· main cause is ill-fitting shoes
· long 2nd ray with buckling of toe
· irregularly shaped middle phalanx with deviation of distal phalanx
· long 4th toe with curling under 3rd toe
· pressure against 2nd toe by hallux
· polio
· Charcot-Marie-Tooth disease
· muscular dystrophy
· inflammatory arthritis
· fracture
· tendon or ligament injury
· syndactyly
· flexion of PIP and DIP jts with hyperextension of MTP jt
· may be mobile or fixed
· may lead to MTP jt subluxation and dislocation
· claw toe different to curly toe
· flexion of PIP and DIP joints with MTP joint in neutral
· usually all lesser toes involved
· associated with pes cavus
· results from imbalance between intrinsic and extrinsic muscles
· weakness of intrinsics PLUS
· simultaneous contraction of flexor and extensors
· seen with
· neurological disorders
· compartment syndrome of leg
· pain and callosities under metatarsal heads
· corns over dorsum of toes
· extra depth shoe with metatarsal bar
· if there is significant deformity of the hindfoot and/or a cavus foot, these should be adressed first
Mild deformity
· young patient with no fixed contracture
· Girdlestone-Taylor flexor to extensor transfer
· may require extensor tenotomy and dorsal MTP capsulotomy
Moderate deformity
· fixed flexion contracture at PIP joint
· options are
· resection of head and neck of proximal phalanx
· arthrodesis of PIP joint
· may require extensor tenotomy and dorsal MTP capsulotomy
Severe deformity
· fixed MTP jt subluxation
· correction by
· extensor tendon tenotomy and dorsal MTP jt capsulotomy
· metatarsal neck osteotomy
· flexion deformity of PIP jt
· may be mobile or fixed
· hyperextension of MTP jt develops with time
· proximal phalanx may become subluxed or dislocated
· DIP jt may be normal or hyperextended
· usually affects 2nd toe
· increased incidence with age
· uncertain
· may be associated with
· long 2nd MT
· hallux valgus
· tight shoes
· three areas may be painful
· dorsum of PIP jt with hard corn
· tip of toe with end corn
· beneath MT head with callus
· extra depth or padded shoe
Mild deformity
· young patient with no fixed contracture
· Girdlestone-Taylor flexor to extensor transfer
Moderate deformity
· fixed flexion contracture at PIP joint
· options are
· excision arthroplasty of PIP jt
· arthrodesis of PIP jt (more difficult to achieve)
Severe deformity
· fixed MTP joint subluxation
· correction by
· extensor tendon tenotomy
· dorsal MTP jt capsulotomy
· flexion deformity of DIP joint
· may be fixed or mobile
· usually in 2nd toe
· associated with
· long 2nd MT
· constrictive footwear
· pain over
· tip of toe
· over dorsum of DIP jt
· may be corn on tip of toe (end corn)
· shoes with roomy toe box
Mobile
· percutaneous FDL tenotomy
Fixed
· excision arthroplasty of DIP joint
· arthrodesis not preferred as difficult to achieve
· enlargement of fibular side of 5th MT head
· often leads to overlying corns and calluses
· broad-toed shoes
· trimming of bony prominence
· congenital deformity with
· flexion, external rotation and medial deviation of distal phalanx
· toe lies beneath adjacent toe
· deformity initially flexible but may become fixed
· deformity accentuated when standing
· may present with
· cosmetic concerns
· callus and blister formation
· most do not require treatment
· most not symptomatic
· 25% improve spontaneously
· no nonoperative treatments effective
· if symptoms judged sufficient
Flexible deformity
· flexor tenotomy
· transverse incision over plantar aspect of proximal phalanx
· long flexor tendon visualised and released
Fixed deformity
· arthrodesis of IP jt(s)
· 5th toe adducted and overrides 4th toe
· toe extended, adducted and laterally rotated at MTP jt
· there is contracture of EDL tendon and dorsal MTP capsule
· familial
· present with
· cosmetic deformity
· problems with footwear
· strapping and taping ineffective
· release of MTP capsule and EHL tendon lengthening
· alternatively, excision of base of proximal phalanx and syndactylisation of 4th and 5th toes