Brachymetatarsia(short metatarsal) is a hereditary anomaly that occurs as a result of premature closure of the growth center of a metatarsal or metatarsals. When multiple metatarsals are involved the name is brachymetapody. Most commonly the fourth metatarsal is affected. The other metatarsals continue to grow and the length becomes exaggerated.

Brachymetatarsia can result from trauma to the metatarsal or from an infectious process. It has also been associated with Down's Syndrome, Sickle-cell anemia, and polio. The defect is not always noted at birth but, becomes more evident between 4-15 years of age. Brachymetatarsia may occur unilateral or bilaterally, though mostly seen on one side.

Clinically, the younger patient notices a shortened or floating toe. Calluses may develop under the adjacent metatarsal heads with pain. The adjacent toes underlap the involved toe.

Radiographs reveal a short, underdeveloped metatarsal with deficient bone content and osteoporosis of the metatarsal head. The affected toe is usually straight, in an extended position, and floats above the weight-bearing plane. Conservatively one may use orthotics.

For surgical correction bone lengthening procedures are performed, bone grafts may be inserted, extensor tenotomy performed, and skin plasty may be performed. Below knee non-weight bearing cast may be applied. Callus distraction (with pins and external fixation) is another procedure performed to attempt to lenghthen the metatarsal. Soft tissues can gradually elongate with the bone. Postoperative non-weight bearing is used for 2-3 months pending xrays evidence of bone healing.

Complications include risk of neurovascular compromise, non-union, collapse of the graft if implemented, painful pseudoarthrosis and painful limitation of motion at the joint.

Bibliography

• Banks, Alan S., et al McGlamry's Comprehensive Textbook of Foot and Ankle Surgery.Philadelphia:Lippincott Williams and Wilkins, 2001.
• McGlamry ED, Fenton CF. Brachymetatarsia:a case report. J AM Podiatry Assoc 1983;73:75-78.
• Robinson J, Ouzounian T. Brachymetatarsia:congenitally short third and fourth metatarsal treatment by distraction lengthening- a case report and literature summary. Foot Ankle Int 1998;19:713-718.

Charcot Foot (also know as Charcot Joint and Charcot Fracture) is named after a French neurologist who, in 1868, began to notice that many of his patients were experiencing bone deterioration with no associated pain. The cause in many of these early cases was syphilis (tabes dorsalis). Today however, there are approximately 24 different diseases that cause Charcot foot, the most common cause is peripheral neuropathy (loss of sensation in the feet) due to diabetes mellitius.

Charcot foot is most commonly a collapse in the mid arch, but can also occur in the rearfoot and ankle. Joint and bone deconstruction can go unnoticed by the diabetic patient and therefore the bones begin to heal improperly, leaving the foot deformed. When a patient complains of symptoms such as swelling, their feet not feeling the same temperature, redness, and no longer being able to comfortably wear their shoes, an early identification of Charcot foot is ideal. Many doctors often mistake these symptoms with that of osteoarthritis. If gone undetected, there is an increased risk of foot deformities ("rocker bottom"), ulcerations, infection, and even limb loss.

Once this condition has been properly diagnosed, your podiatrist will recommend one or more of the following treatments:

1. Bed rest - to give the foot ample time to heal without the stress of walking.
2. Crutches - to help take the weight off of the injured foot.
3. Total contact cast (TCC)- to help take the weight off of the injured foot.
4. Custom orthotics and footwear - to support the healing bones and protect against further damage.

Dr. Horsley recommends that all diabetics:

1. Become educated on diabetic foot care
2. Wash and dry feet thoroughly
3. Inspect your feet daily (or have someone else do it for you)
4. Wear properly fitting shoes
5. Wear seamless socks
6. Do NOT walk around barefoot
7. Visit your podiatrist regularly

If you are experiencing any of the symptoms addressed, we strongly recommend that you seek the advice of your podiatrist for proper diagnosis.

Additional Information

A Charcot Joint or foot is joint destruction caused by a lack of protective sensation or feeling on the top and bottom of the foot. The incidence of Charcot Joints is 5-10% of patients with Diabetes Mellitus. The destructive process of Charcot may be triggered by a single injury or repeat trauma to bones and joints of the foot. The articular cartilage begins to erode. Fragmentation, disintegration, and collapse of the foot will most likely occur.

The exact cause of Charcot is unknown, but a French and German theory exist. With the French theory, there is damage to nerve centers with a change in the control of blood flow to bones and joints leads to persistent hyperemia (an unusual increase in the amount of blood or congestion in a part which gives rise to reddened areas on the skin) and active bone resorption. As far as the German theory is concerned, there is an extreme progression of degenerative joint disease following the loss of proprioception (movements and position of the body), and protective sensation.

The top three causes of Charcot are due to diabetes, syringomyelia (a disease of the spinal cord in which fluid accumulates in the cavities, replacing the nerve tissue and causing muscle atrophy and spasticity), and tabes dorsalis (a late form of syphilis involving the degeneration of the spinal cord and sensory nerve trunks, causing muscular incoordination, intense pain, disturbances in sensation, and eventual paralysis. Some other causes of Charcot are Alcoholism, Cerebral Palsy, Polio, Leprosy, Tuberculosis, Multiple Sclerosis, and brain injury.

Charcot's presentation may come in the form of a red, hot, swollen joint. The joint may also be deformed and unstable. A person may or may not have pain depending on the progression of the illness. Some joint destruction may be noticeable. Achilles and patellar reflexes may be diminished. Pulses in the feet are usually easily palpable. Fractures and dislocations of bones in the foot may occur.

On xray, one may see Atrophic and Hypertrophic Charcot. With Atrophic Charcot, one may see extensive resorption of bone ends, osteoporosis, and no spurs or fragments are present (usually seen in upper extremity). With Hypertrophic Charcot, xrays show no osteoporosis. Fractures and dislocations of bones and disorganization of joints are noticeable. (seen in lower extremity)

The stages of Charcot are Developmental, Coalescence, and Reconstructive. In the Developmental (acute destructive stage), there is joint laxity, soft tissue swelling, and bone cartilage debris. In the Coalescence (reparative stage), there is less swelling and healing of fractures and fragments. In the Reconstructive (Final Stage of Bone Healing), there is bone repair and remodeling with the restoring of stability and revascularization of bony fragments. Although not given a formal stage name, one may also encounter Charcot feet that have ulcers present.

Other diseases that may present in a similar fashion as Charcot include Osteomyelitis, acute septic arthritis, gout, and rheumatoid arthritis.

Treatment of Charcot may be conservative or surgical. Some conservative measures include strict cessation (stopping) of weight bearing. A compression cast may be applied to the foot to control swelling. Cast immobilization for fractures are applied sometimes for 8-12 weeks. One may use long term accommodative footwear such as orthopedic shoes, custom molded shoes, ankle foot orthoses, and patella tendon bracing. Surgical choices are not performed during the acute phase. However, surgery includes excising or cutting out the foot ulcer, stabilizing digits, resecting metatarsal heads, fusing joints of the foot, and amputation. With Stages 1 and 2 protect the joint by immobilization and casting. With Stage 3 use custom molded shoes, orthotics, or surgery.