Lesser Toe Abnormalities
Aetiology
- Shoe Wear
- Main cause is ill fitting shoes
- Anatomic
- Long second ray with buckling of toe
- Irregular shaped middle phalanx with deviation of DP
- Long fourth toe with curling under the third toe
- Pressure of hallux against second toe
- Neuromuscular
- Polio
- CMT
- Muscular Dystrophy
- Connective Tissue Disorders
- Inflammatory arthritis
- Trauma
- Fracture
- Tendon or Ligament injury
- Congenital
- Syndactyly
Claw Toes
- Features
- PIP flexion
- MTP hyperextension – irreducible
- ± DIP flexion
- dorsal PIP callus
- 2nd metatarsalgia
- coronal plane deformity
- MTP varus
- disorder of plantar plate
- Claw toes more common in younger population
- hammer toes more common in older patients
- Often bilateral with multiple toes involved
- Related to cavus foot
- Flexible or rigid
- Aetiology
- imbalance between the intrinsics & extrinsics ( Intrinsic Minus posture )
- simultaneous contraction of long flexors & extensors
- RA / NM & CTD considered but in many cases idiopathic
- Due to plantarflexion of the MT from the extended PP - Metatarsalgia common
- Clinically see pain & callosities under the MT heads & callosities over the PP
Treatment
Non operative
- Extra shoe depth & metatarsal bar
Operative
- If cavus deformity of the hind foot or other hindfoot abnormality then correct first
- Mild: Young patient with no fixed deformity
- Girdlestone -Taylor flexor to extensor tendon transfer
- ± extensor tenotomy
- ± MTPJ capsulotomy
- Technique
- Locate the FDL at the plantar MTPJ crease & divide at the plantar DIPJ crease
- Divide into two bands
- Dorsal longitudinal incision over the PIPJ & make subcutaneous tunnel deep to N-V bundles bilaterally & over the extensor hood
- Pass the two halves of FDL either side of the PP & attach to the extensor hood over the PP at midpoint
- Ensure Ankle neutral & PP in 20° of PF
- Must be corrected passively but can use K wire to protect it
- ModerateFixed Flexion deformity of the PIPJ
- 1. Resection PP head & Neck
- 2. Arthrodesis of the PIPJ
- ± Extensor capsulotomy or Dorsal MTPJ capsulotomy
- SevereSubluxation of the MTPJ
- Needs reduction of the joint through decompression
- 1. Resection of PP base or MT head
- particularly in RA
- 2. MT neck osteotomy (Weil)
- ± Dorsal capsulotomy or extensor tenotomy
- Same as hammertoe
- Add MTP release / realignment
- Dorsal capsulotomy
- Extensor lengthening
- Tendon transfer
- Flexor to extensor
- ± MT condylectomy
- metatarsalgia
- Hammer Toes
- PIP flexion
- Reducible MTP extension
- Dorsal PIP callous
- 2nd metatarsalgia
- Flexible versus rigid
- Need to evaluate MTPJ orientation
- Assess the adjacent toes looking for Hallux valgus or other toes causing reduction in alloted space
- Usually the second toe & incidence ↑ with age
- See three predisposing factors
- Long second MT
- HV
- Tight shoes
- Three painful areas
- Dorsum of the PIPJ corn
- Tip of the toe with end corn
- Under the MT head with callosity
Treatment
Non operative
- In younger patient best option
- Particularly if flexible
- Broad shoe
- MT Pads & soft insoles
- Budin splint
- Toe spacer
Operative
- Flexible
- Flexor Extensor Tendon Transfer
- PIP resection arthroplasaty
- Rigid
- PIP resection arthroplasty / Arthrodesis
- Diaphyseal shortening
- Excision arthroplasty of PIPJ
- Technique
- Elliptical incision over the PIPJ dorsally
- Excise callus , extensor tendon , joint capsule
- Release the collateral ligaments
- Expose the PP head
- Resect the PP head at supracondylar area
- ± FDL tenotomy from dorsum if FFD remains
- K wires then inserted
- Arthrodesis of PIPJ option but more difficult to achieve
- SevereFixed subluxation of the MTPJ
- ± MTPJ dorsal capsulotomy & extensor tenotomy
- ± excision of base of the PP
- performed to decompress & allow reduction
- ± PIPJ procedure
- Mallet Toe
- Definition
- Flexion of the DIPJ
- Associations
- long second ray
- FDL contraction may be causative factor
- Clinical
- Older patient can see restricted shoe wear as problem
- Pain with end corn at tip of toe
- callosity over the DIPJ
- nail pain
- Treatment
- toe pads
- shoe modifications
- In younger patient with flexible deformity & failed nonoperative treatment
- percutaneous tenotomy
- fixed
- excisional arthroplasty / arthrodesisof the DIPJ
- terminal syme amputation
- Cross- over Second Toe
- Pathology
- HV deformity
- lateral pressure from the hallux l
- subluxation of the MTPJ of second toe laterally
- Medial subluxation can occur with long second metatarsal & impingement of the PP of third ray against MT head of the second ray
- toe can then cross over the top of hallux as the plantar capsule stretches
- Pain in second interspace seen initially & difficult to differentiate from interdigital neuroma
- Thompson & Hamilton - test for dorsal / plantar instability - dorsal translation subluxation test
- Differential Diagnosis early includes
- Interdigital neuroma
- MTPJ Osteoarthritis
- Synovial cyst
- MTPJ synovitis
- Friebergs infarction
- Treatment
- MildInitial taping if mild & correctable in slight deformity
- ModerateExtensor tenotomy , dorsal capsulotomy & K wire fixation
- SevereMTPJ arthroplasty to decompress the joint
- ± flexor tendon transfer
- ± reefing of the lateral capsule to augment the reconstruction & realign the MTPJ
Hard Corns :
- Most common on the lateral aspect of the fifth toe from extrinsic pressure of shoe
- Accumulation of keratin in skin occurs
- Non op treatment includes
- Wide roomy shoe with low heel
- Shaving of the corn & padding
- Operative
- Where bony prominence the major problem at lateral condylectomy may be performed
- Soft Corns
- Pressure point in web space between adjacent toes
- Forcing broad forefoot into restricted toe box commonest cause
- See macerated keratotic lesion due to pressure of one bony prominence on the other in apex of webspaces
- Correct by shaving the underlying exostosis or excising the joint & exostosis together
- “ Kissing Corns “ on adjacent toes may need management
Bunionette( Tailors Bunion ) :
- Enlarged fifth MT head on lateral side
- Overlying skin see corns & callous
- Treat with broad toe shoes & trim bony prominences
- Can treat with mid diaphyseal oblique osteotomy & distal soft tissue realignment
- Condylectomy
- MT osteotomy
- MT head resection
- Type 1 Enlarge MT head
- Type 2 4-5° IM angle (Normal 6-8°)
- Type 3 Lateral bowing of MT shaft
Congenital Curly Toes :
- See flexion , ER & Medial deviation of the DP
- Lies beneath adjacent toe
- Initially flexible maybe fixed
- Worse with standing
- May present with cosmetis concern or blister / callus formation
- Treatment
- Non op
- Most do not require treatment
- 25% improve spontaneously
- No effective non op treatment
- Operative
- Symptoms sufficient
- Flexible - Flexor tenotomy useful
- Make transverse incision over the plantar aspect over the PP
- FDL released
- Fixed - IPJ arthrodesis may be required
Congenital Overriding of Fifth Toe :
- Fifth toe adducted & overlying the fourth
- Toe extended / adducted & ER at the MTPJ
- Contracture of the EDL tendon & Dorsal MTPJ capsule
- Familial
- Presents with deformity & footwear problems
- Treatment
- Non op
- taping & strapping is ineffective
- Operative
- Release of the MTPJ capsule & EDL lengthening can be performed if resistent
- Alternatively excision of the base of the PP & syndactylisation of the fourth & fifth toes
2nd MTP synovitis
monoarticular
nontraumatic
overloading
long 2nd MT
HV
metatarsalgia
middle aged patients
Webpage Last Modified:
18 February, 2010
