Fifth-Toe Deformities Workup

  • Author: Stephen M Schroeder, DPM; Chief Editor: Jason H Calhoun, MD, FACS   more...
 
Updated: May 10, 2012
 

Laboratory Studies

  • The only laboratory studies needed are standard preoperative tests.
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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.
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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 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 Diabetes Association, American Podiatric Medical Association, and International College of Angiology

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.

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; Stryker Consulting fee Consulting; Biomet Consulting fee Consulting; AO North America Grant/research funds fellowship funding; MMI inc Honoraria Speaking and teaching; Osteomed Consulting fee Consulting; MedHab Inc Management position

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. Cooper PS. Disorders and deformity of the lesser toes. In: Myerson MS, ed. Foot and Ankle Disorders. 2000: 340-5.

  2. 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). Mar 2010;20(1):12-7. [Medline].

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

  4. Higgs SL. Hammertoe. Med Press. 1931;131:473.

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

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

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

  8. 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. May 2008;29(5):493-7. [Medline].

  9. 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].

  10. 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].

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

  12. 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].

  13. Konkel KF, Menger AG, Retzlaff SA. Hammer toe correction using an absorbable intramedullary pin. Foot Ankle Int. Aug 2007;28(8):916-20. [Medline].

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

  15. 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].

  16. 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. Jul-Aug 2009;48(4):488-94. [Medline].

  17. 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].

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

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

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

  21. Thompson FM, Deland JT. Flexor tendon transfer for metatarsophalangeal instability of the second toe. Foot Ankle. Sep 1993;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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