What is brachymetatarsia?
Brachymetatarsia is a bone development disorder that occurs when one or more metatarsal bones fail to reach their normal length during the growth phase, resulting in a toe that is shorter than usual. It is a congenital condition, meaning it is usually present from birth and has a genetic and hereditary basis.
The fourth metatarsal is the most common bone involved. While Brachymetatarsia can occur in the first, second, or third toes, these instances are much rarer. The shortening happens because the bone’s growth plate closes earlier than it should.
Although in most cases it does not cause pain during childhood, over time discomfort or chronic pain may develop, due to:
- Friction caused by the raised toe rubbing against the others.
- Functional overload on the adjacent metatarsals, leading to metatarsalgia.
- Problems with footwear and foot support when walking.
- Aesthetic and psychological impact, leading to self-consciousness and social limitations.
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Toe-lengthening treatments
The definitive treatment for brachymetatarsia is surgery. Bone length cannot be corrected through medical or conservative treatments. For mild, asymptomatic cases, custom orthopaedic insoles can redistribute pressure and relieve overloaded areas.
Bone lengthening surgery is recommended for symptomatic patients or those seeking an aesthetic correction.
Surgical procedure
There are two main surgical techniques for correcting this condition:
- Bone graft with open surgery
This involves performing an osteotomy (a controlled fracture of the metatarsal bone) and placing a bone graft taken from the patient themselves, usually from the hip or ankle. The graft is inserted between the segments of the fractured bone and fixed in place with a plate and screws.
- Benefits:
- Fast results
- Suitable for minor extensions (up to approx. 8 mm)
- Elongation accuracy
- Drawbacks:
- Visible scars
- More invasive surgery
- Risk of graft rejection
- Correction is limited by the tension in the tendons and ligaments, which can only be stretched so far.
- Benefits:
- Progressive bone distraction
This is the technique we perform at Clínica Planas. Minimal 2 mm incisions are used to create a fracture, allowing for lengthening without a bone graft. A small external distractor is fitted to your foot, allowing the bone to lengthen gradually by using your body’s natural healing tissue, known as a callus.
- The bone is lengthened slowly and carefully, at a rate of about 0.8 mm each day.
- It is adjusted daily by turning the device slightly.
- Millimetre-precise control ensures excellent aesthetic and functional results.
- A less invasive technique, with minimal scarring and greater control over the process.
What does it involve?
At Clínica Planas, we treat brachymetatarsia using the minimally invasive and highly precise progressive bone distraction technique.
This procedure involves creating a small, controlled fracture in the metatarsal via a 2 mm incision, without requiring bone grafts.
Once the osteotomy (the controlled fracture) is performed, an external distraction device is fitted to the foot to allow the bone to be lengthened gradually. This lengthening is based on a biological principle known as distraction osteogenesis: when the body detects a fracture, it initiates a natural regeneration process, forming tissue known as bone callus. Rather than letting the bone heal straight away, we gently stretch the new tissue. This essentially tricks your body into growing more bone in the gap until the desired length is reached.
The procedure is controlled at approximately 0.8 mm per day via small daily adjustments to the distraction device. This technique allows for millimetre-level precision, adapting to the desired aesthetic and functional outcome, and enables the achievement of an exact and gradual lengthening—something that is not possible with conventional bone graft surgery, which performs the lengthening in a single surgical procedure.
Furthermore, this technique minimises scarring on the foot and does not require a further incision to remove the graft. It also allows for continuous monitoring of the lengthening process, with regular radiological follow-ups, to ensure proper formation of the new bone.
Preoperative care
Before performing the procedure, it is essential to carry out a comprehensive and personalised preoperative assessment. This begins with a detailed clinical examination and an X-ray of the affected foot, with the aim of accurately measuring the difference in length between the metatarsals and calculating the exact degree of lengthening required.
Based on this assessment, a surgical plan tailored to the patient’s needs is drawn up, which will include the rate of distraction and follow-up checks. During the lengthening process, weekly X-rays are taken to monitor the development of the bone callus and ensure that bone regeneration is progressing as it should.
In addition, a series of general recommendations are provided prior to the procedure, such as avoiding alcohol and tobacco, as both substances can negatively affect bone healing and regeneration.
Postoperative care and recovery
The recovery process following brachymetatarsia surgery, whether performed using bone grafting or progressive bone distraction, requires commitment on the part of the patient. The total duration of treatment ranges from 4 to 6 weeks, although this period may be extended if a greater length of bone lengthening is required.
During the active distraction phase, the patient must not put weight on the operated foot; therefore, the use of crutches is essential, and the limb must be kept completely weight-bearing. This is crucial to allow for the correct formation of the bone callus and to prevent complications. The procedure is entirely painless.
One of the benefits of the bone distraction technique performed at Clínica Planas is the use of minimally invasive incisions, reducing the risk of surgical site infection and enhancing the post-operative aesthetic result.
Nevertheless, it is essential to follow medical instructions carefully, particularly regarding the handling of the distraction device.
The patient is provided with specific guidelines for progressively adjusting the lengthening device, generally at a rate of 0.8 mm per day, and is instructed on how to make these adjustments safely at home.
It is recommended that patients attend weekly clinical check-ups, during which a follow-up X-ray is taken to verify that new bone formation is progressing correctly, with no interruptions in the bone callus or deviations.
Success depends on consistent follow-up and strict adherence to medical guidelines.
Causes and risk factors
Causes of brachymetatarsia
Brachymetatarsia is congenital and hereditary in 99% of cases. Being present from birth and genetically passed down, the condition impacts the natural growth of the metatarsal bones during the childhood and adolescent years.
The condition develops when the growth plate closes too early, which stops the metatarsal bone from reaching its full, natural length. Genetic origin is the most common cause, but several other less frequent factors can also lead to the development of this condition.
Some cases are acquired. Repetitive injuries from high-impact sports during the growth phase are a known factor. These small, repetitive injuries can impact the growth plate, leading to early closure and preventing the bone from reaching its full length.
Risk factors
Primary risk factors include significant aesthetic and psychological impacts. The visible difference of a shorter, raised toe can lead to deep self-consciousness, low self-esteem, and a tendency to avoid social situations where the feet are exposed, particularly during the formative years.
Physically, although brachymetatarsia is usually asymptomatic in childhood or youth, symptoms such as localised pain or metatarsalgia may develop over the years. This occurs because the shorter metatarsal bone does not provide adequate support when walking, leading to overloading of the adjacent metatarsal bones. Over time, this imbalance can lead to inflammation or chronic pain.
Another common risk factor is keeping the affected toe raised, which can lead to chafing, irritation or friction-related injuries caused by footwear.
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F.A.Q.
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How do I know if I have brachymetatarsia?
The condition is easily recognisable by the appearance of a shorter toe, which is typically the fourth one on the foot. Visual checks aren't enough. An X-ray is the only way to confirm if the metatarsal bone—and not the toe—is the source of the shortening.
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How much can I lengthen my toe with surgery?
The lengthening is gradual and can be tailored to the individual. There is no strict limit, but the aim is to achieve symmetry with the surrounding toes.
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Is brachymetatarsia hereditary?
Yes. A hereditary or genetic cause is present in approximately 99% of cases.