Claw Toe Workup

  • Author: James K DeOrio, MD; Chief Editor: Jason H Calhoun, MD, FACS   more...
 
Updated: Feb 17, 2012
 

Laboratory Studies

  • Depending on the clinician's diagnostic considerations, the following laboratory tests may be appropriate:
    • Fasting glucose to rule out diabetes
    • Sedimentation rate to determine the possibility of an underlying infection
    • Rheumatoid factor
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Imaging Studies

  • Radiographs are obtained to determine or exclude the following:
    • Arthritic changes from old fractures or inflammatory arthropathies
    • Increased MTP joint space from synovitis
    • Osteomyelitis at the tip of the toe from an abscess with a callus
    • Position of the toes
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Other Tests

  • Vascular pressure measurements, including ankle-brachial indices and absolute toe pressures, are helpful for the following reasons:
    • To assess toe viability
    • To determine whether the toe might reasonably be expected to heal following surgery
  • Electromyography findings provide information regarding the origin of the claw toe deformity and whether the patient has a neuropathy.
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Proceed to Treatment & Management
 
 
Contributor Information and Disclosures
Author

James K DeOrio, MD  Associate Professor of Orthopedic Surgery, Duke University School of Medicine

James K DeOrio, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Foot and Ankle Society, Florida Medical Association, and German Society of Neurology

Disclosure: Nothing to disclose.

Specialty Editor Board

John S Early, MD  Foot/Ankle Specialist, Texas Orthopaedic Associates, LLP; Co-Director, North Texas Foot and Ankle Fellowship, Baylor University Medical Center

John S Early, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Medical Association, American Orthopaedic Foot and Ankle Society, Orthopaedic Trauma Association, and Texas Medical Association

Disclosure: AO North America Honoraria Speaking and teaching; Osteotech Consulting fee Consulting; Stryker Consulting fee Consulting; Biomet Consulting fee Consulting; AO North America Grant/research funds fellowship funding; MMI inc Honoraria Speaking and teaching

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Shepard R Hurwitz, MD  Executive Director, American Board of Orthopaedic Surgery

Shepard R Hurwitz, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association for the Advancement of Science, American College of Rheumatology, American College of Sports Medicine, American College of Surgeons, American Diabetes Association, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, Association for the Advancement of Automotive Medicine, Eastern Orthopaedic Association, Orthopaedic Research Society, Orthopaedic Trauma Association, and Southern Orthopaedic Association

Disclosure: Nothing to disclose.

Dinesh Patel, MD, FACS  Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital

Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons

Disclosure: Nothing to disclose.

Chief Editor

Jason H Calhoun, MD, FACS  Frank J Kloenne Chair in Orthopedic Surgery, Professor and Chair, Department of Orthopedics, The Ohio State University Medical Center

Jason H Calhoun, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Diabetes Association, American Medical Association, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, Missouri State Medical Association, Musculoskeletal Infection Society, Southern Medical Association, Southern Orthopaedic Association, Texas Medical Association, and Texas Orthopaedic Association

Disclosure: Nothing to disclose.

References

  1. Coughlin MJ. Lesser toe abnormalities. In: Chapman M, ed. Operative Orthopaedics. Philadelphia, Pa: JB Lippincott; 1988:1765-76.

  2. Coughlin MJ. Lesser toe deformities. Orthopedics. Jan 1987;10(1):63-75. [Medline].

  3. Coughlin MJ, Mann RA. Lesser toe deformities. In: Mann RA, ed. Surgery of the Foot and Ankle. 7th ed. St. Louis, Mo: Mosby; 1999:320-91.

  4. Mann R, Coughlin M. Lesser toe deformities. In: Jahss M, ed. Disorders of the Foot and Ankle. Philadelphia, Pa: WB Saunders; 1991:1208-9.

  5. Barnicot NA, Hardy RH. The position of the hallux in West Africans. J Anat. Jul 1955;89(3):355-61. [Medline].

  6. Engle ET, Morton DJ. Notes on foot disorders among natives of the Belgian Congo. J Bone Joint Surg. 1931;13:311-9.

  7. James CS. Footprints and feet of natives of the Solomon Islands. Lancet. 1939;2:1390-3.

  8. Wells LH. The foot of the South African native. Am J Physiol Anthropol. 1931;15:185-289.

  9. Scheck M. Etiology of acquired hammertoe deformity. Clin Orthop. Mar-Apr 1977;(123):63-9. [Medline].

  10. Arnold H. [Lesser toe deformities. Definition, pathogenesis, and options for surgical correction]. Orthopade. Aug 2005;34(8):758-66. [Medline].

  11. Marx RM. Anatomy and pathophysiology of lesser toe deformities. In: Foot and Ankle Clinics. Philadelphia, Pa: WB Saunders; 1998:. 199.

  12. Sarrafian SK. Correction of fixed hammertoe deformity with resection of the head of the proximal phalanx and extensor tendon tenodesis. Foot Ankle Int. Jul 1995;16(7):449-51. [Medline].

  13. Sarrafian SK, Topouzian LK. Anatomy and physiology of the extensor apparatus of the toes. J Bone Joint Surg Am. Jun 1969;51(4):669-79. [Medline].

  14. Myerson MS, Shereff MJ. The pathological anatomy of claw and hammer toes. J Bone Joint Surg Am. Jan 1989;71(1):45-9. [Medline].

  15. Claisse PJ, Binning J, Potter J. Effect of orthotic therapy on claw toe loading: results of significance testing at pressure sensor units. J Am Podiatr Med Assoc. May-Jun 2004;94(3):246-54. [Medline].

  16. Coughlin MJ, Thompson FM. The high price of high-fashion footwear. In: American Academy of Orthopaedic Surgeons, eds. Instructional course lectures. Vol 44. Rosemont, Ill: American Academy of Orthopaedic Surgeons; 1995:371-7.

  17. Lutter LD. Sexy shoes or sorry feet. Foot Ankle Int. Jan 2004;25(1):1-2. [Medline].

  18. Taylor RG. The treatment of claw toes by multiple transfers of flexor into extensor tendons. J Bone Joint Surg. 1951;33B:539-542.

  19. Taylor RG. The treatment of claw toes by multiple transfers of flexor into extensor tendons. J Bone Joint Surg Br. Nov 1951;33-B(4):539-42. [Medline].

  20. Vaseenon T, Phisitkul P. A novel tendinous interconnection release technique for claw-toe deformity. Iowa Orthop J. 2010;30:157-60. [Medline]. [Full Text].

  21. Steensma MR, Jabara M, Anderson JG, Bohay DR. Flexor hallucis longus tendon transfer for hallux claw toe deformity and vertical instability of the metatarsophalangeal joint. Foot Ankle Int. Sep 2006;27(9):689-92. [Medline].

  22. Lui TH. Arthroscopic-assisted correction of claw toe or overriding toe deformity: plantar plate tenodesis. Arch Orthop Trauma Surg. Nov 2007;127(9):823-6. [Medline].

  23. Nakamura S. Temporary Kirschner wire fixation for a mallet toe of the hallux. J Orthop Sci. Mar 2007;12(2):190-2. [Medline].

  24. Bayod J, Losa-Iglesias M, Becerro de Bengoa-Vallejo R, Prados-Frutos JC, Jules KT, Doblaré M. Advantages and drawbacks of proximal interphalangeal joint fusion versus flexor tendon transfer in the correction of hammer and claw toe deformity. A finite-element study. J Biomech Eng. May 2010;132(5):051002. [Medline].

  25. Pyper JB. The flexor-extensor transplant operation for claw toes. J Bone Joint Surg Br. Aug 1958;40-B(3):528-33. [Medline].

  26. Frank GR, Johnson WM. The extensor shift procedure in the correction of clawtoe deformities in children. South Med J. Aug 1966;59(8):889-96. [Medline].

  27. McCluskey WP, Lovell WW, Cummings RJ. The cavovarus foot deformity. Etiology and management. Clin Orthop. Oct 1989;(247):27-37. [Medline].

  28. Barbari SG, Brevig K. Correction of clawtoes by the Girdlestone-Taylor flexor-extensor transfer procedure. Foot Ankle. Sep-Oct 1984;5(2):67-73. [Medline].

  29. Cyphers SM, Feiwell E. Review of the Girdlestone-Taylor procedure for clawtoes in myelodysplasia. Foot Ankle. Apr 1988;8(5):229-33. [Medline].

 
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Claw toe is named for its similarity to an eagle claw or talon.
Claw toe.
Plastic model of claw toe.
Claw toe. Hammer toe.
Claw toe. Plastic model of hammer toe.
Claw toe. Curly toe.
Claw toe. Mallet toes 3 and 4.
Claw toe. Mallet toe.
Multiple claw toes.
Claw toe. Extensor tendon connecting with extensor hood.
Claw toe. Extensor tendon splits into 3 parts distally.
Claw toe. Plantar plate stretches out, and proximal phalanx is dorsiflexed.
Callus at the tip of second claw toe.
Pad beneath multiple claw toes to reduce pressure at tips.
Claw toe. Silicone cap on second toe and sleeve on third toe, with sleeve reversed to show silicone inside.
Claw toe. Extensor tendon exposure.
Claw toe. Z lengthening of extensor tendon.
Claw toe. Capsulotomy.
Claw toe. Collateral ligament release.
Claw toe. Repaired extensor tendon.
Claw toe. Make a longitudinal incision across the plantar metatarsophalangeal joint.
Claw toe. Split the tendon sheath to expose the flexor tendons.
Claw toe. Isolate the flexor digitorum longus tendon from the flexor digitorum brevis, and place it under tension.
Claw toe. Cut the flexor digitorum longus tendon just proximal to its attachment.
Claw toe. Pull the flexor digitorum longus tendon loose from its attachment.
Claw toe. Separate the 2 raphe of the flexor digitorum longus tendon.
Claw toe. Grasp each side (raphe) of the flexor digitorum longus tendon with a small hemostat.
Claw toe. Make a dorsal incision to grasp the flexor digitorum longus tendon.
Claw toe. Through the dorsal incision, curve the hemostat around the proximal phalanx, avoiding the neurovascular bundle, and grasp the tip of the same side flexor digitorum longus tendon.
Claw toe. Repair each end of the raphe to the other raphe and the split extensor tendon.
Final repair of claw toe.
Multiple repaired claw toes; K-wires added for stability.
Claw toe. Elliptical outline of the skin incision.
Claw toe. Redundant skin being excised.
Claw toe. Isolation of the distal portion of the proximal phalanx.
Claw toe. Remove the distal portion of the proximal phalanx.
Claw toe. Feather the edges of the proximal phalanx to ensure no prominent edges.
Claw toe. Remove the articular cartilage of the middle phalanx.
Claw toe. Drill the pin retrograde from the middle phalanx out of the tip of the toe.
Claw toe. After the pin has been drilled back into the proximal phalanx and metatarsal head, repair the skin and extensor tendon over the proximal interphalangeal joint.
Claw toe. Bent pin at the end of the toe; the proximal incision has been used for Z lengthening of the extensor tendon.
Claw toe. The dorsal approach to the proximal interphalangeal joint and extensor tendon.
Claw toe. Z-lengthened extensor tendon with the end of the proximal phalanx exposed.
Claw toe. Remove the distal portion of the proximal phalanx.
Claw toe. Grasp the end of the proximal phalanx for removal.
Claw toe. Remove the articular cartilage of the middle phalanx.
Claw toe. The bone ends of the proximal interphalangeal joint.
Claw toe. Place a wire in the middle of the proximal phalanx.
Claw toe. Drill the wire out of the tip of the toe, then back through the proximal phalanx and metatarsal head.
Claw toe. Toe in straightened position, with a dorsal incision used to expose the dorsal metatarsophalangeal capsule for release.
Claw toe. Algorithm to determine the appropriate surgical procedure and postoperative treatment.
Claw toe. The movie shows a flexor-to-extensor tendon transfer with an extensor Z lengthening tenotomy and dorsal capsular release in a 54-year-old man with multiple claw toes following a brain injury. The toe is pinned with a 0.54-mm Kirschner wire just prior to transferring the tendon dorsally (not shown in movie). The remainder of the lesser toes, 2 and 4, underwent an identical procedure following the making of this movie. In addition, the fifth toe had a flexor digitorum longus release with extensor tendon lengthening and the great toe underwent an interphalangeal fusion with an extensor hallucis longus Z lengthening.
Table. Lesser Toe Deformities
Deformity MTP Joint PIP Joint DIP Joint
Hammer toeDorsiflexed* or neutralPlantar flexedNeutral, hyperextended, or plantar flexed*
Claw toeDorsiflexedPlantar flexedPlantar flexed
Mallet toeNeutralNeutralPlantar flexed
Curly toeNeutral or plantar flexedPlantar flexed



(>5°)



Plantar flexed



(>5°)



*Cannot coexist
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