LESSER TOE ABNORMALITIES

1. LESSER TOE ABNORMALITIES
DR. ANAND J KARIA

2. •1.HAMMER TOE
•2.CLAW TOE
•3.MALLET TOE
•4.CORN

3. HAMMER TOE
• Abnormal flexion posture of the
PIP joint of one of the lesser four
toes.
• Types :-
• 1. Flexible hammer toe :-If the toe
still can be moved at the joint, it's a
flexible hammertoe.
• 2. Fixed hammer toe:- If the
tendons in the toe become rigid
the toe becomes fixed.

4. CLINICAL FINDINGS
• Joint is flexed at the PIP joint and extended and DIP
joint.
• Pain :- Dorsum of the PIP joint.
• Pressure against the shoe and under the metatarsal
head.
• Painful callus formation beneath the metatarsal head.
• Tenderness (Dorsofibular side of the 2nd
metatarsophalangeal joint)

5. Causes
• Long-term use of poorly fitting shoes.
• Diabetes
• Neuromuscular diseases
• Trauma

6. Treatment
• Conservative:- Pads and strappings.
• They reduce the deformity and relieve pressure over painful
points.
• Manipulations:- Short duration deformity and in absence of
extension deformity ; daily manipulations and taping the toe correct
the flexion deformity at the PIP joint.
• Operative treatment

7. Operative treatment
• Soft-tissue procedure:-
• Flexor-to-extensor transfer.
• Reliable in patients younger than 30 years old, have no deformity at the
MTP joint
• No fixed flexion deformity at the PIP joints.
• Bone and joint procedures:-
• Resection ( Most common )
• Complete proximal phalangectomy
• Arthrodesis of the proximal interphalangeal joint
• Complication:- Postoperative ischemia of the toe.

8. Procedures for Hammer Toe Deformities
DEFORMITY CHARACTERISTICS TREATMENT
Flexible hammer toe No fixed contracture at MTP or PIP
joint
nonoperative; rarely, flexor-to-
extensor transfer using FDL
Fixed hammer toe with fixed
extension of MTP
Fixed flexion contracture at PIP;
MTP subluxation in extension
Resection of condyles of proximal
phalanx, dermodesis; lengthening
of EDL, tenotomy of EDB; MTP
capsulotomy, collateral ligament
sectioning
Fixed hammer toe with MTP
subluxation
Fixed flexion contracture at PIP;
MTP subluxation in extension
Plantar plate repair after Weil
osteotomy
Crossover toe Fixed flexion contracture at PIP;
MTP subluxation in varus or valgus
Resection of condyles of proximal
phalanx, dermodesis; collateral
ligament/capsular repair; EDB
transfer
Mallet toe Fixed flexion contracture at DIP Resection of condyles of middle
phalanx, dermodesis; FDL
tenotomy

9. Claw toe
• Characterized by hyperextension at
MTP joint and resulting PIP and
DIP flexion.
• Location:- Involves multiple toes
• Often bilateral
• Cause:- synovitis ( Most common )
• Trauma
• Presentation
• Pain at the level of the unstable MTP
joint.
• Metatarsalgia.
• Depressed metatarsal
head with tenderness.

10. Biomechanics
• Extensor digitorum longus tendon :- Most powerful extension force.
• The EDL tendon is able to extend the interphalangeal joints of the toe
only when the MTP joint is in a neutral or flexed position.
• If a toe is held in an extended position, such as in a high-heeled shoe,
the EDL becomes a deforming force on the MTP joint.
• Intrinsic muscles:- Flexion of the MTP joint
• lumbrical muscle:- Acts as a plantar flexor of the MTP joint

11. • Normally, the axis of the pull of
these muscles is plantar to the
center of rotation of the MTP
joint.
• As the MTP joint becomes
chronically extended the line of
action moves dorsal to the center
of rotation of the MTP joint
• These tendons become a
deforming force for dorsal
subluxation.

12. Pathophysiology
• Loss of intrinsic function of
the foot leads to an
imbalance
• Allowing the extensor
digitorum longus to extend
the MTP joint and the flexor
digitorum longus to flex the
interphalangeal joints.

13. Differentiating points from hammer toe
Claw toe Hammer toe
Similar deformity is present in all toes Deformity only one or two toes are involved
Always have extension deformity at the MTP joint Extension of the MTP joint may or may not be present
Flexion deformity at the distal
interphalangeal joint
This deformity usually does not occur

14. Treatment
• Nonoperative:- Taping and shoe modification
• Shoe with a high toe box
• Operative:-
• EDL lengthening
• FDL flexor-to-extensor transfer
• MTP capsulectomy and proximal phalanx head and neck resection

15. MALLET TOE
• Flexion posture of the DIP joint.
• Cause:- Uncertain
• Site:- 2nd toe ( Most common )
• It can occur as an isolated deformity
or in conjunction with hammer toe
deformity
• Complication:- Painful end corn just
beneath the nail.

16. • Pathoanatomy:-
• projection of the 2nd toe distal to the other toes can cause pressure
at the tip of the toe and buckling at the DIP joint in a shoe with a
narrow or short toe box.
• With time, this flexion posture can attenuate the terminal extensor
tendon until it no longer can extend the distal joint.
• The flexor digitorum longus holds the DIP joint in flexion until the
deformity becomes fixed.

17. Treatment
• Nonoperative:- shoes with high toe boxes, Silicone/foam toe
sleeves
• Operative:-
• 1. flexor tenotomy at the DIP flexion crease.
• 2. Subtotal or Total resection of the middle phalanx with dorsal
dermodesis.
• 3. Amputation of the distal half of the distal phalanx.

18. • 1. FDL tenotomy:- Transfer of the deforming flexor digitorum
longus to the extensor mechanism to correct a flexion deformity.
• Indication :- flexible deformities that have failed nonoperative
management
• The wound is closed with one or two sutures & wooden-soled shoe is
recommended until the sutures are removed at 2 weeks.
• The patient is encouraged to wear adequately long shoes with wide
toe boxes.

19. Corn
• Hyperkeratotic lesions occurring
over bony prominences and
involving the stratum corneum
layer of the skin.
• Classification :-
• 1. Hard
• 2. Soft
• Cause:- Pressure and friction
from unyielding structures.

20. Hard corn
Site:- Dorsolateral aspect of the PIP joint
of the 5th toe.
• Pathology:-
• Phalangeal condyle beneath the skin and
an unyielding shoe toe box over the skin
generate pressure and friction.
• With time, a painful lesion develops
• Lesion is firm, dry, and tender.
• Surrounding erythema and heat are
present.

21. Treatment
• Nonoperative:-
• Sleeve with a friction absorbing pad consisting of medical-grade
paraffin
• Operative:-
• Resection :-
• Remove the bony prominence on the dorsolateral aspect of the
condyle of the proximal phalanx.
• Resection of the head and neck of the proximal phalanx to prevent
recurrence

22. Soft corn
• Site :- 4th interdigital space
• Associated with :- An
abnormally short 5th metatarsal
• hallux valgus, which causes
adduction pressure on the fifth
toe from the shoe.
• Cause:- Underlying pressure
from the medial flare of the base
of the distal phalanx of the 5th
toe.

23. Treatment
• Wash the web spaces twice a day with household soap
• Dry the web completely and apply an antifungal, antibacterial powder
• Lamb’s wool or a self-adherent rubber web spacer (doughnut).
• Operative:-
• Indication:-
• 1. Remains painful, becomes infected again
• 2. Ulcerates despite preventing bony impingement
• 3. If the patient tires of the time and care necessary to control the corn
• This problem can be resolved surgically by removing the underlying
bony problem.

24. • 1. Resection:- Lateral flare of the base of the proximal phalanx of
the 4th toe flush with the diaphysis or removing the head and neck of
the proximal phalanx of the 5th toe.
• 2. Syndactylization:- For a recurrent interdigital corn.

25. The plantar corn
• Another example of a hard corn.
• Common in older people
• Location:-Beneath a metatarsal
head, plantar to the prominent
fibular side of the condyle of the
metatarsal head
• Presentation:-
• pain, mobility impairment, and
functional limitation.

26. Treatment
• Conservative care:- 1st line of treatment
• If a lengthy course of conservative care fails, the following procedures
should be done.
• Operative :-
• 1. Arthroplasty:- For a small, intractable plantar keratosis.
• 2. Osteotomy:- Diffuse callosity and abnormally long metatarsal.

27. “ Careful, girls! try to limit your wearing of
heels to a minimum.”
THANK YOU
• Reference:- campbell's operative
orthopaedics 13 edition