the toes are common in the pediatric population. Generally they are congenital
in nature with both or one of the parents having the same or similar condition.
Many of these deformities are present at birth and can become worse with time.
Rarely do children outgrow these deformities although rare instances of
spontaneous resolution of some deformities have been reported.
the toes in infancy and early childhood are rarely symptomatic. The complaints
of parents are more cosmetic in nature. However, as the child matures these
deformities progress from a flexible deformity to a rigid deformity and become
progressively symptomatic. Many of these deformities are unresponsive to
conservative treatment. Common digital deformities are underlapping toes,
overlapping toes, flexed or contracted toes and mallet toes.
Quite often a prolonged course of digital splitting and exercises may be
recommended but generally with minimal gain. As the deformity becomes more
rigid surgery will most likely be required if correction of the deformity is
are commonly seen in the adult and pediatric population. The toes most often
involved are the fourth and fifth toes. A special form of underlapping toes is
called clinodactyly or congenital curly toes. Clinodactyly is fairly common and
follows a familial pattern. One or more toes may be involved with toes three,
four, and five of both feet being most commonly affected.
The exact cause
of the deformity is unclear. A possible etiology is an imbalance in muscle
strength of the small muscles of the foot. This is aggravated by a subtle
abnormality in the orientation on the joints in the foot just below the ankle
joint called the subtalar joint. This results in an abnormal pull of the
ligaments in the toes causing them to curl. With weight bearing the deformity
is increased and a folding or curling of the toes results in the formation of
callus on the outside margin of the end of the toe. Tight fitting shoes can
aggravate the condition.
The age of the
patient, degree of the deformity and symptoms determine treatment. If symptoms
are minimal, a wait and see approach is often the best bet. When treatment is
indicated the degree of deformity determines the level of correction. When the
deformity is flexible in nature a simple release of the tendon in the bottom of
the toe will allow for straightening of the toe. If the deformity is rigid in
nature then removal of a small portion of the bone in the toe may be necessary.
Both of these procedures are common in the adult patient for the correction of
hammertoe deformity. If skin contracture is present a derotational skin plasty
may be required.
Toes - Overlapping Fifth Toe
This deformity is
characterized by one toe lying on top of an adjacent toe. The most common toe
involved is the fifth toe. When one of the central toes is involved the second
toe is most commonly affected. The etiology of the condition is not well understood.
It is though that it may be caused by the position of the fetus in the womb
during development. The condition my run in families so there may be a
hereditary component to the deformity.
conservative treatment depends upon how early the diagnosis is made. In
infancy, passive stretching and adhesive tapping is most commonly used. This
may require 6 to 12 weeks to accomplish and reoccurrence is not uncommon.
Rarely will the deformity correct itself. As the individual matures the deformity
becomes fixed. When surgical correction is warranted a skin plasty is required
to release the contracture of the skin associated with the deformity.
Additionally a tendon release and a release of the soft tissues about the joint
at the base of the fifth toe may be required. In severe cases the toe may
require the placement of a pin to hold the toe in a straightened position. The
pin, which exits the tip of the toe, may be left in place for up to three
weeks. During this period of time the patient must curtail their activities
significantly and wear either a post-operative type shoe or a removable cast.
Excessive movement at the surgical site can result in a less than desirable
result. The pin can be easily removed in the doctor's office with minimal discomfort.
Following removal of the pin splinting of the toe may be required for an
additional two to three weeks.
digital deformity is contracture of the toes in the formation of hammertoes and
mallet toes. Hammertoes are described in depth in another article. Mallet toes
are a result of contracture of the last joint in the toe. In the pediatric
population it is often flexible and not painful. Over time the deformity
becomes rigid and a callus may form on the skin overlying the joint at the end
of the toe. Additionally the toenail may become thickened and deformed form the
repetitive jamming of the toe while walking. The deformity usually involves one
or two toes, with the second toe most commonly affected. Mallet toes have
several etiologies. Longer toes that are forced against a short toe box in the
shoe will, over time, develop a contracture of the last joint in the toe
causing a mallet toe.
treatment consists of padding and strapping the toes into a corrected position.
This treatment may alleviate the symptoms but will not correct the deformity.
Diabetic patients often develop ulcerations on the ends of their toes secondary
to mallet toe deformity and the pressure that results from the toe jamming into
the shoe. When standing, the toe will demonstrate a contracture, with the tip
of the toe facing downward into the floor. If the deformity is flexible a
simple release of the tendon in the bottom of the toe will allow straightening
of the toe. Following the procedure the patient must avoid shoes that cause
jamming of the toe or the deformity can reoccur. When the deformity is rigid
surgical correction requires the removal of a small section of bone in the last
joint of the toe. On occasion fusion of the last two bones in the toe may be
necessary. This requires removing the cartilage from the last joint in the toe
and pinning the bones together. When the bone heals it forms a single bone and
the toe remains in a straightened position. Healing time is dependent upon the
procedure selected. If a tendon release is performed the patient my return to a
roomy shoe within a week. If the toe is straightened by removing a section of
the bone in the toe it make ten days to three weeks for a patient to return to
normal shoes. If a fusion is performed to straighten the toe, the patient may
not return to normal shoes for 6 to 8 weeks. Time off from work will depend
upon the type of shoe gear that must be worn and the level of activity
necessary to perform the job. A minimum of three to four days off from work is
generally recommended and longer if the job responsibilities can not be
modified to accommodate the normal healing time for the surgery.