Lesser toe disorders

1. Lesser Toe Disorders

2. Introduction
• Lesser toes:
– Help with balance
– Dissipate foot pressures
– Contribute to arch stability
• Dynamic, static and bony restraints
maintain alignment and stability
• Failure in one leads to domino-like failure
of other joints
• Involved in systemic conditions

3. Hammertoes, Mallet Toe and Claw toes
• Deformities in the sagittal plane of 2-5
• Medical consultations:
– Shoe wear difficulties
– Mechanical problems – metatarsalgia
– Involve one or more toes
• Multifactorial etiologies, traumatic,
rheumatologic, mechanical
• Ill-fitting shoes are most common

4. Definitions
• Mallet toe – Flex DIP
• Curley toe – Flex DIP and PIP
• Hammer toe – Flex PIP and Ext MTP
• Crossover toe – Flex at PIP, also
deformity in axial plane
• Claw toe - 1º def is hyperext at MTP
• Classify into “rigid” or “ flexible”

5. • PICS……

6. Anatomy
• Static
– Planter plate, planter aponeurosis, joint
capsule, and collaterals
– Allow DIP and PIP to flex but not extend past
neutral, allow MTP to flex/ext during gait cycle
• Dynamic
– Intrinsic (7 Interosseus, 4 lumbrical, abductor
digiti minimi, EDB, FDB)
– Extrinsic (EDL, FDL)

7. Flexion/Extension forces at joint
• DIP – FDL strong flex, EDL weak ext
• PIP – FDL weak flex, FDB strong flex
• MTP – EDL strong ext, FDB and FDL no
direct insertion – weak flex
• MTP – Intrinsics, lumbricals, interossei
main opposition to EDL
• In ext interossei muscles become ext as
tendons travel dorsally

8. Flexion/Extension forces at joint

9. PathophysioIogy
• Mallet toe:
– flexion deformity at the DIP joint
– trauma or impingement of tight shoes
– EDL tendon at the DIP joint attenuates/
ruptures
– unopposed flexion by the FDL tendon at the
DIP joint

10. PathophysioIogy
• Hammer toe:
– flexion deformity at the PIP
– result of impingement of the end of the toe
against the shoe, or MTP joint synovitis
– MTP joint to dorsiflex
– FDB and FDL strongly flexing
– EDL being unable to oppose the flexion,
because it can extend the joint only when the
proximal phalanx is neutrally aligned

11. PathophysioIogy
• Claw Toe:
– Dorsiflexion at the MTP flexion at the PIP and
DIP
– Imbalance of the intrinsic and extrinsic foot
musculature
– neurologic origin
– extrinsic overpower the intrinsic
– EDL overpowers the lumbricals and interossei
muscles, creating dorsiflexion at the MTP joint

12. Evaluation
• Hx and Ex
• Evaluate whole foot function not only
deformity
• PTT dys – clawing over time due to over-
pull of FDL
• Lesser Toe:
– Tip of toe
– Dorsum of PIP
– Under MTP

13. Evaluation
• Fixed/Rigid
• Push Up Test
– pushing under the metatarsal
heads
– ankle is brought to neutral
– flexible toe the toes correct
– Rigid no correction

14. Non-operative
• Flexible respond better
• Accommodative toe box
• Metatarsal pads
• Tips of toes – soft toe cap
• Taping, strapping and stretching can slow
progression of deformity
• May become rigid and require surgery

15. Operative
• “The number one predictor of patient
satisfaction after toe surgery is realistic
pre-operative expectations”
• Surgery:
– Shorter
– More swollen
– Less motion
– Less control

16. Operative
• Trade off for:
– Less painful
– Straighter
– “shoeable”
• Other issues:
– NV damage
– Recurrence

17. Choice Of Procedure

18. Second Metatarsal Joint Instability
• Static and passive restraints of the MTP
overcome
• Dorsal subluxation of the proximal phalanx
on the Met head during gait
• Acute rupture of planter plate – occurs at
insertion at met neck (restraint to dorsal
translation)
• Commonly – Gradual attenuation
(Overload)

19. Second Metatarsal Joint Instability
• This subluxation during the toe-off - pain and
synovitis
• Causes (increase 2ond MTP Pressures):
– long second metatarsal (longest making it prone)
– hypermobile first ray
– hallux valgus
– equinus
– hallux rigidus
– hammertoe and claw
• Rheumatological causes:
– synovitis in the joint, stretching or attenuation of the
collateral ligaments

20. Second Metatarsal Joint Instability
• Progressive claw toe
• Pain:
– Joint – swelling and synovitis
– Neuritic pain as planter nerve involved
– Worse on walking, better with rest
• Instability:
– “pop” in foot after walking or running

21. Second Metatarsal Joint Instability
• Clinically:
– Swollen dorsally around MTP
– Separation of 2/3 – Y-toe deformity, crossover toe
– Examine for hypermobile 1st
Ray
– ↓ ROM at ankle ↑ foot pressure
– Clinically unstable on Lachman test

22. Non-operative Treatment
1. alleviate pain:
– Mild – splint/taping, offload with Orthotics
– Severe- Stiff rocker bottom shoe
– Injections
– Physiotherapy
1. predisposing cause

23. Operative Treatment
– FDL Girdlestone-Taylor flexor to extensor
tendon transfer
– Corrects angular deformity and stabilty at MTP
– Stiffness
– Long MT may need shortening
– FDL taken of DP, Split in two and sutured to ext
expansion

24. Operative Treatment
– Plantar condylectomy and pinning
– Ext lengthening from dorsal approach
– Capsule release + dorsal collaterals
– ¼ of planter met head
– Held for 3 weeks
– Unloads met head
– Leaves pt with more flexible toe

25. Operative Treatment
– Metatarsal osteotomy
– Long oblique manner of short horizontal (Weil)
– Combined with ext lengthening and capsule
release

26. Bunionette Deformity
• Equivalent of hallux valgus deformity of
the fifth toe
• Historically known as a tailor's bunion
• Crossed leg sitting position makes the
lateral aspect of the foot particularly prone

27. Bunionette Deformity
• Medially directed pressure on the fifth toe
as a result of shoe wear
• Shoe wear - a small toe box will push the
fifth toe over (adduction force)
• Pressure against the lateral eminence
• Widening of the forefoot to hallux valgus
may indirectly increase pressure and
mirroring deformity of the great toe

28. Evaluation
• Radiographic angles:
– 4/5 metatarsal angle, abnormal >8°
– 5th
MTP angle, normal <10°
• Concomitant HV – splayfoot
• Grading:
– type 1 bunionette has a prominent lateral eminence
– type 2 bunionette has a bowed metatarsal shaft
– type 3 bunionette has an increased IMA

29. Evaluation

30. Non-operative Treatment
• Mainstay is shoe modification
• Metatarsal pad
• Orthotics – with medial column support (In
FF)

31. Operative Treatment
– type 1
– Lateral eminence excision up to border of articular
cartilage
– Lateral capsule is reefed
– type 2
– Distal chevron, metatarsal osteotomy
– Chevron – stable, small shift, AVN
– type 3
– Long oblique metatarsal osteotomy with stable
internal fixation

32. Freiberg Infraction
• Freiberg infraction is an osteochondrosis of the lesser
metatarsal head
• First described in 1914 and attributed to trauma
• Current theory suggests that the condition results from a
vascular insult to the subchondral bone
• Commonly seen in the 2nd but can occur in the 3rd or
4th
• Women in the age group of 11 -17
• Initially leads to swelling and stiffiress of the joint,
• Later leads to various degrees of subchondral collapse
and arthritic changes of the MTP joint

33. Diagnostic tests
• Degenerative changes of the MTP joint - Xray
• Evaluate the second metatarsal length -
implicated as predisposing factor
• Freiberg disease will often present with no
significant radiographic findings
• Bone scan or MRI may be helpful in diagnosis
but will not generally alter clinical treatment.
• later stages, radiographs demonstrate joint
collapse, flattening of the metatarsal head,
osteophytes, and joint narrowing

35. Non-operative
• Early stages – stiff, swollen joint, painful
flex/ext
• Acute phase – strapping, orthotics
• Steroid injections – can make arthritis
worse

36. Operatiave
• Limited to dorsal joint – Cheilectomy
• Larger portion involved but planter portion
is persevered – closing wedge osteotomy
• Complete degeneration
– excision of met head
– prox phalanx resection with capsular
interposition
– Both produce an unstable joint

37. Intractable Planter Keratosis (IPK)
• IPK forms on the sole of the foot under the
metatarsal heads as a result of pressure
on the underlying skin
• mechanical pressure Increases the activity
of keratinocytes
• Two Types:
– Discrete: corn, well-defined
– Diffuse: calluses, thickened skin

38. Non-operative
• Trimming or corns and calluses
• Pumice stone – after bath
• Topical salicyclic
• Insoles

39. Operative
• Remove underling bony prominences
• Planter condylectomy
• Dorsal closing wedge

40. Interdigital Corns
• Corns are discrete areas of dense hyperkerarintzation
that form as the result of external pressure on the skin
overlying a bony prominence.
• Two type, hard corns and soft corns.
• Hard corns: occur over the exposed surface of the fifth
toe in response to pressure from a shoe box.
• Soft corns form between the toes and have a unique
macerated appearance because they are kept moist
from opposition of the neighboring toes
• Soft corns - between the fourth and fifth
• Soft corns are produced by the impingement of the bony
prominences of adjacent toes,

41. Interdigital Corns
• Non-op:
– Toe sponge spacers, padding
– Address shoewear
– Trim hard corns
– Remove soft corns with a scalpel
• Op:
– Remove underlying bony prominences
– Soft – partial syndactylization

42. • Thank you