стопы, не поднимая пятку. Исследуемая конечность находится в положении сгибания в тазобедренном, коленном и голеностопном суставе. При рентгенологическом исследовании в передне-задней плоскости на рентгенограмме определяют разницу в длине плюсневых костей по отношению к 2 плюсневой кости, расстояние между плюсневыми костями и ширину переднего отдела стопы. При рентгенологическом исследовании в горизонтальной плоскости на рентгенограмме определяют высоту 2, 3, 4 плюсневой кости относительно «костной основы», которая в свою очередь представляет собой линию, соединяющую самую подошвенную часть сесамовидных костей и 5 плюсневой кости. На основе полученных результатов рентгенологического обследования пациентов случайной выборки были выведены формулы для расчета индивидуальной относительной длины и высоты плюсневых костей для использования в качестве инструментов предоперационного планирования при реконструкции переднего отдела стопы.Closest to the present invention is a method of X-ray examination of the feet, which consists in conducting radiography under static load in two planes: the anterior-posterior plane with the direction of the x-ray beam 10 degrees caudally, and the horizontal plane with a new direction of the beam from the medial side of the foot at an angle of 20 degrees anteriorly , which made it possible to visualize the heads of all five metatarsal bones ([2] Simonsen O, Vuust M, Understrup B,

Voigt M. 2009. The transverse forefoot arch demonstrated by a novel X-ray projection. Foot Ankle Surg. 15:7-13. DOI: 10.1016/j.fas.2008.04.004). Both X-ray examinations were performed in the standing position. The subject was asked to transfer all his weight on one leg, lean forward and load the front part of the foot as much as possible without lifting the heel. The examined limb is in the position of flexion in the hip, knee and ankle joints. An X-ray examination in the anterior-posterior plane on the radiograph determines the difference in the length of the metatarsal bones in relation to the 2nd metatarsal bone, the distance between the metatarsal bones and the width of the forefoot. X-ray examination in the horizontal plane on the radiograph determines the height of the 2nd, 3rd, 4th metatarsal bones relative to the "bone base", which in turn is a line connecting the most plantar part of the sesamoid bones and the 5th metatarsal bone. Based on the obtained results of radiological examination of patients in a random sample, formulas were derived for calculating the individual relative length and height of the metatarsal bones for use as preoperative planning tools for forefoot reconstruction.

However, the known method has significant disadvantages: 1. In this method, the X-ray examination is carried out in an uncomfortable position for the patient, when the supporting leg is in the position of flexion in the hip, knee and ankle joint. In elderly patients, patients with diseases and contractures of the joints of the lower extremities, this study may not be feasible.

2. When walking at the beginning of the push phase, when the heel breaks away from the support surface, a roll occurs and the leg support is transferred to the heads of the metatarsal bones ([3] Kardanov A.A. Surgical correction of foot deformities - Moscow: MEDPRAKTIKA-M Publishing House, 2016, 220 pp. (p. 15)). When resting on the entire foot in a standing position, without raising the heel, it is impossible to give the maximum load on the area of the heads of the metatarsal bones. Due to insufficient load on the forefoot, an unobjective x-ray picture and unreliable information about the position of the metatarsal heads can be obtained.

3. There is no scheme for placing the patient's foot relative to the X-ray source with clear guidelines for directing the X-ray beam at an angle of 20 degrees, which may affect the reliability of determining the position of the heads of the metatarsal bones.

4. In the prototype, when determining the height of the 2nd, 3rd, 4th metatarsal bones on the radiograph, the height of the soft tissues under the heads of the metatarsal bones is not taken into account, but calculations are made relative to the "bone base". When walking under the load of body weight, not only the heads of the metatarsal bones fall, but also the soft tissues under the heads. It is in the soft tissues that, due to the redistribution of the load, painful corns (hyperkeratosis) are formed, accompanying metatarsalgia and deformities of the toes.

The technical result of the proposed method is a more objective study of the position of the heads of the metatarsal bones, simplification of the technology of placing the foot before radiography for the patient and the specialist, a specific definition of tactics when planning surgical treatment of the pathology of the forefoot and elimination of pain.

The result of the invention is achieved by the fact that before examining the foot, markings are applied to the platform, first an axial line is drawn that coincides with the direction of the X-ray machine beam, perpendicular to the front edge of the platform, a point is marked on this line at a distance of 20 cm from the front edge of the platform, through which crossed lines at an angle of 20 degrees relative to the center line to examine the right or left foot. The cassette of the X-ray apparatus is placed in front of the foot perpendicular to the horizontal plane of the platform, and the X-ray tube is placed behind the subject.

Then, under the guidance of a specialist, the patient places the inner edge of the foot on the platform on a crossing line, while bringing the fingers closer to the front edge of the platform and the cassette. The examined patient raises the heel on a stand 4 cm high without tearing the forefoot from the platform. After performing radiography on the radiograph, a horizontal line of support is drawn along the lower border of the soft tissues of the foot under the heads of the metatarsal bones. On the plantar surface of the heads of the 2nd, 3rd, 4th, 5th metatarsal bones and the sesamoid bone under the head of the 1st metatarsal bone, the lower points are marked, lines parallel to the horizontal line of support of the soft tissues of the foot are drawn through the marked points. These lines determine the high or low position of the heads of the 2nd, 3rd, 4th metatarsal bones relative to the heads of adjacent metatarsal bones. The position of the heads of the 2nd, 3rd or 4th metatarsal bones above or at the level of the heads of adjacent metatarsal bones is considered as a variant of the norm, the position of the heads of the 2nd, 3rd or 4th metatarsal bones below the heads of adjacent metatarsal bones is considered as a variant of deviation from the norm.

Conducted patent information studies on subclass A61B 6/00, 6/04, A61B 5/00 and analysis of scientific and medical information, reflecting the current level of technologies for determining the position of metatarsal heads, did not reveal identical technologies. From the presented analysis of the proposed technical solution and known methods, it was concluded that the proposed technology differs in the above methods and meets the criterion of the invention "novelty".

During the clinical testing of the proposed technology and the analysis of the results obtained, the authors revealed the following advantages:

1. The application of special markings on the platform before examining the foot makes it possible to unify the process of performing X-ray examination of the patient's foot in the horizontal plane, to provide convenience and simplification of diagnostics for the specialist and the patient.

2. Drawing crossed lines 20 cm away from the platform and at an angle of 20 degrees relative to the center line, placing the inner edge of the patient's foot on the platform on the crossing line, bringing the fingers closer to the front edge of the platform and the cassette, allows you to correctly position the foot to focus the beam x-rays to the center of the transverse arch of the foot to obtain a clearer and optimal visualization of the heads of all metatarsal bones.

3. The position of the patient's foot with a raised heel on a stand 4 cm high allows simulating the push phase when walking, when the maximum load of the body weight is transferred to the heads of the metatarsal bones. This provides an image of the actual position of the heads of the metatarsal bones in a particular patient on the radiograph.

4. Drawing a horizontal line of support along the lower border of the soft tissues of the foot under the heads of the metatarsal bones, relative to which parallel lines are drawn under the heads of the 2nd, 3rd, 4th, 5th metatarsal bones and the sesamoid bone under the head of the 1st metatarsal bone, allows you to take into account the support function of the soft tissues under the heads metatarsal bones, which fall under the greatest load of body weight when walking, which can lead to pain syndrome, the formation of rough painful corns, disrupt the function of the foot, the patient's gait and require prompt elimination of this position and raising the head of the metatarsal bone.

5. According to the marked lower points of the heads of the 2nd, 3rd, 4th metatarsal bones and the sesamoid bone under the head of the 1st metatarsal bone and the lines drawn through them parallel to the horizontal line of support of the soft tissues of the foot, it allows quite simply to determine the high or low position of the heads 2, 3, 4 metatarsal bones relative to the heads of adjacent metatarsal bones.

6. An assessment of the position of the heads of the 2nd, 3rd or 4th metatarsal bones above or at the level of the heads of adjacent metatarsal bones is considered as a variant of the norm, and the position of the head of the 2nd, 3rd or 4th metatarsal bone below the heads of adjacent metatarsal bones is considered as a variant of deviation from the norm, which allows you to determine the tactics when planning surgical treatment of the pathology of the forefoot. The choice of optimal tactics allows to reduce the risk of postoperative complications (transient metatarsalgia, finger deformities).

From the foregoing, it follows that the proposed method for determining the position of the heads of the metatarsal bones meets the criterion of the invention "inventive step".

The proposed technology is intended for use in practical healthcare in orthopedic and traumatological clinics to determine the surgical tactics for the treatment of toe deformities, metatarsalgia, and meets the criterion of the invention "industrial applicability".

The method for determining the position of the heads of the metatarsal bones is illustrated by illustrations, which show:

Fig. 1 - scheme of special markings on platform 1 for placing the foot of the patient being examined;

Fig. 2 - layout of the foot of the examined patient on platform 1 before radiography;

Fig. 3 - photo of the plantar surface of the left foot of patient B., zone of hyperkeratosis (painful corns);

Fig. 4 - radiograph of patient B. with lines drawn to determine the position of the heads of the metatarsal bones relative to the horizontal line of support along the lower border of the soft tissues under the heads of the metatarsal bones before surgery:

1a - line under the sesamoid bone,

2a - line under the head of the 2nd metatarsal bone,

3a - line under the head of the 3rd metatarsal bone,

4a - line under the head of the 4th metatarsal bone,

5a - line under the head of the 5th metatarsal bone,

2 b - the line of the planned surgical correction of the position of the head of the 2nd metatarsal bone,

3 b - the line of the planned surgical correction of the position of the head of the 3rd metatarsal bone;

Fig. 5 - radiograph of patient B. after surgery with the restored normal position of the metatarsal heads relative to the horizontal line of support along the lower border of the soft tissues under the metatarsal heads:

1a - line under the sesamoid bone,

2c - line under the head of the 2nd metatarsal bone in the corrected position,

3c - line under the head of the 3rd metatarsal bone in the corrected position,

4c - line under the head of the 4th metatarsal bone in the corrected position,

5a - line under the head of the 5th metatarsal bone.

We explain some of the positions used in the presented layout of the patient's foot on platform 1:

1 - platform of the x-ray machine,

2 - longitudinal center line in the center of platform 1,

3 - a point on the longitudinal line at a distance of 20 cm from the front edge of the platform 1,

4 and 5 - crossing lines at an angle of 20 degrees, drawn through point 3 to examine the right or left foot of the patient,

6 - x-ray tube,

7 - cassette,

8 - heel support,

9-horizontal line of support along the lower border of the soft tissues under the heads of the metatarsal bones,

10 - hyperkeratosis (painful corns) on the foot of patient B. before surgery.

The essence of the proposed "Method for determining the position of the heads of the metatarsal bones" is as follows:

The position of the heads of the metatarsal bones is determined by X-ray examination. Before X-ray examination of the patient's foot on the horizontal surface of the platform (1) put a special markup (see Appendix to the description of the application for the invention, figure 1). On the horizontal surface of the platform (1), an axial line (2) is drawn perpendicular to its front edge, which runs in the direction of the central X-ray beam. Next, point (3) is marked on the center line (2), stepping back from the front edge of the platform (1) - 20 cm. Crossing lines (4) and (5) are drawn through point (3) at an angle of 20 degrees to the center line (2) to examine the right or left foot of the patient.

Perform radiography of the foot under static load in the horizontal plane. The examined patient stands on a special platform (1), holding hands on the railing. The X-ray tube (6) is located behind the foot of the examined patient, the cassette of the X-ray machine (7) is in front of the foot perpendicular to the horizontal plane of the platform (1), tightly pressed against the front edge of the platform (1). To determine the position of the heads of the metatarsal bones, the patient is recommended to stand on the platform (1), place the inner edge of the examined foot on the crossing line (4) or (5), respectively, for the right or left foot, bring the fingers closer to the front edge of the platform (1) and the cassette (7 ). The examined patient lifts the heel on the stand (8) 4 cm high, without lifting the forefoot from the platform (1). The patient lifts the intact foot, holding it above the platform (1), while transferring the body weight to the foot under study (see the appendix to the description of the application for the invention, Fig. 2).

An x-ray of the examined patient's foot is performed, directing the central beam of x-ray radiation anteriorly horizontally, perpendicular to the cassette (7), from the medial side of the foot. With this installation of the foot, the heads of the five metatarsal bones are visualized.

During preoperative planning, the necessary calculations are made on the obtained radiograph. First, a horizontal line of support is drawn along the lower border of the soft tissues of the foot (9) under the heads of the metatarsal bones. On the plantar surface of the 2nd, 3rd, 4th, 5th heads of the metatarsal bones and the sesamoid bone, under the head of the 1st metatarsal bone, the lower points are marked. Through the marked points, lines are drawn parallel to the horizontal line of support of the soft tissues of the foot (9) under the heads of the metatarsal bones, and these lines determine the high or low position of the heads of the 2nd, 3rd, 4th metatarsal bones relative to the heads of adjacent metatarsal bones.

The position of the heads of the 2nd, 3rd, or 4th metatarsal bones above or at the level of the heads of adjacent metatarsal bones is considered as a variant of the norm, the position of the heads of the 2nd, 3rd, or 4th metatarsal bones below the adjacent heads of the metatarsal bones is considered as a variant of deviation from the norm.

If the metatarsal head is located below the adjacent metatarsal heads, surgical treatment is recommended to increase the height of the metatarsal head and reduce the risk of increased load on the soft tissues under the metatarsal head, the development of metatarsalgia, deformity of the small toe and pain.

The essence of the proposed method is illustrated by a clinical example:

Patient B., 51 years old. Admitted to the clinic FSBSI "INTSCT" for surgical treatment with a diagnosis of Left-sided transverse-longitudinal flat feet II-III degree. Metatarsalgia under the heads of the 2nd and 3rd metatarsal bones of the left foot, hyperkeratosis. From the anamnesis, the patient previously (2 years ago) underwent surgery for hallux valgus of the first toe of the left foot (hallux valgus). In the postoperative period, pain appeared on the plantar surface of the left foot under the heads of the 2nd and 3rd metatarsal bones, aggravated by walking, painful corns (10) formed in this area (see the appendix to the description of the application for the invention, Fig. 3), a complication developed - metatarsalgia .

The presence of pain and painful hyperkeratosis under the heads of the 2nd and 3rd metatarsal bones was a direct indication for surgical treatment in the following scope: corrective osteotomy of the 2nd and 3rd metatarsal bones to raise their heads and remove the soft tissues under the heads of the 2nd and 3rd metatarsal bones from the body weight bones. This well-known tactic will eliminate metatarsalgia and normalize the soft tissue structure of the plantar surface of the foot.

To clarify the diagnosis and prevent the development of possible complications (transient metatarsalgia, deformity of the fingers) before surgical treatment, the position of the heads of the metatarsal bones was assessed according to the proposed method.

An x-ray examination was performed in a standing position on a special platform with markings applied on it for the correct position of the foot. The inner edge of the left foot was placed on a crossing line, the fingers were close to the front edge of the platform and the cassette. The patient lifted her heel on a stand (8) 4 cm high without lifting the forefoot from the platform. The X-ray tube (6) was located behind the patient (see the appendix to the description of the application for the invention, Fig. 1).

After performing radiography on the radiograph, a horizontal line of support was drawn along the lower border of the soft tissues of the foot (9) under the heads of the metatarsal bones. On the plantar surface of the heads of the 2nd, 3rd, 4th, 5th metatarsal bones and the sesamoid bone under the head of the 1st metatarsal bone, the lower points are marked, lines are drawn through the marked points parallel to the horizontal line of support of the soft tissues of the foot (9): 1a, 2a, 3a, 4a 5a (see appendix to the description of the application for the invention, Fig. 4).

Additional lines 2b, 3b were also noted, indicating the new elevated position of the heads 2 and 3 of the metatarsal bone, in which they will be after performing the planned known surgical intervention (see appendix to the description of the application for the invention, Fig. 4).

When using the proposed method, a lower location of the line of the head of the 4th metatarsal bone (4a) relative to the line of the head of the 5th metatarsal bone (5a) and the additional line of the head of the 3rd metatarsal bone (3b) was revealed, which can be considered as a variant of deviation from the norm (see Appendix to description of the application for the invention, Fig. 4). In the event of a planned osteotomy of the 2nd and 3rd metatarsal bones, the head of the 4th metatarsal bone will be lower than the heads of adjacent metatarsal bones, which will lead to an increase in the load on the soft tissues under the head of the 4th metatarsal bone and the development of transient metatarsalgia, deformity of the 4th toe and pain.

As a result of the analysis, the chosen tactics were changed and a surgical intervention was planned to increase the height of the heads of the 2nd, 3rd and 4th metatarsal bones relative to the horizontal line of support at the border of the soft tissues (9) under the heads of the metatarsal bones: corrective osteotomy of the 2nd, 3rd and 4th metatarsal bones, fixation with screws.

The patient underwent surgical treatment according to the chosen plan. After the operation, an X-ray of the left foot was performed. On the control radiograph, the necessary points and lines were marked: 1a 2c, 3c, 4c, 5a, and it was determined that the position of the heads 2, 3 and 4 of the metatarsal bone refers to the normal variant (see Appendix to the description of the application for the invention, Fig. 5 ).

In the postoperative period, dynamic observation revealed no complications, development of metatarsalgia, deformities of the toes. The patient is completely satisfied with the cosmetic and functional results of the treatment, the pain syndrome was stopped, painful corns were eliminated, and it became possible to wear standard shoes.

Using the proposed method for determining the position of the heads of the metatarsal bones, 20 patients were examined after reconstructive surgery for deformity of the toes. As a result of the analysis of the obtained radiographs, the following was established:

In 10 patients who did not complain and did not have postoperative complications, the position of the heads of the 2nd, 3rd, or 4th metatarsal bones above or at the level of the heads of adjacent metatarsal bones was established by X-ray, which made it possible to evaluate it as a variant of the norm.

In the other 10 patients in the postoperative period, transient metatarsalgia was observed, manifested by pain and painful corns on the sole under the metatarsal head. Analysis of radiographs in this group of patients showed that the heads under which metatarsalgia developed were below the heads of adjacent metatarsal bones. This mutual position of the heads of the metatarsal bones was defined as a variant of deviation from the norm. Patients with abnormalities underwent reconstructive surgery.

Thus, the proposed "Method for determining the position of the metatarsal heads" in comparison with other known technologies provides a more objective study of the position of the heads of the metatarsal bones, simplification for the patient and the specialist of the stage of placing the foot before taking radiography, the quality of the study of the forefoot will subsequently clearly determine tactics in planning surgical treatment of forefoot pathology.

Sources of information taken into account:

1. Suzuki J, Tanaka Y, Takaoka Τ, Kadono Κ, Takakura Υ. 2004. Axial radiographic evaluation in hallux valgus: evaluation of the transverse arch in the forefoot. J Orthop Sci. 9:446-451. DOI: 10.1007/s00776-004-0800-9.

Voigt M. 2009. The transverse forefoot arch demonstrated by a novel X-ray projection. Foot Ankle Surg. 15:7-13. DOI: 10.1016/j.fas.2008.04.004.2 Simonsen O, Vuust M, Understrup B,

Voigt M. 2009. The transverse forefoot arch demonstrated by a novel X-ray projection. Foot Ankle Surg. 15:7-13. DOI: 10.1016/j.fas.2008.04.004.

3. Kardanov A.A. Surgical correction of foot deformities - Moscow: MEDPRAKTIKA-M Publishing House, 2016, 220 p. (p.15).

Claims (1)

A method for determining the position of the heads of the metatarsal bones, including an X-ray examination of the foot in a standing position on a platform with a static load on the examined foot, the direction of the beam of the X-ray machine anteriorly from the medial side of the foot, characterized in that before examining the foot, markings are applied to the platform, first an axial line is drawn, coinciding with the direction of the beam of the X-ray machine, perpendicular to the front edge of the platform, a point is marked on this line at a distance of 20 cm from the front edge of the platform, through which crossing lines are drawn at an angle of 20 degrees with respect to the center line to examine the right and left foot, while the cassette the X-ray machine is placed in front of the foot perpendicular to the horizontal plane of the platform, and the X-ray tube is behind the subject, then the patient places the inner edge of the foot on the platform on a crossing line, while the fingers are brought closer to the front edge of the platform and the cassette, then the subject raises the heel on a stand with a height of 4 cm, without detaching the forefoot from the platform, after performing radiography on the radiograph, a horizontal line of support is drawn along the lower border of the soft tissues of the foot under the heads of the metatarsal bones, then on the plantar surface of the heads of 2, 3, 4, 5 metatarsal bones and the sesamoid bone under head 1 the lower points of the metatarsal bone are marked, lines parallel to the horizontal line of support of the soft tissues of the foot are drawn through the marked points, and along these lines the high or low position of the heads of 2, 3, 4 metatarsal bones relative to the heads of adjacent metatarsal bones is determined, while the position of the head is 2, 3 or 4 metatarsal bones above or at the level of the heads of adjacent metatarsal bones are considered as a variant of the norm, the position of the head of the 2nd, 3rd or 4th metatarsal bone below the heads of adjacent metatarsal bones is considered as a variant of the deviation from the norm.

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