eMedicine Specialties > Orthopedic Surgery > Foot & Ankle

Fifth-Toe Deformities

Stephen M Schroeder, DPM, Chief of Podiatric Foot and Ankle Surgery, Southwest Washington Medical Center
Raymond O'Hara, DPM, Chief Resident, Department of Orthopedic Surgery, Yale-New Haven Hospital; Peter Blume, DPM, Director of Diabetic Foot Surgery, Department of Orthopedics, Yale New Haven Hospital; Clinical Assistant Professor, Department of Podiatric Surgery, Yale University School of Medicine; 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

Updated: Dec 19, 2008

Introduction

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. 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. Exposure showing a severely contracted extensor digitorum longus tendon. This is lengthened during the procedure.

History of the Procedure

Fifth-toe deformities have been present since the evolution of bipedal ambulation. However, 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.

Problem

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 proximal interphalangeal joint (PIPJ), with or without varus rotation.¹

Related eMedicine topics:

Claw Toe

Hammertoe Deformity

Mallet Toe

Presentation

The simplest lesions are hard corns (helomata durum) and soft corns (helomata molle). Both lesions are epidermal hyperkeratoses resulting from frictional or pressure irritation. They develop over bony prominences, such as enlarged phalangeal condyles or exostosis.

Hard corns

Hard corns result from intrinsic pressure from bony prominence combined with extrinsic pressure (typically in the form of footwear irritation) over the exposed fifth toe. The most common site is the dorsal lateral aspect of the PIPJ, but corns can also occur in the same location over the distal interphalangeal joint (DIPJ) (see Image below and Image 1 in Multimedia).

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.

In the neuropathic population, hard corns that go untreated can develop into ulcerations that lead to soft tissue and bone infection.

Soft corns

Soft corns develop between adjacent toes.

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.

Kissing corns

Kissing corns result from 2 calluses rubbing against each other on adjacent toes (see Images below and Image 3, Image 4 in Multimedia). Kissing corns are usually painful when the toes are squeezed together. Maceration is often noted in the web space and may contribute to the development of kissing corns (see Images below and Image 5, Image 6 in Multimedia). When they occur, other common problems, such as fungal infections or verruca, need to be ruled out. If left untreated, these lesions may also develop into ulcerations in people with neuropathies.

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.

Hammertoe,^2,3,4 claw-toe,⁵ and cock-up deformities are all variations of the same problem.⁶ The presence of a dorsiflexion contracture at the MTPJ and a plantarflexion contracture at the PIPJ is constant between the 3 (see Image below and Image 7 in Multimedia). The claw-toe deformity has the addition of a plantarflexion contracture at the DIPJ. The term cock-up deformity is typically used to describe a severe hammertoe, in which the proximal phalanx articulates at a nearly 90° angle to the fifth metatarsal and may be fixed in that position. A cock-up deformity can also be associated with plantar-plate ruptures or adhesions between the plantar MTPJ capsule and the metatarsal head.

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.

Unlike the other conditions mentioned, overlapping and underlapping fifth toes are usually congenital deformities. The overlapping fifth toe is a common familial deformity with equal sex predilection and usually presents bilaterally (see Images below and Image 8, Image 9 in Multimedia). About half of patients become symptomatic because of pressure from footwear against the dorsal aspect of the toe and nail. The toe is dorsally hyperextended at the MTPJ with a varus rotation and medial deviation onto the top of the fourth digit.

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.

The underlapping fifth toe is another common congenital deformity and is often referred to as a curly toe or congenital varus toe (see Images below and Image 10, Image 11 in Multimedia). This deformity may also occur bilaterally and has a high familial prevalence. The toe is plantarflexed at the MTPJ, rotated into a varus position, and positioned under the fourth digit. A contracture typically occurs at the plantar-medial MTPJ capsule and flexor digitorum longus (FDL) tendon. These are paired with an elongated EDL and attenuated dorsal capsule. Constant pressure at the lateral nail and digital skin creates pain.

Fifth-toe deformities. Images 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.

Indications

Hard and soft corns

Surgical correction is indicated for chronically painful cases in which conservative treatment fails. Patients with neuropathies may also choose surgery or prophylaxis to treat chronic lesions.

Hammer, overlapping, or underlapping toes

Surgical correction is indicated for progressively painful deformities if conservative treatment fails.

Relevant Anatomy

Three bones make up the fifth toe. These are the distal, middle, and proximal phalanges. They articulate together to make the DIPJ and 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 2-boned 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 unable to accommodate pressure from shoes and a normal digit. This toe is therefore more susceptible to irritation and development of a painful deformity.

The MTPJ has an extensor wing-and-sling mechanism that aids in extension of the digit. A slip of the 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 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 planter medial fibers of the extensor wing to help abduct and extend 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 FDL and EDL. The abductor digiti minimi muscle originates from the calcaneus and inserts into the plantar lateral aspect of the proximal phalanx to place an abductory force on the toe.

The last 2 muscles to affect the fifth digit are the FDL and flexor digitorum brevis (FDB); both 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 plantar portion of the distal phalanx. The FDB then rejoins to insert into the plantar aspect of the middle phalanx.

Contraindications

Contraindications for surgery include adequate control with conservative treatment, poor circulation, underlying infection, or any systemic condition that would inhibit healing of the surgical site.

Workup

Laboratory Studies

• The only laboratory studies needed are standard preoperative tests.

Imaging Studies

• Standard anteroposterior, lateral, and oblique weight-bearing radiographs are obtained as part of the initial workup.
• Lesion markers can be applied over the hard and soft corns to help identify the correct underlying condyle.
• Anteroposterior and oblique views readily show exostosis, enlarged condyles, and varus deformity of the toe.
• The lateral view is helpful in identifying the severity of the dorsal and plantar contractures at the MTPJ and PIPJ.

Treatment

Medical Therapy

Medical therapy is commonly considered conservative care. Conservative treatment for hard corns and soft corns involves periodic shaving by a health care professional using a scalpel or paring device. This is reinforced by regular use of a pumice stone or callus file during or after bathing.

Protective padding can be used over hard corns to decrease shoe irritation, and toe spacers are available to ease pressure on soft corns. To decrease pressure, multiple devices such as gel pads, foam, felt, devices with cutouts to accommodate lesions, and moleskin are available over the counter. Wearing wider shoes is a simple way to decrease pressure placed on hammertoes or other rotational deformities. Modifying and stretching the shoes can accomplish the same goals.

Surgical Therapy

Surgical therapy depends on the type and level of the deformity. One must determine the underlying pathology and the degree of bone and soft tissue involvement (see Images below and Image 12, Image 13 in Multimedia).

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.

Hard corns

Hard corns are probably the most common fifth-toe deformities and yield the most options for treatment. These lesions occur most frequently on the dorsum of the PIPJ as a result of a hammertoe deformity or on the dorsolateral aspect of the PIPJ due to a hammertoe with varus rotation. Corrective procedures include partial condylectomy, exostectomy, hemiphalangectomy, PIPJ arthroplasty with resection of the proximal phalangeal head, or a combination of these. A derotational skin plasty is often included for the varus-rotated toe, and a flexor tenotomy or extensor lengthening can be included for a straight hammertoe deformity.

Soft corns

Surgical correction for soft corns involves resection of the appropriate bony prominence. This usually involves a combination of condyles from the fourth and fifth digits. A rotational deformity may also be present in the fifth toe, which should be addressed. Typical combinations are (1) resection of the lateral condyle on the base of the fourth toe proximal phalanx and the medial condyle on the head of the fifth toe proximal phalanx or (2) resection of the prominent condyles at the lateral aspect of the fourth PIPJ and the medial aspect of the fifth DIPJ. Web space incisions should be avoided to prevent infections and painful scarring.

Hammertoe, claw-toe, cock-up fifth-toe deformities

Surgical approaches vary depending on the severity of a deformity. The simplest hammertoe is one that is completely reducible with no bony obstruction to straightening. This is clinically determined by manually straightening the toe. If a very mild deformity is completely reducible, a soft tissue procedure with proper splinting of the digit may be all that is needed for correction. Examples of these are extensor tendon lengthening, dorsal MTPJ capsulotomy, and flexor tendon release.^9,10,11

PIPJ arthroplasty is added to the soft tissue releases in more advanced cases that are semireducible or nonreducible. Most surgeons favor PIPJ arthroplasty as a primary procedure because it resolves a contracted PIPJ and functionally lengthens the extensor and flexor tendons, decompressing the MTPJ and DIPJ. After this is performed, the foot is put into a simulated weight-bearing position by pushing up on the fifth metatarsal head.

The dorsal contracture at the MTPJ should resolve, and the toe should straighten. If residual contracture at the MTPJ is present, dorsal capsulotomy is performed and lengthening the extensor tendon should be considered. Arthrodesis is described for correction of hammertoes but should not be performed in the fifth digit because it leaves the toe too straight, which causes irritation when wearing shoes.

The Ruiz-Mora and syndactylization procedures are commonly described salvage options for severe or recurrent cock-up fifth-toe deformities.¹² The original Ruiz-Mora procedure involved removing the entire proximal phalanx, which left the toe somewhat shortened and unstable. Janecki described the modification that is more commonly used today and calls for a subtotal proximal phalangectomy.¹³ Patients should be advised that a good deal of shortening occurs, which may not be cosmetically appealing. The the 4 Images below (see also Image 14 through Image 17 in Multimedia) illustrate the surgical procedure for a severe cock-up deformity.

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.

Complications of the Ruiz-Mora procedure include instability of the toe, fourth digit hammertoe formation, callus formation, and bunionette deformity. The patient is allowed to ambulate postoperatively in a stiff-soled shoe, and the toe is splinted or taped in the corrected position for 6 weeks.

Syndactylization of the fifth toe to the fourth is generally reserved as a salvage procedure or to resolve a painfully fibrosed web-space lesion secondary to long-standing soft corns. Syndactylization provides excellent stability for an unstable or flail fifth toe. With this procedure, the skin incisions on the fourth and fifth toes should be mirror images of each other. A good technique is to scribe the initial incision on the fifth digit with a surgical pen and then press the 2 digits together where they are to be joined. The ink is transferred to the fourth digit in the precise area where the incision should be placed.

The island of tissue created with the incision is carefully dissected to remove only the skin and to leave the subcutaneous tissue intact. Meticulous hemostasis is practiced, and a needle-tipped electrocautery device should be used for precision. Bone work and isolated tendon balancing can be performed through the open sulcus if needed. The skin is closed by placing all of the sutures throughout the site prior to tying the knots. This allows easier and more accurate passing of the needle through the skin margins of the toes. Sutures are left in for 1 extra week (3 wk total), and the digits are splinted for an additional 2-3 weeks.

Underlapping and overlapping fifth-toe deformities

Many procedures have been described for the correction of an overlapping fifth toe. The deformities range from moderate to more severe, and the procedure chosen should address the existing contractures. The surgical treatment often includes (1) lengthening the contracted skin and tendon and releasing the tight capsular structures and (2) resection of redundant skin and soft tissue. Osseous contractures, if present, also need to be addressed by performing ostectomy and/or arthroplasty. 

The Images below (see also Image 18 through Image 24 in Multimedia) illustrate one technique for correcting a painful overlapping fifth-toe deformity. Schuh et al describe their experiences with the Butler technique.¹⁴

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.

The DuVries procedure is indicated for correcting a mildly overlapping fifth toe. The area over the fourth interspace is longitudinally incised from the base of the toe to just proximal to the fifth metatarsal head. The MTPJ contractures are released via medial capsulotomy and release of the medial collateral ligament. The EDL tendon is then released or lengthened to achieve the final release. The toe is placed into an overcorrected plantar and lateral position, and the skin is closed in this orientation. Dog ears are removed when they occur.

Wilson described a modification to the procedure incorporating a V-Y skin advancement to lengthen the contracted skin dorsomedially.¹⁵ Similar releases of the capsule and tendon are performed through the V-Y incision to complete the procedure. The authors use a Z-plasty advancement technique to lengthen the contracted skin dorsomedially. This allows for greater lengthening potential, and the results are more cosmetically appealing than without the modification. PIPJ arthroplasty with appropriate capsule balancing completes the procedure, resulting in an excellent correction.

Lapidus described using a tendon transfer to correct severely overlapping fifth toes.¹⁶ He transferred the EDL under the MTPJ and into the abductor digiti quinti. Other modifications have been described including transfer of the EDL into the metatarsal neck, Z-plasty, dorsal capsulotomy with plantar capsulorraphy, and PIPJ arthroplasty. When possible, extensive dissection should be avoided because the toes tend to become postoperatively edematous, leading to pain and difficulty fitting shoes.

Underlapping fifth toes typically have a contracted plantar MTPJ capsule and FDL with an attenuated EDL and a redundant dorsal MTPJ capsule. Underlapping fifth toes are usually flexible deformities in the pediatric population; tenotomy at the FDL and FDB with appropriate splinting typically offers good results. However, as with the other conditions mentioned, the degree of deformity must be accounted for, and the appropriate adjunct procedures should be performed.

The Thompson technique is widely used and offers good results.^17,18 Thompson described a Z-type incision over the proximal phalanx with the distal limb laterally oriented and the proximal limb medially oriented. Dissection extends to the PIPJ, where the head of the proximal phalanx is freed of soft tissue attachments and resected using a microsagittal saw. The amount of head resection depends on the severity of the deformity, but care should be taken not to remove too much because this makes the toe unstable.

The soft tissue is appropriately augmented, the toe is derotated, and the flexor and extensor tendons are held together with purse-string sutures by using 2-0 nonabsorbable material. In less severe deformities, the purse-string suture can be left out and the capsule simply closed in a standard fashion. Adding a K-wire across the PIPJ for 3-4 weeks or splinting with dressings for the same period can provide stability.

Lastly, the Z-incision is reversed and closed using 4-0 nylon. A variation of the Thompson procedure involves a derotational skin plasty by creating a tissue island with a converging semielliptical incision over the PIPJ oriented from distal-dorsal-medial to proximal-plantar-lateral. As with the other procedures, the patient is allowed to ambulate in a postoperative shoe and is gradually transitioned to a roomy athletic-style shoe. The toe should be splinted in the corrected position for 6 weeks.

Follow-up

For excellent patient education resources, visit eMedicine's Foot Care Center. Also, see eMedicine's patient education article Corns and Calluses.

Complications

The most common complication involving fifth-toe procedures is the development of a flail toe. Other potential problems include vascular embarrassment, undercorrection, recurrence, and prolonged edema. Meticulous dissection and tissue handling are the best defenses against vascular problems or prolonged edema. Proper planning should decrease the chance of recurrence or undercorrection.

Multimedia

Media file 1: 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.

Media file 2: 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.

Media file 3: 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.

Media file 4: 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.

Media file 5: 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.

Media file 6: 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.

Media file 7: 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.

Media file 8: 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.

Media file 9: 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.

Media file 10: Fifth-toe deformities. Images 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.

Media file 11: 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.

Media file 12: 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.

Media file 13: 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.

Media file 14: 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.

Media file 15: 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.

Media file 16: Fifth-toe deformities. Exposure showing a severely contracted extensor digitorum longus tendon. This is lengthened during the procedure.

Media file 17: Fifth-toe deformities. Postoperative photo showing a corrected fifth digit.

Media file 18: Fifth-toe deformities. This Image and the ones that follow demonstrate an operative technique for a painful overlapping fifth-toe deformity.

Media file 19: Fifth-toe deformities. Painful overlapping fifth-toe deformity.

Media file 20: 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.

Media file 21: 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.

Media file 22: 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.

Media file 23: Fifth-toe deformities. This Image and the one below were taken 5 days postoperatively with the contractures addressed and the toe in good position.

Media file 24: Fifth-toe deformities. Five days after surgery, the contracture is addressed and the toe is in good position.

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Keywords

fifth-toe deformities, toe deformities, hard corns, heloma durum, helomata durum, soft corns, heloma molles, helomata molle, ainhum, hammertoes, hammer toes, claw toes, overlapping toes, underlapping toes, curly toes, congenital varus toes, cock-up toes, little toe, small toes, kissing corns, epidermal hyperkeratosis, Ruiz-Mora procedure, syndactylization, arthroplasty, Z-plasty, flail toe, dorsiflexion contracture, plantarflexion contracture, capsulotomy, DuVries procedure, skin plasty, pinky toe pain, pinky toe deformity, toe pain, intrac table plantar keratosis, clavus, bunionette, pes cavus

Contributor Information and Disclosures

Author

Stephen M Schroeder, DPM, Chief of Podiatric Foot and Ankle Surgery, Southwest Washington Medical Center
Stephen M Schroeder, DPM is a member of the following medical societies: American College of Foot and Ankle Surgeons
Disclosure: Nothing to disclose.

Coauthor(s)

Raymond O'Hara, DPM, Chief Resident, Department of Orthopedic Surgery, Yale-New Haven Hospital
Disclosure: Nothing to disclose.

Peter Blume, DPM, Director of Diabetic Foot Surgery, Department of Orthopedics, Yale New Haven Hospital; Clinical Assistant Professor, Department of Podiatric Surgery, Yale University School of Medicine
Peter Blume, DPM is a member of the following medical societies: American Diabetes Association
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: Academy of Medical Royal Colleges, American Academy of Orthopaedic Surgeons, American Orthopaedic Foot and Ankle Society, Eastern Orthopaedic Association, and North American Spine Society
Disclosure: Nothing to disclose.

Medical Editor

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: Zimmer Inc Consulting fee Independent contractor; Smith Nephew Consulting fee Independent contractor; AO North America Honoraria Speaking and teaching

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

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.

CME Editor

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, American Association of Physicians of Indian Origin, American College of International Physicians, and American College of Surgeons
Disclosure: Nothing to disclose.

Chief Editor

Jason H Calhoun, MD, FAAOS, Chairman, J Vernon Luck Distinguished Professor, Department of Orthopedic Surgery, University of Missouri
Jason H Calhoun, MD, FAAOS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, and American Orthopaedic Foot and Ankle Society
Disclosure: Nothing to disclose.

Related eMedicine topics:

Claw Toe

Hammertoe Deformity

Mallet Toe

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