eMedicine Specialties > Orthopedic Surgery > Foot & Ankle
Fifth-Toe Deformities: Treatment
Updated: Dec 19, 2008
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.
Angular deformities can be corrected with a combination of bone cuts and derotational skin incisions. Areas with contracted skin or tendons may require lengthening procedures and/or tenotomy.7,8
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.
The initial step of the Ruiz-Mora procedure is the removal of an ellipse of skin plantar to the proximal phalanx curving slightly medial at the proximal margin of the incision. The flexor tendons are dissected and retracted to expose the PIPJ. A transverse capsulotomy is performed, the collateral ligaments are released, and a subtotal phalangectomy is performed at the head of the proximal phalanx. If a large portion of the bone is removed, the flexor and extensor tendons are held together with purse-string sutures with 2-0 nonabsorbable material. The skin is closed in such a manner that allows the toe to be corrected in a plantar-medial direction.
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.
More on Fifth-Toe Deformities |
| Overview: Fifth-Toe Deformities |
| Workup: Fifth-Toe Deformities |
 Treatment: Fifth-Toe Deformities |
| Multimedia: Fifth-Toe Deformities |
| References |
| Further Reading |
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References
Cooper PS. Disorders and deformity of the lesser toes. In: Myerson MS, ed. Foot and Ankle Disorders. 2000: 340-5.
Ely LW. Hammertoe. Surg Clin N Am. 1926;6:433.
Higgs SL. Hammertoe. Med Press. 1931;131:473.
Dereymaeker G, van der Broek C. Biphalangeal fifth toe. Foot Ankle Int. Nov 2006;27(11):948-51. [Medline].
Mills GP. The etiology and treatment of claw-toe. J Bone Joint Surg. 1924;6:142.
Schnepp KH. Hammertoe and claw foot. Am J Surg. 1933;36:351.
Jacobs R, Vandeputte G. Flexor tendon lengthening for hammer toes and curly toes in paediatric patients. Acta Orthop Belg. Jun 2007;73(3):373-6. [Medline].
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].
Soule RE. Operation for the correction of hammertoe. N Y Med J. 1910;91:649.
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. Mar-Apr 2008;47(2):125-37. [Medline].
Konkel KF, Menger AG, Retzlaff SA. Hammer toe correction using an absorbable intramedullary pin. Foot Ankle Int. Aug 2007;28(8):916-20. [Medline].
Ruiz-Mora J. Plastic correction of overriding 5th toe. Orthop Lett Club. 1954;6:6.
Janecki CJ, Wilde AH. Results of phalangectomy of the fifth toe for hammertoe. The Ruiz-Mora procedure. J Bone Joint Surg Am. Oct 1976;58(7):1005-7. [Medline].
Schuh A, Werber S, Zeiler G, Schraml A. [Experiences with the Butler procedure for overlapping fifth toe]. Zentralbl Chir. Apr 2005;130(2):153-6. [Medline].
Wilson JN. V-Y correction for varus deformity of the fifth toe. Br J Surg. Sep 1953;41(166):133-5. [Medline].
Lapidus P. Transplantation of the extensor tendon for correction of the overlapping 5th toe. J Bone Joint Surg. 1942;24:555.
Thompson FM, Hamilton WG. Problems of the second metatarsophalangeal joint. Orthopedics. Jan 1987;10(1):83-9. [Medline].
Thompson FM, Deland JT. Flexor tendon transfer for metatarsophalangeal instability of the second toe. Foot Ankle. Sep 1993;14(7):385-8. [Medline].
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
