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Short Second Metatarsal

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Mark_M, Jun 15, 2016.

  1. Mark_M

    Mark_M Active Member

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    I have a 15 year old male presented with a pain in the second toe from shoe irritation. His mother reports a family history of the 'sticking up 2nd toe'
    The digit felt unstable, was over riding the hallux and obvious signs of a short 2nd metatarsal. He had no pain at the met head or MTP joint.

    I taped his toe into plantar flexion and sent him off for an X ray and usound.

    All soft tissue structures appeared intact in ultrasound.
    X ray showed no bony lesion (no freibergs) although the growth plate had fused in the second met only.

    What treatment options do you think would be suitable for him? His only complaint is that his shoes rub on the 2nd toe.


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  2. Mark_M

    Mark_M Active Member

  3. I would suggest that a lengthening osteotomy of the second metatarsal would give this young man the best results clinically. This procedure would give the best clinical results since it would not only increase the ground reaction force plantar to the second metatarsal but would also plantarflex the 2nd digit into a plantigrade position where it would no longer be irritated by shoegear.
  4. efuller

    efuller MVP

    Because the growth centers are still open, waiting on the lengthening osteotomy might be a good idea. If you were to lengthen the bone perfectly now, the other bones might grow a bit and mess up your result. Also if you lengthen the bone, you would also have to assess the tendons and slips to the plantar fascia for lengthening as well. Lengthening the bone could alter passive tension in those structures that could create a new toe deformity.

    It would be really interesting to see a pressure distribution in stance for that foot. Do you have access to a Harris Mat or Force platform. Or you could look into the inside of his shoe to see if there are any areas that get particularly high wear. That information would be helpful in predicting future problems. One of the major indications for lengthening the 2nd met would be high loads on the other metatarsals. He's not complaining of it now, but it could be an issue later.

    The problem, now, is the toe. You could continue to tape it until you figure out what bone work you need to do. One of the problems with fusing the toe, but not the MPJ is maintaining volitional movement and getting the toe to sit level.

    He's also an interesting case for a geneticist. If there is a familial mutation that causes early closure of the growth plate of the 2nd metatarsal, the family could help geneticists figure out which gene codes for growth plate closure. I have no idea what is currently known in that area.

  5. I agree with Eric that it would be best to wait on lengthening the 2nd metatarsal until the growth plates on the other metatarsals have closed. This young man will never likely have normal digital purchase until the metatarsal is lengthened due to the slack in the slip to the 2nd digit within the central component of the plantar aponeurosis that has occurred due to the short 2nd metatarsal. There are other surgical alternatives, but in a boy this age, the lengthening osteotomy seems the most permanent and best option.

    However, if the patient wanted to know about another surgical procedure, with decreased need for post-operative non-weightbearing status, a 2nd digit flexor transfer could alternatively be performed which would bring the toe down to the plantigrade position nicely, but would not address the structurally shortened 2nd metatarsal.

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