My Toe is Short!

A congenital or idiopathic condition shown here is known as brachymetarsia. The toe isn’t actually the problem. The toe is roughly the correct size. The real issue is that one of the long bones in the foot, the metatarsal, is short. “Brachy” means short. Simple enough. A short bone, a toe that isn’t in the “right” place and a cosmetic concern.

How and why does this develop?

Shortened Toes

Shortened Toes

The short metatarsal occurs because of a premature closure of the growth plate. This is a rare condition, and is linked with a number of different medical conditions, yet, there is no exact understanding why this happens, just that it does. It doesn’t show up at birth, but, develops between the ages of 4 to 15 years old.1 For unknown reasons, females are tweny five times more likely to develop this condition. It usually appears with the 4th toe, but could happen to any of the toes, multiple toes, or even both feet, as seen above.

Diagnosis

With many conditions and topics, there is some discussion about how the diagnosis is made. In the case of brachymetatarsia, this is a straightforward diagnosis. Xrays confirm that the bone is indeed short. Other symptoms include pain and callus under the adjacent bones because of unequal weight distribution, floating toe, and shoe rubbing.

Treatment

Conservative treatments involve managing symptoms and treating the resulting soreness, blisters, callus, etc. This may include orthotic therapy, taping, and shoe gear modifications. Truthfully, this condition cannot be fully corrected without surgery. Three solutions include bone cuts that lengthen the bone, the insertion of a bone graft, and what is seen below, callus distraction. The problem with the first two options, although quicker, there is a risk of stretching the tissue out two quickly. The blood vessels and nerves can’t tolerate being pulled and stretched out to length when it is used to being short. The blood vessels spasm leading to lack of blood flow to the toe. The nerves give an immense pain signal. I have seen many successful surgeries of this manner, but this surgery allows the tendons, nerves, skin, and blood vessels to adapt slowly overtime. You see, fixing the bone with callus distraction is like fixing the teeth with braces: it is done SLOWLY! The surgeon doesn’t have to harvest bone graft for this surgery, with this process, can adjust the amount of correction achieved.

Lengthening Insertion

Lengthening Insertion

X-Rays Before, During, After

X-Rays Before, During, After

These are xrays of the before, during and after treatment. During surgery, a bone cut is made and the distraction device drilled into place. After surgery, the long road to recovery and a more cosmetic appearance begins. This involves multiple post-operative visits and xrays to assess bone growth and “callus” formation. A week after surgery, the distraction process begins. Most often, the rate of distraction is one millimeter per day, 4 separate turns of 0.25mm each. Your surgeon will be looking for the new bone growth called “callus.” Once the bone fills in overtime and adequate strength of the new bone is achieved, the distraction device is removed. The time that the distraction device is in place varies from patient to patient, but is typically in place for about 5 weeks and healing time is estimated between 69 and 82 days.(1)

Images:
1. footanklealliance.com
2. brachyfreeforme.wordpress.com
3. http://www.huffingtonpost.com/neal-m-blitz/brachymetatarsia-_b_3412033.html

Reference:
McGlamry, 4th edition. Textbook of Foot and Ankle Surgery

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