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Fifth-Toe Deformities

  • Author: Stephen M Schroeder, DPM, FACFAS; Chief Editor: Vinod K Panchbhavi, MD, FACS  more...
 
Updated: May 02, 2016
 

Background

Since the advent of shoes, the fifth toe has been a source of discomfort for many people. Complaints typically involve poorly fitting shoes that create friction, irritation, and pain with each step. The problem can typically be solved conservatively with shoe modifications or proper foot maintenance; however, structural deformities of the toe often require surgical correction.

Fifth-toe deformities comprise several congenital and developmental problems that affect the fifth digit. Most are associated with contractures at the metatarsophalangeal joint (MTPJ) and the proximal interphalangeal joint (PIPJ), with or without varus rotation.[1]

Although fifth-toe deformities have long been recognized, correction of these deformities did not become prevalent until the early 20th century, when many authors began describing different aspects of the problem, along with surgical procedures to help correct them (see Treatment).

For patient education resources, see Corns and Calluses.

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Anatomy

Three bones make up the fifth toe: the distal, middle, and proximal phalanges. They articulate together to make the distal interphalangeal joint (DIPJ) and the PIPJ. The proximal phalanx then articulates with the fifth metatarsal to make the fifth MTPJ. Medial and lateral condyles are present at the base of each phalanx, and epicondyles are present at the heads of the proximal and middle condyles.

A two-boned (biphalangeal) fifth toe has been reported in 37-76% of the population and involves a union of the distal and middle phalanges. When this occurs, the fifth toe is less flexible and often unable to accommodate pressure from standard shoes. This variant is more susceptible to irritation and may develop into a painful deformity.[2]

In a descriptive prospective study of 2494 feet in 1247 people, Gallart et al reported that a biphalangeal fifth toe was present in 46.3% of the feet and was bilateral in 97.4% of these cases.[3] The percentage of pathologic toes was significantly higher in patients with triphalangeal fifth toes (29.91%) than in those with biphalangeal toes (15.60%). The authors suggested that there may be an association between pathologic deviations and the greater mobility of triphalangeal fifth toes and that the greater rigidity of biphalangeal fifth toes may lead to lesser accommodation inside the shoe, which might result in less painful feet and decreased need for surgery.

The MTPJ has an extensor wing-and-sling mechanism that aids in extension of the digit. A slip of the extensor digitorum longus (EDL) to the fifth toe travels deep to the extensor wing and sling to insert into the dorsal aspect of the distal phalanx. No slip occurs from the extensor digitorum brevis (EDB) to the fifth toe; however, an occasional anomaly takes place in which an offshoot from the peroneus brevis tendon travels distal to insert into the dorsal-lateral aspect of the fifth MTPJ.

The fourth lumbrical muscle inserts into the plantar-medial fibers of the extensor wing to help adduct and plantarflex the proximal phalanx. The intrinsic third plantar interosseous and flexor digiti quinti brevis muscles insert into the plantar-medial and lateral aspects of the proximal phalanx respectively and function to stabilize the MTPJ against the stronger extrinsic flexor digitorum longus (FDL) and EDL. The abductor digiti minimi originates from the calcaneus and inserts into the plantar-lateral aspect of the proximal phalanx to place an abductory force on the toe.

The final two muscles to affect the fifth digit are the FDL and the flexor digitorum brevis (FDB), both of which plantarflex the toe. The FDL is deep to the FDB until the PIPJ, where the FDB splits, allowing the FDL to become superficial and continue distally to insert into the plantar portion of the distal phalanx. The FDB then rejoins to insert into the plantar aspect of the middle phalanx.

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Contributor Information and Disclosures
Author

Stephen M Schroeder, DPM, FACFAS Foot and Ankle Surgeon, Sports Medicine Oregon

Stephen M Schroeder, DPM, FACFAS is a member of the following medical societies: American College of Foot and Ankle Surgeons

Disclosure: Nothing to disclose.

Coauthor(s)

Peter A Blume, DPM, FACFAS Assistant Clinical Professor of Surgery, Department of Surgery, Yale University School of Medicine; Assistant Clinical Professor of Orthopedics and Rehabilitation, Department of Orthopedics and Rehabilitation, Section of Podiatric Surgery, Yale University School of Medicine

Peter A Blume, DPM, FACFAS is a member of the following medical societies: American Association of Hospital and Healthcare Podiatrists, American College of Foot and Ankle Surgeons, American Podiatric Medical Association, International College of Angiology, American Diabetes Association

Disclosure: Nothing to disclose.

Raymond O'Hara, DPM Chief Resident, Department of Orthopedic Surgery, Yale-New Haven Hospital

Disclosure: Nothing to disclose.

Enzo Sella, MD Chief, Orthopedic Foot and Ankle Surgery, Yale-New Haven Hospital; Associate Clinical Professor, Department of Orthopedics and Rehabilitation, Yale University School of Medicine

Enzo Sella, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Foot and Ankle Society, Eastern Orthopaedic Association, North American Spine Society, Academy of Medical Royal Colleges

Disclosure: Nothing to disclose.

Specialty Editor Board

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

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Vinod K Panchbhavi, MD, FACS Professor of Orthopedic Surgery, Chief, Division of Foot and Ankle Surgery, Director, Foot and Ankle Fellowship Program, Department of Orthopedics, University of Texas Medical Branch School of Medicine

Vinod K Panchbhavi, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, Orthopaedic Trauma Association, Texas Orthopaedic Association

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Styker.

Additional Contributors

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, Texas Medical Association

Disclosure: Received honoraria from AO North America for speaking and teaching; Received consulting fee from Stryker for consulting; Received consulting fee from Biomet for consulting; Received grant/research funds from AO North America for fellowship funding; Received honoraria from MMI inc for speaking and teaching; Received consulting fee from Osteomed for consulting; Received ownership interest from MedHab Inc for management position.

References
  1. Ellington JK. Hammertoes and clawtoes: proximal interphalangeal joint correction. Foot Ankle Clin. 2011 Dec. 16(4):547-58. [Medline].

  2. Dereymaeker G, van der Broek C. Biphalangeal fifth toe. Foot Ankle Int. 2006 Nov. 27(11):948-51. [Medline].

  3. Gallart J, González D, Valero J, Deus J, Serrano P, Lahoz M. Biphalangeal/triphalangeal fifth toe and impact in the pathology of the fifth ray. BMC Musculoskelet Disord. 2014 Sep 5. 15:295. [Medline].

  4. Bevans JS, Bosson G. A comparison of electrosurgery and sharp debridement in the treatment of chronic neurovascular, neurofibrous and hard corns. A pragmatic randomised controlled trial. Foot (Edinb). 2010 Mar. 20(1):12-7. [Medline].

  5. Ely LW. Hammertoe. Surg Clin N Am. 1926. 6:433.

  6. Higgs SL. Hammertoe. Med Press. 1931. 131:473.

  7. Mills GP. The etiology and treatment of claw-toe. J Bone Joint Surg. 1924. 6:142.

  8. Schnepp KH. Hammertoe and claw foot. Am J Surg. 1933. 36:351.

  9. Kim JY, Kim TW, Park YE, Lee YJ. Modified resection arthroplasty for infected non-healing ulcers with toe deformity in diabetic patients. Foot Ankle Int. 2008 May. 29(5):493-7. [Medline].

  10. Jacobs R, Vandeputte G. Flexor tendon lengthening for hammer toes and curly toes in paediatric patients. Acta Orthop Belg. 2007 Jun. 73(3):373-6. [Medline].

  11. Togashi S, Nakayama Y, Hata J, Endo T. A new surgical method for treating lateral ray polydactyly with brachydactyly of the foot: lengthening the reconstructed fifth toe. J Plast Reconstr Aesthet Surg. 2006. 59(7):752-8. [Medline].

  12. Coughlin MJ, Kennedy MP. Operative repair of fourth and fifth toe corns. Foot Ankle Int. 2003 Feb. 24(2):147-57. [Medline].

  13. Bouché RT, Heit EJ. Combined plantar plate and hammertoe repair with flexor digitorum longus tendon transfer for chronic, severe sagittal plane instability of the lesser metatarsophalangeal joints: preliminary observations. J Foot Ankle Surg. 2008 Mar-Apr. 47(2):125-37. [Medline].

  14. Konkel KF, Sover ER, Menger AG, Halberg JM. Hammer toe correction using an absorbable pin. Foot Ankle Int. 2011 Oct. 32(10):973-978.

  15. Ruiz-Mora J. Plastic correction of overriding 5th toe. Orthop Lett Club. 1954. 6:6.

  16. Janecki CJ, Wilde AH. Results of phalangectomy of the fifth toe for hammertoe. The Ruiz-Mora procedure. J Bone Joint Surg Am. 1976 Oct. 58(7):1005-7. [Medline].

  17. Lamm BM, Ades JK. Gradual digital lengthening with autologous bone graft and external fixation for correction of flail toe in a patient with Raynaud's disease. J Foot Ankle Surg. 2009 Jul-Aug. 48(4):488-94. [Medline].

  18. Schuh A, Werber S, Zeiler G, Schraml A. [Experiences with the Butler procedure for overlapping fifth toe]. Zentralbl Chir. 2005 Apr. 130(2):153-6. [Medline].

  19. Wilson JN. V-Y correction for varus deformity of the fifth toe. Br J Surg. 1953 Sep. 41(166):133-5. [Medline].

  20. Lapidus P. Transplantation of the extensor tendon for correction of the overlapping 5th toe. J Bone Joint Surg. 1942. 24:555.

  21. Thompson FM, Hamilton WG. Problems of the second metatarsophalangeal joint. Orthopedics. 1987 Jan. 10(1):83-9. [Medline].

  22. Thompson FM, Deland JT. Flexor tendon transfer for metatarsophalangeal instability of the second toe. Foot Ankle. 1993 Sep. 14(7):385-8. [Medline].

 
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Fifth-toe deformities. Example of a hard corn. They commonly occur on the dorsal lateral aspect of the proximal interphalangeal joint, but they can also occur in the same location over the distal interphalangeal joint.
Fifth-toe deformities. Example of a soft corn deep in the web space. Intrinsic pressure develops between adjacent condyles of the lateral fourth proximal interphalangeal joint abutting the medial fifth distal interphalangeal joint, or the lateral fourth metatarsophalangeal joint abutting the medial fifth proximal interphalangeal joint. The lesions can develop on the skin over the lateral fourth proximal interphalangeal joint, medial fifth distal interphalangeal joint, medial fifth proximal interphalangeal joint, or deep in the web space.
Fifth-toe deformities. This Image and the one below are examples of kissing corns. They are 2 calluses that rub against each other on adjacent toes and are usually painful when squeezed together.
Fifth-toe deformities. Example of a kissing corn. These corns are 2 calluses that rub against each other on adjacent toes and are usually painful when squeezed together.
Fifth-toe deformities. This Image and the one below are further examples of kissing corns. Maceration is often noted in the web space and may contribute to their development. When they occur, other common problems, such as fungal infections or verruca, need to be ruled out. These lesions may develop into ulcerations in the neuropathic population if untreated, as is seen in this case.
Fifth-toe deformities. Example of kissing corns. Maceration is often noted in the web space and may contribute to their development. When they occur, other common problems, such as fungal infections or verruca, need to be excluded. These lesions may develop into ulcerations in the neuropathic population if untreated, as is seen in this case.
Fifth-toe deformities. Example of a hammertoe with a dorsiflexion contracture at the metatarsophalangeal joint and plantarflexion contracture at the proximal interphalangeal joint. Note the irritated skin secondary to shoe pressure.
Fifth-toe deformities. This Image and the one below represent an overlapping fifth toe. It is dorsally hyperextended at the metatarsophalangeal joint with a varus rotation and medial deviation onto the top of the fourth digit. Contractures develop dorsomedially at the metatarsophalangeal joint and eventually form in the extensor digitorum longus tendon and the dorsomedial skin overlying the metatarsophalangeal joint.
Fifth-toe deformities. Overlapping fifth toe. It is dorsally hyperextended at the metatarsophalangeal joint with a varus rotation and medial deviation onto the top of the fourth digit. Contractures develop dorsomedially at the metatarsophalangeal joint and eventually form in the extensor digitorum longus tendon and the dorsomedial skin overlying the metatarsophalangeal joint.
Fifth-toe deformities. This image and the one below are examples of an underlapping fifth toe, or curly toe. It is plantarflexed at the metatarsophalangeal joint, rotated into a varus position, and positioned under the fourth digit. A contracture typically occurs at the plantar-medial metatarsophalangeal joint capsule and flexor digitorum longus tendon.
Fifth-toe deformities. Underlapping fifth toe, or curly toe. It is plantarflexed at the metatarsophalangeal joint, rotated into a varus position, and positioned under the fourth digit. A contracture typically occurs at the plantar-medial metatarsophalangeal joint capsule and flexor digitorum longus tendon.
Fifth-toe deformities. This radiograph shows a prominent fifth-toe proximal phalanx medial condyle contacting the base of the proximal phalanx on the fourth toe, creating increased pressure and an interdigital clavi.
Fifth-toe deformities. This radiograph shows the distal phalanx of a varus-rotated fifth toe contacting the proximal phalanx on the fourth toe, creating another area of increased pressure and interdigital clavi.
Fifth-toe deformities. This Image and the following 3 Images demonstrate the surgical course for a severe fifth digit cock-up deformity. Note the dorsal contracture in this preoperative photo.
Fifth-toe deformities. Planned incision with arms for the Z-plasty skin-lengthening flap drawn in. The central arm of the Z-plasty is along the line of skin contracture.
Fifth-toe deformities. Exposure showing a severely contracted extensor digitorum longus tendon. This is lengthened during the procedure.
Fifth-toe deformities. Postoperative photo showing a corrected fifth digit.
Fifth-toe deformities. This Image and the ones that follow demonstrate an operative technique for a painful overlapping fifth-toe deformity.
Fifth-toe deformities. Painful overlapping fifth-toe deformity.
Fifth-toe deformities. When the toe is derotated and plantarflexed into the correct position, the dorsal skin "tents up," showing the exact location of the skin contracture.
Fifth-toe deformities. A Z-plasty is performed in this case to lengthen the contracted skin. Length is achieved along the central arm of the "Z" so it is placed along the line of contracture. Adjunctive procedures such as metatarsophalangeal joint release and extensor digitorum longus tendon lengthening should be performed through the same incision. An alternative to the Z-plasty is a V-Y flap.
Fifth-toe deformities. After rotation of the "Z" flaps and soft tissue release, the toe is reevaluated. The toe is down, and the proximal phalanx is in excellent position, but the distal portion of the toe has a varus rotation at the proximal interphalangeal joint. A proximal interphalangeal joint arthroplasty with derotational skin plasty is then performed to address this portion of the deformity.
Fifth-toe deformities. This Image and the one below were taken 5 days postoperatively with the contractures addressed and the toe in good position.
Fifth-toe deformities. Five days after surgery, the contracture is addressed and the toe is in good position.
 
 
 
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