Toe Deformity
Toe deformity is a frequent condition. We should distinguish between Claw toe, Hammer Toe and Mallet Toe.
Patients suffer from pain on dorsal surface with shoe wear, and from deformity. Metatarsalgia may also be present.
It is important to always check if the deformity is reducible or not, since it changes the treatment strategy.
Surgical treatment depend on the type of the deformity and its reducibility. Bony gestures and/or tendon transfer may be required.
associated conditions should be corrected too ( hallux valgus)
Full weight bearing is allower , protected by an orthopedic shoe for 3 to 6 weeks.
Claw Toe
MTP hyperextension (primary) which then leads to PIP and DIP flexion
Associated conditions:
Pes cavus
Neuromuscular disease (e.g: compartment syndrome) affecting intrinsic and extrinsic muscle balance (especially if all 4 lesser toes are involved)
Inflammatory arthropathies
Treatment:
Taping and shoe modification : 1st line
EDB tenotomy, EDL lengthening, FDL flexor-to-extensor transfer (Girdlestone) : for flexible deformity
P1 head and neck resection + Girdlestone (or the above) : fixed contracture
Weil osteotomy (if tall metatarse)
Isolated flexor tenotomy (flexible contracture with tip of the toe ulcer, non infected
flexor to extensor tendon transfert
1st phalanx head resection
Weil osteotomy
BRT osteotomy
PIP joint fusion (arthrodesis)
Hammer Toe
Most frequent deformation : PIP flexion, DIP extension, MTP neutral (or extended)
2nd toe most affected
Pathoanatomy
overpull of EDL
imbalance of intrinsics
Rigid or flexible (push up test: flexible if deformation disappear when dorsal pressure is applied head metatarse. furthermore, if deformation disappear on ankle plantar flexion, thus the deformation is flexible)
Treatment
Shoe modification, silicone pads….
Surgical
flexor tendon (FDL) to EDL tendon transfer : for flexible deformation
PIP resection arthroplasty +/- tenotomy and tendon transfers
Girdlestone procedure with FDL to EDL transfer ( If MTP joint involvment)
EDL Z-lengthening or tenotomy (for MTP involvement)
PIPJ arthrodesis
Mallet toe
Hyperflexion of the DIP joint
Physiopathology :
Contracture (or spasm) of FDL because of pressure of toe against the end of shoe
> 70% of patients have a longer digit
Rupture of EDL (traumatic)
Treatment
Shoes with high toe boxes, Silicone/foam toe sleeves
Surgery :
percutaneous/open FDL tenotomy ( flexible deformity)
FDL transfer to dorsum of phalanx
DIPJ fusion or middle phalangeal distal condylectomy (excisional arthroplasty of DIP)
