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Mallet Toe Treatment & Management

  • Author: Christopher Brown, MBBS, FRCSC, FRACS, FAOrthA; Chief Editor: Jason H Calhoun, MD, FACS  more...
 
Updated: Sep 17, 2014
 

Medical Therapy

Nonoperative treatment focuses on relieving the pressure under the tip of the toe. This can be accomplished with extra-depth toe-box footwear. Soft orthoses or toe protectors are useful.

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Surgical Therapy

Surgery can be performed under local or regional block, and in appropriate patients, it can be performed on an outpatient or day-surgery basis.

Surgical therapy includes the following options[5] :

  • Flexor tenotomy, possibly including plantar capsular release and pinning
  • Condylectomy and fusion of the middle to distal phalanx
  • Partial or complete amputation of the distal phalanx (occasionally indicated)

A flexible mallet toe is best treated with a flexor tenotomy. A fixed deformity requires a condylectomy. An ulcerated or infected toe would do best with a terminal Syme amputation.[6]

Tenotomy is performed by making a small lateral or medial incision over the distal end of the middle phalanx. The author prefers to visualize the tendon sheath directly by retracting the skin with double skin hooks or a Ragnell. The sheath is incised longitudinally, and the tendon is hooked with a small arthroscopic probe. The tendon then can be divided under direct vision.

If some residual contracture is present, the plantar capsule can be stripped of the phalanx with a Freer dissector. A 1.1 Kirschner wire (K-wire) can be used to immobilize the joint in the neutral position.[7] One skin stitch or Steri-Strip is used to close.

Distal interphalangeal (DIP) joint fusion is carried out by excising a small ellipse over the dorsal aspect of the joint, including the extensor. The bone ends are excised, and pinning is carried out. The skin and extensor are closed in one layer.[8]

Amputation is usually performed as a terminal Syme procedure. The nail bed and the terminal half of the phalanx are excised.

Postoperatively, routine dressings are applied. The patient can mobilize weightbearing in a postoperative shoe. Elevating the limb for the first 5-7 days reduces postoperative swelling. Sutures are removed at 10-14 days. Pins are usually removed at 4 weeks.

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Complications

Recurrence is possible, especially if associated joint lesions at the metatarsophalangeal (MTP) joint (eg, hyperextension) are not appreciated. Failure to divide the flexor completely can also cause recurrence. Flail toe, if excessive resection has occurred, is occasionally a problem with shoes or stockings, but it is seldom painful.

Neurovascular problems, including numbness, neuromata, and dysvascularity, can also occur. Prolonged swelling is often noted, and patients should be warned beforehand that this may occur. Residual nail deformity is also common. Hyperextension deformity of the DIP joint and flexion deformity of the proximal interphalangeal (PIP) joint can also occur.

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Outcome and Prognosis

Most series found excellent results in 85-97% of cases. In some series, tenotomy seemed to increase satisfaction rates. Bony union of the DIP joint where resection was carried out had higher satisfaction rates than fibrous union did.

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Future and Controversies

Treatment of mallet toe deformity is relatively straightforward. Some controversy exists over the need for flexor tenotomy when DIP joint fusion is attempted and the question of whether this leads to a higher incidence of hyperextension deformity and PIP joint flexion at the adjacent PIP joint.

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Contributor Information and Disclosures
Author

Christopher Brown, MBBS, FRCSC, FRACS, FAOrthA Clinical Lecturer, Department of Orthopaedics and Trauma, University of Adelaide, Australia

Christopher Brown, MBBS, FRCSC, FRACS, FAOrthA is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Australian Orthopaedic Association, American Orthopaedic Foot and Ankle Society

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.

N Ake Nystrom, MD, PhD Associate Professor of Orthopedic Surgery and Plastic Surgery, University of Nebraska Medical Center

Disclosure: Nothing to disclose.

Chief Editor

Jason H Calhoun, MD, FACS Department Chief, Musculoskeletal Sciences, Spectrum Health Medical Group

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, Michigan State Medical Society, Missouri State Medical Association, Southern Medical Association, Southern Orthopaedic Association, Texas Medical Association, Texas Orthopaedic Association, Musculoskeletal Infection Society

Disclosure: Nothing to disclose.

Additional Contributors

Heidi M Stephens, MD, MBA Associate Professor, Department of Surgery, Division of Orthopedic Surgery, University of South Florida College of Medicine; Courtesy Joint Associate Professor, Department of Environmental and Occupational Health, University of South Florida College of Public Health

Heidi M Stephens, MD, MBA is a member of the following medical societies: Alpha Omega Alpha, American Academy of Orthopaedic Surgeons, American Medical Association, American Orthopaedic Foot and Ankle Society, Florida Medical Association

Disclosure: Nothing to disclose.

Acknowledgements

Nancy Cullen, MD, FRCSC, FRACS Senior Visiting Medical Officer, Clinical Lecturer, Department of Orthopaedics and Trauma, University of Adelaide, Australia

Nancy Cullen, MD, FRCSC, FRACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons and American Orthopaedic Foot and Ankle Society

Disclosure: Nothing to disclose.

References
  1. Cooper PS. Disorders and Deformities of the Lesser Toes. In: Myerson MS, ed. Foot and Ankle Disorders. Philadelphia, Pa: WB Saunders; 2000:321-322.

  2. Coughlin MJ. Mallet toes, hammer toes, claw toes, and corns. Causes and treatment of lesser-toe deformities. Postgrad Med. 1984 Apr. 75(5):191-8. [Medline].

  3. Lancaster SC, Sizensky JA, Young CC. Acute mallet toe. Clin J Sport Med. 2008 May. 18(3):298-9. [Medline].

  4. Schuh A, Hönle W. [Deformities of the smaller toes]. MMW Fortschr Med. 2008 Feb 21. 150(8):37, 39. [Medline].

  5. Molloy A, Shariff R. Mallet toe deformity. Foot Ankle Clin. 2011 Dec. 16(4):537-46. [Medline].

  6. Coughlin MJ. Operative repair of the mallet toe deformity. Foot Ankle Int. 1995 Mar. 16(3):109-16. [Medline].

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

  8. Waizy H, Abbara-Czardybon M. [Arthodesis of the proximal and distal interphalangeal joint]. Oper Orthop Traumatol. 2014 Jun. 26(3):307-21; uqiz 322. [Medline].

 
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Classic mallet toe. Note flexion when toe is dorsiflexed.
 
 
 
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