eMedicine Specialties > Orthopedic Surgery > Foot & Ankle

Mallet Toe: Treatment

Author: Christopher Brown, MBBS, FRCS(C), FRACS, FAOrthA, Clinical Lecturer, Department of Orthopaedics and Trauma, University of Adelaide, Australia
Coauthor(s): Nancy Cullen, MD, FRCSC, FRACS, Senior Visiting Medical Officer, Clinical Lecturer, Department of Orthopaedics and Trauma, University of Adelaide, Australia
Contributor Information and Disclosures

Updated: Jan 11, 2009

Treatment

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.

Surgical Therapy

Surgical therapy includes flexor tenotomy, possibly including plantar capsular release and pinning; condylectomy and fusion of the middle to distal phalanx; and, occasionally, partial or complete amputation of the distal phalanx.

A flexible mallet toe is best treated with the flexor tenotomy. A fixed deformity requires a condylectomy. An ulcerated or infected toe would do best with a terminal Syme amputation.5

Preoperative Details

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

Intraoperative Details

Local anesthesia and tourniquet control are used.

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.6 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.

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

Postoperative Details

Routine dressings are applied. Sutures are removed at 10-14 days. Pins are usually removed at 4 weeks.

Follow-up

The patient can mobilize weight bearing in a postoperative shoe. Elevating the limb for the first 5-7 days reduces postoperative swelling.

Complications

Recurrence is possible, especially if associated joint lesions at the metatarsophalangeal (MTP) joint (eg, hyperextension) are not appreciated. Failure to completely divide the flexor 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 distal interphalangeal (DIP) joint and flexion deformity of the proximal interphalangeal (PIP) joint can also occur.

More on Mallet Toe

Overview: Mallet Toe
Workup: Mallet Toe
Treatment: Mallet Toe
Follow-up: Mallet Toe
Multimedia: Mallet Toe
References
Further Reading
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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. Apr 1984;75(5):191-8. [Medline].

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

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

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

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

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Further Reading

A mallet toe is a fixed or flexible deformity of the distal interphalangeal (DIP) joint of the toe.

Related eMedicine topics:

Claw Toe

Hammertoe Deformity

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Keywords

mallet toe, toe pain, toe callus, mallet toe deformity, hammertoe deformity, claw toe, toe deformity, diabetic foot, diabetic foot, clavus

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Contributor Information and Disclosures

Author

Christopher Brown, MBBS, FRCS(C), FRACS, FAOrthA, Clinical Lecturer, Department of Orthopaedics and Trauma, University of Adelaide, Australia
Christopher Brown, MBBS, FRCS(C), FRACS, FAOrthA is a member of the following medical societies: American Academy of Orthopaedic Surgeons and American Orthopaedic Foot and Ankle Society
Disclosure: Nothing to disclose.

Coauthor(s)

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.

Medical Editor

Heidi M Stephens, MD, Associate Professor, Department of Surgery, Division of Orthopedic Surgery, Director of Diabetic Foot Clinic, Assistant Dean for Clinical Outreach, 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 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, and Florida Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

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

Managing Editor

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

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