Congenital Hallux Varus
1. Definition—Deformity
a. Congenital varus alignment of the hallux on the 1st MT (Figure 5-52)
b. Often associated with tight cordlike structure in place of, or in addition to, the abductor hallucis (Figure 5-52B)
c. Idiopathic or associated with an underlying chromosome abnormality—Pierre Robin syndrome, others
d. Often associated with 1st MT longitudinal epiphyseal bracket (see Chapter 6; and Figure 5-53)
Figure 5-52. A. Clinical appearance of CHV. B. Fibrous band (in button hook) that is occasionally seen between the hallux and a cartilaginous duplicate tarsal anlage (From Mosca VS. The Foot. In: Morrissy RT, Weinstein SL, eds. Lovell and Winter’s Pediatric Orthopaedics, 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2001:1187, Figure 29-34.)
2. Elucidation of the segmental deformities
a. Hallux and metatarsophalangeal joint
i. Varus deformity of the hallux in relation to the 1st MT—i.e., hallux varus
ii. Varus deformity of the distal end of the 1st MT with medial positioning of the articular cartilage creating medial deviation/mal-orientation of the 1st MTP joint—i.e., “reverse,” or varus, distal MT articular angle (DMAA; see Figure 5-56, this chapter)
iii. Medial subluxation of the hallux on the 1st MT head—i.e., 1st MTP joint incongruity
b. Forefoot
i. Neutral
ii. Often associated with a 1st MT longitudinal epiphyseal bracket (see Chapter 6) with relative shortening and widening of the MT
c. Midfoot—neutral
d. Hindfoot—neutral
e. Ankle—neutral
3. Imaging
a. Simulated standing or standing AP and lateral of the foot (Figure 5-53)
Figure 5-53. AP x-ray of an infant’s foot with CHV and a 1st MT longitudinal epiphyseal bracket (see Chapter 6). Note the straight-to-slightly concave dense lateral diaphyseal cortex and the convex hypodense medial diaphyseal cortex of the 1st MT.
4. Natural history
a. Increasing or persistent varus deformity of the hallux causing shoe-fitting difficulties
b. If a 1st MT longitudinal epiphyseal bracket (see Chapter 6) coexists, there will be increasing length discrepancy between the 1st and 2nd MTs, resulting in stress overload and pain under the 2nd MT head (see Longitudinal Epiphyseal Bracket, Figure 6-4, Chapter 6)
5. Nonoperative treatment
a. None
6. Operative indications
a. The presence of this deformity
7. Operative treatment with reference to the surgical techniques section of the book for each individual procedure
a. Distal release of abductor hallucis (see Chapter 7) and release of medial 1st MTP joint capsule and resection of tight cordlike medial band (if present)—perform this for isolated congenital hallux varus (CHV)
b. Distal release of abductor hallucis (see Chapter 7) and release of medial 1st MTP joint capsule and resection of tight cordlike medial band (if present) and resection of 1st MT longitudinal epiphyseal bracket (see Chapter 8)—perform this if a 1st MT longitudinal epiphyseal bracket coexists
c. Distal 1st MT opening wedge varus-correcting ± lengthening osteotomy (see Chapter 8)—perform this if varus mal-orientation of a congruous 1st MTP joint persists in an older child or adolescent
d. Z-plasty medial skin of the forefoot (see Longitudinal Epiphyseal Bracket Resection, Figure 8-8, Chapter 8)—perform this along with any of these procedures if the skin is under excessive stretch following deformity correction
Juvenile Hallux Valgus
1. Definition—Deformity
a. Greater than 15° of valgus alignment of the hallux on the 1st MT, with medial prominence of the 1st MT head (Figure 5-54)
b. Age at onset less than 16 years, regardless of when it is treated
c. No arthritis of the 1st MTP joint
d. Other features
i. Maternal inheritance in over 70% of cases
ii. 3:1 female: male ratio
iii. The prevalence of juvenile hallux valgus (JHV) is unknown, but it is believed to be high.
2. Elucidation of the segmental deformities, not all necessarily present in every case
a. Hallux and metatarsophalangeal joint
i. Valgus deformity of the hallux in relation to the 1st MT—i.e., hallux valgus (HV)—always present.
ii. Valgus deformity of the distal end of the 1st MT with lateral positioning of the articular cartilage creating lateral deviation/mal-orientation of the 1st MTP joint—i.e., high DMAA—see below—not always present, but more common in JHV than in adult onset HV.
iii. Lateral subluxation of the hallux on the 1st MT head—i.e., 1st MTP joint incongruity—not always present. Can exist with a normal or high DMAA, but more common with a normal DMAA.
iv. Valgus deformity of the distal end of the hallux proximal phalanx creating lateral deviation/mal-orientation of the interphalangeal joint—i.e., hallux valgus interphalangeus (HVIP)—not always present.
b. Forefoot—neutral, but may be pronated or supinated, based on any coexisting hindfoot deformity
c. Midfoot
i. Adducted 1st MT—i.e., metatarsus primus varus (MPV)—always present
ii. Varus/medial-deviation/mal-orientation of 1st MT–medial cuneiform joint—always present
iii. Adduction of all MTs—i.e., MA—rarely present
d. Hindfoot—neutral, valgus/everted, or varus/inverted.
e. Ankle—neutral or plantar flexed (equinus)
Figure 5-54. A. Bilateral JHV in a 15-year-old girl.
3. Imaging
a. Standing AP and lateral of foot (Figures 5-55 and 5-56)
4. Natural history
a. MPV is most likely a congenital deformity. It is unknown whether the angle between the 1st and 2nd MTs changes during growth. According to the law of triangles, the distance between the MT heads will increase as the foot grows, even if the exaggerated angle between the MTs remains the same (Figure 5-57).
b. When the width of the forefoot at the level of the MT heads is greater than the width of the shoe, the exaggerated medial–lateral pressures experienced by the soft tissues over the 1st and 5th MT heads create pain, tenderness, and callus formation at those sites. If the 1st MT head is particularly prominent because of MPV and HV, the smaller surface area on the medial side of the 1st MT head creates even greater stresses.
c. The local environment of the foot, i.e., the shoe, clearly relates to the comfort of the foot with JHV
d. An unknown percentage of individuals with JHV experience unacceptable pain, tenderness, and callus formation on the medial surface of the 1st MT head
Figure 5-55. Standing AP x-ray of bilateral JHV. MPV is defined as an increased 1st to 2nd intermetatarsal angle (IMA)— normal is <9°. MPV is due to varus/medial-deviation/mal-orientation of the 1st MT–medial cuneiform joint with a trapezoid-shaped medial cuneiform (black trapezoid). HV is defined as a hallux valgus angle (HVA) > 15°. This can be due to valgus/lateral-deviation/mal-orientation of a congruous and stable 1st MTP joint with a high DMAA, or to lateral subluxation and incongruity of the hallux on a 1st MT with normally positioned articular cartilage. DMAA defines the position of the articular cartilage on the distal end of the 1st MT, which is variable in humans (see Figure 5-56). The proximal phalanx articular angle (PPAA) defines the shape of the hallux proximal phalanx, which may be rectangular or trapezoidal in shape. If the proximal and distal articular surfaces are not parallel, but instead converge laterally, the interphalangeal joint will deviate laterally, creating HVIP. The latter deformity is much easier to treat than HV.
5. Nonoperative treatment
a. Foot wear accommodations
i. Ensure that there is adequate width of the shoe at the level of the MT heads. Apply the sole of the shoe from one foot to the plantar surface of the other. If the shoe cannot be seen extending beyond the borders of the foot, it is too narrow (Figure 5-58).
ii. Recommend a low heel height to prevent the foot from sliding forward into the narrow toe box (Figure 5-59)
iii. Recommend that girls wear boys’ athletic shoes. They are made wider at the level of the MT heads for the equivalent length
iv. Recommend a bunion stretcher, available at shoe repair stores (Figure 5-59)
6. Operative indications
a. Failure of nonoperative treatment to relieve the pain:
i. on the medial side of the 1st MT head and/or in the 1st MTP joint
ii. and/or associated with under-overlapping of the hallux and 2nd toe that is often associated with toenail ingrowth problems and skin irritation between the toes.
7. Operative treatment with reference to the surgical techniques section of the book for each individual procedure. There are too many to show. By admission, this is not the definitive work on JHV, a frustratingly complex and poorly understood group of deformities. All JHVs are not the same. By following the principles of assessment and management, your surgical results should be good (Figures 5-60and 5-61).
a. Medial cuneiform medial opening wedge osteotomy (see Chapter 8) or 1st MT base osteotomy (see Chapter 8)—perform one of these to correct MPV
b. Distal 1st MT osteotomy (see Chapter 8)—perform this when there is a high DMAA
c. Resection of the exostosis on the medial aspect of 1st MT head and plication of the medial 1st MTP joint capsule (see pertinent description in 1st Metatarsal Distal Osteotomy, Chapter 8)—perform this in essentially all cases, regardless of the other procedures being performed concurrently. Create or maintain a congruous 1st MTP joint.
d. Release the adductor hallucis and lateral 1st MTP joint capsule—perform this for lateral subluxation of the 1st MTP joint. Do not perform this concurrent with a distal 1st MT osteotomy (see Technique “e” under 1st Metatarsal Distal Osteotomy, Chapter 8)
e. Possible calcaneal lengthening osteotomy (see Chapter 8) and gastrocnemius recession (see Chapter 7)—perform these if severe hindfoot valgus with a gastrocnemius contracture coexist
Figure 5-56. The DMAA defines the position of the articular cartilage on the distal end of the 1st MT. In most individuals, the articular cartilage is centered at the distal end of the bone. In around 50% of adolescents and 10% of adults with HV, the articular cartilage is laterally positioned on the end of the 1st MT. A. The DMAA is determined by measuring the angle between the shaft of the MT and the line that is perpendicular to the line representing the articular surface. The reliability of accurately drawing the line that represents the articular surface has been questioned, but it can be drawn accurately in many feet. The normal DMAA is<9°. A high DMAA means that there is valgus deformity of the distal end of the 1st MT. (From Coughlin M. Juvenile hallux valgus. In: Coughlin M, Mann R, eds. Surgery of the Foot and Ankle.7th ed. St Louis, MO: Mosby; 1999:270, with permission.) B. The analogy to a high DMAA is valgus deformity of the distal femur, as is seen in many conditions, including fibula hemimelia. This image is the upside down AP x-ray of a knee in a child with fibula hemimelia. The anatomic distal femoral articular angle is exaggerated, creating a congrous, but malaligned, joint with genu valgum. Consider how this might be treated. One would never consider releasing the lateral joint capsule and creating joint incongruity by positioning the tibia under the medial femoral condyle. C. Sketch of a MT with a normal DMAA and a laterally subluxated hallux. (Redrawnfrom Coughlin M. Juvenile hallux valgus. In: Coughlin M, Mann R, eds. Surgery of the Foot and Ankle. 7th ed. St Louis, MO: Mosby; 1999:270, with permission.) D. Sketch of a MT with a high DMAA and a congruous 1st MTP joint. (Redrawn from Coughlin M. Juvenile hallux valgus. In: Coughlin M, Mann R, eds. Surgery of the Foot and Ankle. 7th ed. St Louis, MO: Mosby, 1999:270, with permission.)
Bunionette (Tailor’s Bunion)
1. Definition—Deformity
a. Lateral prominence of the 5th MT head with varus alignment of the 5th toe at the 5th MTP joint (Figure 5-62)
b. The prevalence of tailor’s bunions is unknown.
2. Elucidation of the segmental deformities
a. Fifth toe
i. Varus deformity of the 5th toe in relation to the 5th MT—i.e., 5th toe varus
ii. DMAA for the 5th MT has not been reported
b. Forefoot—neutral, but may be pronated or supinated, based on any coexisting hindfoot deformity
c. Midfoot
i. Abducted 5th MT—i.e., metatarsus 5th valgus
ii. Valgus/lateral-deviation/mal-orientation of the 5th MT–cuboid joint (Figure 5-62)
d. Hindfoot—neutral
e. Ankle—neutral
3. Imaging
a. Standing AP, lateral, and oblique of foot (Figure 5-62)
4. Natural history
a. Abduction/valgus of the 5th MT in relation to the cuboid and the 4th MT is most likely a congenital deformity. It is unknown whether the angle between the 4th and 5th MTs changes during growth. According to the law of triangles, the distance between the MT heads will increase as the foot grows, even if the exaggerated angle between the MTs remains the same (analogous with JHV—see Figure 5-57).
b. When the width of the forefoot at the level of the MT heads is greater than the width of the shoe, the exaggerated medial–lateral pressures experienced by the soft tissues over the 1st and 5th MT heads create pain, tenderness, and callus formation at those sites. If the 5th MT head is particularly prominent because of valgus deformity of the 5th MT and varus deformity of the 5th toe, the smaller surface area on the lateral side of the 5th MT head creates even greater stresses.
c. The local environment of the foot, i.e., the shoe, clearly relates to the comfort of the foot with a tailor’s bunion.
d. An unknown percentage of individuals with a tailor’s bunion experience unacceptable pain, tenderness, and callus formation on the lateral surface of the 5th MT head.
Figure 5-57. Standing AP x-ray of a foot in a 5-year-old girl with symptomatic JHV and MPV (IMA 11.5°). As her foot grows, the distance between the MT heads will increase, according to the law of triangles, even if the IMA does not increase. This geometric principle explains the reason that JHV looks worse and may cause more problems with shoe fitting as children age.
Figure 5-58. To ensure that there is adequate width of the shoe for the width of the foot at the level of the MT heads, place the shoe from one foot upside down under the other. If the shoe can be seen on both sides, it has adequate width.
5. Nonoperative treatment
a. Foot wear accommodations (same as for JHV)
i. Ensure that there is adequate width of the shoe at the level of the MT heads. Apply the sole of the shoe from one foot to the plantar surface of the other. If the shoe cannot be seen extending beyond the borders of the foot, it is too narrow (Figure 5-58).
ii. Recommend a low heel height to prevent the foot from sliding forward into the narrow toe box (Figure 5-59)
iii. Recommend that girls wear boys’ athletic shoes. They are made wider at the level of the MT heads for the equivalent length
iv. Recommend a bunion stretcher, available at shoe repair stores (Figure 5-59)
6. Operative indications
a. Failure of nonoperative treatment to relieve the pain:
i. on the lateral side of the 5th MT head
ii. and/or associated with under-overlapping of the 5th and 4th toes that may be associated with toenail ingrowth problems and skin irritation between the toes.
7. Operative treatment with reference to the surgical techniques section of the book for each individual procedure
a. Fifth MT osteotomy (see Chapter 8)
b. Possible resection of exostosis on lateral aspect of 5th MT head and plication of lateral 5th MTP joint capsule
Figure 5-59. A. A lower heel height will prevent the foot from sliding down into the toe box of the shoe, where the width will be narrower. B. Shoe repair stores offer bunion stretching shoe services.
Figure 5-60. A. JHV with increased DMAA (valgus deformity of the distal end of the 1st MT), congruous 1st MTP joint, and increased 1st–2nd MT angle. B. It is not appropriate to make the 1st MTP joint incongruous by adducting the hallux on the 1st MT. Instead, a valgus-correction distal 1st MT closing wedge osteotomy (see Chapter 8) is performed to correct the DMAA and reorient the 1st MTP joint. The medial prominence on the 1st MT head is resected and the medial capsule of the 1st MTP joint is repaired, without creating incongruity of the already congruous joint. The vascularity to the 1st MT head could be compromised by performing a concurrent release of the adductor hallucis and lateral joint capsule. A medial cuneiform medial opening wedge osteotomy (purple line) is used to correct the metatarsus primus varus (see Chapter 8). C. Immediately after surgery, the deformity corrections can be appreciated. The triangular bone graft in the medial cuneiform is identified by the black arrow D. Deformity corrections have been maintained long term.
Figure 5-61. A. JHV with normal DMAA, incongruous/subluxated 1st MTP joint, and increased 1st–2nd MT angle. B. The hallux must be repositioned on the distal end of the 1st MT by release of the adductor hallucis and the lateral capsule of the 1st MTP joint (dotted pink line). The medial prominence on the 1st MT head is resected (straight pink line) and the medial capsule of the 1st MTP joint is plicated, thereby creating congruency of the joint. An oblique rotational 1st MT base osteotomy (see Chapter 8) is used to correct the MPV. C. Lateral view of the 1st MT base osteotomy (purple line). D and E.Long-term follow-up AP and lateral x-rays.
Figure 5-62. A. Standing top view of a foot with a prominent tailor’s bunion. B. Standing AP x-ray of the foot. Lateral deviation of the 5th MT in relation to the cuboid and the 4th MT (metatarsus 5th valgus) and 5th toe varus deformity at the MTP joint can be seen.
Congenital Overriding 5th Toe
1. Definition—Deformity
a. Congenital dorsomedial angular alignment of the 5th toe at the MTP joint. The malalignment at the MTP joint is associated with a capsular contracture as well as an extensor tendon contracture. The web space skin between the 4th and 5th toes is “malformed,” as evidenced by its excessively proximal position. The toe appears to have erupted from the fetal mitten more dorsal and medial in relation to its MT than the other toes in relation to their MTs (Figure 5-63).
b. Congenital overriding affects the 5th toe almost exclusively, though I have seen a congenital overriding 4th toe in two syndromic children.
Figure 5-63. Congenital overriding 5th toe. The toe is dorsomedially angulated over the 4th toe.
2. Elucidation of the segmental deformities
a. Fifth toe—dorsiflexed and varus
i. dorsomedial angulation of the 5th toe at the MTP joint
3. Imaging
a. None required, though AP, lateral, and oblique x-rays of the forefoot should be obtained before surgery
4. Natural history
a. Persistence of the deformity throughout life
b. Reportedly, approximately 50% do well with careful shoe selection and the rest experience unacceptable pain from rubbing in the shoe
5. Nonoperative treatment
a. Accommodative shoe wear
6. Operative indications
a. Pressure-induced pain from shoes that is not relieved by accommodative shoe wear
7. Operative treatment with reference to the surgical techniques section of the book for each individual procedure
a. Butler procedure for congenital overriding 5th toe (see Chapter 7)
Curly Toe
1. Definition—Deformity
a. Congenital flexion, adduction, and external rotation of one or more toes, most commonly the 4th toe (Figure 5-64)
b. Usually, an idiopathic deformity that may be bilateral and asymmetric
2. Elucidation of the segmental deformities
a. Flexion, adduction, and external rotation of one or more toes with contracture of the FDL, and occasionally the flexor digitorum brevis, to the affected toe
Figure 5-64. Curly toe defined as congenital flexion, adduction, and external rotation of the 4th toe.
3. Imaging
a. None indicated in infants.
b. In an older child with a persistent symptomatic deformity, x-rays of the toe can be obtained preoperatively, though they are not absolutely indicated
4. Natural history
a. Most spontaneously correct either completely or sufficiently so as to avoid pain and long-term disability
i. In many cases, the flexion deformity corrects completely, and the mild residual adduction and external rotation deformities are of no clinical significance.
b. A very small percentage of curly toe deformities do not spontaneously correct adequately, resulting in pain and callosities on the dorsal or plantar aspect of the affected toe and/or the overlapping adjacent toe. There may also be pain associated with ingrowth or irritation of the nail plate on the curly toe.
5. Nonoperative treatment
a. Stretching exercises for the long toe flexor tendon, although the efficacy of stretching, taping, and strapping have not been demonstrated
b. Accommodative shoe wear
Figure 5-65. A. Curly 4th toe in a 4-year-old. B. Percutaneous FDL tenotomy was performed because of pain and irritation caused by the complete overlapping of the 3rd toe on the tip of the 4th toe. C. Immediately following the FDL tenotomy, the 4th toe elevated completely, but the adductus/varus and external rotation deformities remained. It is anticipated that, in time, those deformities will improve. D. Webril and Coban dressing.
6. Operative indications
a. Failure of the flexion/adduction/external rotation deformities to correct sufficiently through natural history and/or with stretching exercises to avoid:
i. pain and callosities on the dorsal or plantar aspect of the affected toe and/or the overlapping adjacent toe.
ii. pain associated with ingrowth or irritation of the nail plate on the curly toe.
7. Operative treatment with reference to the surgical techniques section of the book for each individual procedure
a. Percutaneous tenotomy of the FDL (and possibly the flexor digitorum brevis [FDB]) to the affected toe (see Chapter 7)
i. Be aware that the toe will immediately extend fully, but the adduction/varus and external rotation deformities will persist. Often, these two additional deformities will partially correct gradually over time (Figure 5-65).
Mallet Toe
1. Definition—Deformity
a. Contracture of the FDL to a lesser toe creating a flexible, and eventually rigid, flexion deformity of the distal interphalangeal (DIP) joint, without coincident extension deformity of the MTP joint (Figure 5-66)
b. The etiology is usually unknown, but most are idiopathic and not the result of a neuromuscular disorder.
c. One or more toes may be affected in one foot, and the deformity may be unilateral or bilateral (Figure 5-66).
Figure 5-66. A. Right foot of a young teenager with 2nd and 3rd mallet toes and 4th and 5th curly toes. B. Left foot of the same child as in A. C. Unilateral 2nd mallet toe in a teenager.
2. Elucidation of the segmental deformities
a. Flexion deformity of the DIP joint of a lesser toe without coincident extension deformity of the MTP joint
i. The deformity is flexible at first. Plantar flexion of the ankle and toe will relax tension on the FDL and allow full extension of the DIP joint.
ii. With time, the volar capsule of the DIP joint becomes contracted and will not allow the joint to extend fully, despite relaxing tension on the FDL by plantar flexion of the ankle and toe
3. Imaging
a. Standing AP, lateral, and oblique of the toes/forefoot
4. Natural history
a. Mallet toes are most common in adults (with a female predominance), increasing in prevalence almost exponentially with age
b. Poor shoe fitting is considered a risk factor for the development of mallet and hammer toes in adults, but the risk factors for the few that develop in adolescents are unknown
c. Pain/tenderness over the dorsum of the affected joint and/or at the tip of the plantar flexed toe, and/or toenail growth disturbances occur in many cases
d. Flexible deformities become rigid over time
5. Nonoperative treatment
a. Stretching exercises for the long toe flexor tendons
b. Accommodative shoe wear
6. Operative indications
a. Pain/tenderness over the dorsum of the affected joint and/or at the tip of the plantar flexed toe, and/or toenail growth disturbances despite attempts at nonoperative treatment
7. Operative treatment with reference to the surgical techniques section of the book for each individual procedure
a. Percutaneous (see Chapter 7) or open tenotomy of the FDL to the affected toe—perform this when no capsular contracture exists and the DIP joint rests in the fully extended position following tenotomy
b. Percutaneous (see Chapter 7) or open tenotomy of the FDL to the affected toe with temporary longitudinal K-wire fixation—perform this when no capsular contracture exists, but the DIP joint rests in flexion immediately following tenotomy due to skin or other soft tissue contractures
c. Volar DIP joint capsulotomy along with tenotomy and temporary longitudinal wire fixation—perform this in cases with early DIP joint capsular contracture
d. DIP joint arthrodesis—perform this in long standing cases with severe deformity and/or degenerative arthritis of the joint
Hammer Toes
1. Definition—Deformity
a. Contracture of the (FDB and FDL to a lesser toe creating a flexible, and eventually rigid, flexion deformity of the proximal interphalangeal (PIP) joint, with occasional flexion deformity of the DIP joint, but without coincident extension deformity of the MTP joint (Figure 5-67)
b. The etiology is usually unknown, but most are idiopathic and not the result of a neuromuscular disorder.
c. One or more toes may be affected in one foot and the deformity may be unilateral or bilateral (Figure 5-67)
2. Elucidation of the segmental deformities
a. Flexion deformity of the PIP joint, and often the DIP joint, of a lesser toe without coincident extension deformity of the MTP joint
i. The deformity is flexible at first. Plantar flexion of the ankle and toe will relax tension on the FDB and FDL and allow full extension of the PIP and DIP joints.
ii. With time, the volar capsule of the PIP and/or DIP joints become contracted and will not allow the joint(s) to extend fully despite relaxing tension on the FDB and FDL by plantar flexion of the ankle and toe.
Figure 5-67. A. Unilateral 2nd hammer toe in a young teenager. B. Bilateral hammer toes 2 to 5 in a teenager.
3. Imaging
a. Standing AP, lateral, and oblique of the toes/forefoot
4. Natural history
a. Hammer toes are most common in adults (with a female predominance), increasing in prevalence almost exponentially with age.
b. Poor shoe fitting is considered a risk factor for the development of hammer and mallet toes in adults, but the risk factors for the few that develop in adolescents are unknown.
c. Pain/tenderness over the dorsum of the affected joint and/or at the tip of the plantar flexed toe, and/or toenail growth disturbances occur in many cases.
d. Flexible deformities become rigid over time.
5. Nonoperative treatment
a. Stretching exercises for the long toe flexor tendons
b. Accommodative shoe wear
6. Operative indications
a. Pain/tenderness over the dorsum of the affected joint and/or at the tip of the plantar flexed toe, and/or toenail growth disturbances despite attempts at nonoperative treatment
7. Operative treatment with reference to the surgical techniques section of the book for each individual procedure
a. Percutaneous (see Chapter 7) or open tenotomy of the FDL and FDB to the affected toe—perform this when no capsular contractures exist and the IP joints rest in the fully extended position following tenotomy
b. Percutaneous (see Chapter 7) or open tenotomy of the FDL and FDB to the affected toe with temporary longitudinal K-wire fixation—perform this when no capsular contractures exist, but one or both IP joints rest in flexion immediately following tenotomy due to skin or other soft tissue contractures
c. Volar DIP joint capsulotomy along with tenotomy and temporary longitudinal wire fixation—perform this in cases with early PIP joint capsular contracture
d. PIP joint arthrodesis—perform this in long standing cases with severe deformity and/or degenerative arthritis of the joint
Claw Toe
1. Definition—Deformity
a. Contracture of the flexors and extensors of a toe creating a flexible, and eventually rigid, extension (dorsiflexion) deformity of the MTP joint and flexion deformity of the interphalangeal (IP) joint(s) of a toe (Figure 5-68)
b. Claw toes are most often associated with a cavus foot deformity, both of which are due to an underlying neuromuscular abnormality until proven otherwise. CMT disease is the most common cause.
c. Usually all 5 toes are affected.
d. When the underlying neuromuscular condition is systemic (CMT) or central (myelomeningocele, tethered cord), the toes of both feet are affected.
2. Elucidation of the segmental deformities
a. Extension deformity of the MTP joint and Flexion deformity of the IP joint(s) of the hallux or any lesser toe
i. The deformities are flexible at first. Plantar flexion and dorsiflexion of the ankle and toe will selectively relax tension on the flexors and extensors and allow full extension of the IP joint(s) and full flexion of the MTP joint.
ii. With time, the dorsal capsule of the MTP joint and the volar capsule of the IP joint(s) become contracted and will not allow the joints to flex or extend fully despite relaxing tension on the extensors and flexors by dorsiflexion and plantar flexion of the ankle and toe.
b. Also, see Cavovarus Foot—Elucidation of the segmental deformities—this chapter.
Figure 5-68. A. Claw toes coincident with a cavus foot in a young teenager with CMT disease. The MTP joints are extended (dorsiflexed) and the IP joints are flexed. B. Claw toes coincident with a cavovarus foot in another teenager with CMT disease. The MTP joints are extended (dorsiflexed) and the IP joints are flexed.
3. Imaging
a. Standing AP and lateral of foot
b. Standing AP and lateral thoracolumbar spine
4. Natural history
a. The clawing increases in severity and rigidity with time because of the progressive nature of the underlying neuromuscular disorder.
b. Pain/tenderness over the dorsum of the IP joint(s) and/or at the tip of the plantar flexed toe, and/or toenail growth disturbances occur in many cases.
c. Pain/tenderness under the adjacent MT head occurs in many cases due to the associated cavus deformity.
5. Nonoperative treatment
a. None
6. Operative indications
a. Pain/tenderness over the dorsum of the flexed IP joint(s)
b. Pain/tenderness at the tips of the plantar flexed toe
c. Pain/tenderness under the adjacent MT head
7. Operative treatment with reference to the surgical techniques section of the book for each individual procedure
a. Jones transfer of the extensor hallucis longus to the 1st MT neck (see Chapter 7) with percutaneous tenotomy of the FHL (see Chapter 7)—perform this for a clawed hallux
b. Hibbs transfer of the extensor digitorum longus to the cuboid or the peroneus tertius (see Chapter 7) with percutaneous tenotomy of the FDL tendons (see Chapter 7)—perform this for clawed lesser toes
c. Correct all coincident cavovarus foot deformities (see Cavovarus Foot—Operative Treatment, this chapter; Individual Soft Tissue Procedures, Chapter 7; and bony procedures, Chapter 8)