Robert Perone, MD

A 41-year-old woman presented with a known history of bilateral foot deformities and new complaints of bilateral foot pain.

Anteroposterior (Figures 1 and 2) and lateral (Figures 3 and 4) plain films of the patient's feet demonstrate bilateral shortening of the third and fourth metatarsals with associated shortening of the distal phalanges. Additionally, the patient has bilateral hallux valgus deformities (bunions).

Bilateral brachymetapody with associated hallux valgus deformities.

Brachymetatarsia, or hypoplastic metatarsal, is a form of brachydactyly in which a single metatarsal is abnormally short. Brachymetapody involves multiple short metatarsals. Brachymetapody is most often congenital in origin and usually occurs as an isolated dysmelia. The considered pathogenesis is premature closure of the epiphyseal plate of the metatarsal bones without a specific cause.


Brachymetapody has been linked to several disease processes, including Down syndrome, Apert's syndrome, Albright hereditary osteodystrophy, myositis ossificans, Turner's syndrome, pseudohypoparathyroidism, sickle cell anemia, and dystrophic dwarfism. Brachymetatarsia and brachymetapody may be acquired postsurgery or secondary to trauma or Freiberg's disease.


Brachymetapody and brachymetatarsia can be unilateral, but patients present most often with a bilateral process. Many authors describe the fourth digit as the one most commonly involved. Some, however, state that congenital shortening of the first metatarsal, also known as Morton's syndrome, is the condition's most common manifestation.


Incidence of brachymetapody and brachymetatarsia is reported to be between 0.022% (one in 4586) and 0.05% (one in 1820). The ratio of male to female patients is approximately 1:20. The limited reports on hereditary patterns of brachymetapody and brachymetatarsia suggest the anomaly is autosomal dominant with incomplete manifestation. Variability of expression explains the differences in laterality and number of digits involved.


Patients with brachymetatarsia or brachymetapody usually present between the ages of 10 and 14, when the shortness of the metatarsals becomes apparent. Clinical suspicion of this diagnosis is raised in patients who present with atrophy of the involved toe and/or the toe drawn upwards on the dorsum of the foot in what is known as the “cocked-up” deformity.


Diagnosis is made radiographically when the involved metatarsal is 5 mm or more proximal to the parabolic arc of the metatarsal heads.


Patients may remain asymptomatic, or metatarsalgia may develop. The proximal phalanx of the shortened metatarsal comes to lie between the metatarsal heads and is unable to bear weight, which results in transfer metatarsalgia.


he cocked-up toe deformity sometimes also causes painful callus formation, and adjacent metatarsals may have increased plantar hyperkeratosis as a result of the increased load. As demonstrated in our case, a short third metatarsal can result in hallux valgus deformity when the medial toes angulate to occupy the space of the dorsiflexed third digit.


Treatment options for brachymetapody and brachymetatarsia include both operative and nonoperative techniques. Most patients do not require treatment, though both pain and cosmesis are appropriate indications for surgery. Nonoperative techniques include metatarsal pads and orthoses. Operative techniques include one-stage lengthening procedures for cases in which less than 15 mm of lengthening is needed. If more than 15 mm is needed, gradual metatarsal lengthening reduces the risk of neurovascular compromise in the affected digit.

Submitted by Andrew Allmendinger, DO, Paul Yeghiayan, MD, and Robert Perone, MD, all of St. Vincent's Medical Center in New York City.

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This 41-year-old woman presented with a known history of bilateral foot deformities and new complaints of bilateral foot pain. She had associated hallux valgus deformities.

Bilateral brachymetapody

A 13-year-old girl presents with abdominal pain, right lower quadrant tenderness, guarding, elevated lipase, and a history of gastroesophageal reflux disease.

On contrast-enhanced CT images, a heterogeneous low-attenuation intraluminal mass is identified in the stomach (Figure 1), duodenum, and jejunum (Figure 2). Multiple intussusceptions are seen in several segments of the small bowel demonstrating mesenteric fat separating the intussusceptum from the intussuscipiens.

The top differential diagnosis includes gastric carcinoma, postprandial food, and intramural mass.

A bezoar is a ball of ingested foreign material that collects in the lumen of the gastrointestinal tract. Foreign materials, such as hair, plastic, paper, string, cotton, and prune pits, fail to pass through the pylorus and small intestine. The most common bezoar in a child is a hairball, or trichobezoar. Rapunzel's syndrome occurs when the main portion of the trichobezoar is located in the stomach with extension of the tail into the small bowel and/or right colon.

The incidence of trichobezoar is very low. Approximately 90% of bezoars are seen in girls aged 10 to 19 years. The risk is greater among the mentally retarded, emotionally disturbed, and those with underlying psychological problems. There is usually a history of trichophagia, the compulsive eating of one's hair, and/or trichotillomania, the impulse control disorder of a repeated urge to pull out one's hair. Because the stomach is full all the time, the patient presents with abdominal pain, nausea, vomiting, obstruction, weight loss, and poor appetite.

Trichobezoars tend to be large, well-defined, ovoid masses. The typical CT finding is a heterogeneous, mottled intraluminal mass with a meshlike, concentric ring pattern due to debris, barium, and entrapped air. Complications such as intussusception, obstruction, perforation, ulceration, peritonitis, or abscess formation can also be seen. Several other imaging modalities may also be used for diagnosis, but they are not as definitive as CT.

On plain film, there may be a mottled soft-tissue opacity with the shape of a stomach. The outer rim of the bezoar may also be calcified. There may also be signs of bowel obstruction. An upper GI series outlines a filling defect in the stomach or small bowel. Ultrasound examination reveals an echogenic arclike surface with sharp posterior acoustic shadowing. MRI is not as useful as CT, because the images vary depending on the actual contents of the trichobezoar, and the low signal intensity is easily confused with air.

Treatment includes surgical or endoscopic removal. Endoscopy is difficult in most cases due to the large size of the trichobezoar.

Submitted by Pooja Voria, M.D., MBA, Irini Youseff, M.D., MPH, and Robert Perone, M.D., at St. Vincent's Medical Center in New York City.

Federle MP, Guliani-Chabra S. Gastric bezoar: diagnostic imaging abdomen, gastroduodenal. Salt Lake City: Amirsys, 2004;I-3:68-72.

Koplewitz B, Daneman A, Fields S, et al. Case 29: Gastric trichobezoar and subphrenic abscess. Radiology 2000;217(3):739-742.

O'Sullivan M, McGreal G, Walsh J. Trichobezoar. J R Soc Med 2001;94(2):68-70.

Robert Perone, MD

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Bilateral brachymetapody

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