Claw Toe

Introduction

A claw toe deformity is characterized by MTP hyperextension and resulting PIP and DIP flexion
- analogous to intrinsic minus deformity in the hand
Epidemiology
- location
  - typically involves multiple toes
  - often bilateral
Pathophysiology
- MTP hyperextension is the primary pathology
  - chronic MTP hyperextension leads to unopposed flexion of the DIP and PIP by FDL
- the MTP plantar plate becomes insufficient over time
- base of proximal phalanx translates dorsally
- interossei and lumbricals move dorsally
  - shifts flexion moment arm to the wrong side of the center of rotation
Etiology
- synovitis is the most common cause
- trauma
- delayed or missed compartment syndrome involving the deep posterior compartment of the leg or foot
Associated conditions
- cavus deformity
- neuromuscular disease affecting intrinsic and extrinsic muscle balance
  - clawing of all 4 lesser toes implicates a neurologic abnormality
- inflammatory arthropathies
  - lead to soft tissue structure attenuation and MTP joint instability

Classification

	Claw Toe	Hammer Toe	Mallet Toe

DIP	flexion	extension	flexion
PIP	flexion	flexion	normal
MTP	hyperextension	normal (slight extension)	normal

Presentation

Symptoms
- pain at the level of the unstable MTP joint
- metatarsalgia
Physical exam
- inspection & palpation
  - claw-type deformity of the toe is present
  - depressed metatarsal head with callus formation and tenderness
  - flexed IP joints with callosities and tenderness

Treatment

Nonoperative
- taping and shoe modification
  - indications
    - first line of treatment
  - techniques
    - provide adequate plantar padding using metatarsal and/or crest pads or orthotics to offload plantarly-subluxed metatarsal heads
    - wear a shoe with a high toe box
    - use a sling to hold the proximal phalanx parallel to the ground
Operative
- EDB tenotomy, EDL lengthening, FDL flexor-to-extensor transfer (Girdlestone)
  - indications
    - painful, flexible deformities without contractures
    - ulcerations caused by shoe wear
- Girdlestone (above), MTP capsulectomy, and proximal phalanx head and neck resection
  - indications
    - fixed contracture
- Girdlestone and distal MT shortening osteotomy (Weil lesser MT osteotomy)
  - indications
    - claw toe deformity of all four lesser toes
  - technique
    - oblique shortening osteotomy
    - translates metatarsal head proximal and plantar

Complications

Floating toe
- most common complication of a Weil osteotomy
- caused by intrinsics migrating dorsal to the joint and acting as MTP extensors
Recurrence
- caused by persistent plantar plate dysfunction

TAG

(OBQ10.164) A 56-year-old diabetic female presents with the painful right toe deformity shown in Figure A. Physical exam reveals MTP dorsiflexion, and flexion at the DIP and PIP joints. The PIP and MTP joints are flexible, and she has failed conservative treatment. Which of the following is the best surgical treatment option for this patient? Topic

Review Topic

FIGURES: A

1. Girdlestone-Taylor flexor-to-extensor tendon transfer
2. PIP arthrodesis
3. Complete MTP capsulotomy and resection arthroplasty of the proximal phalanx with tendon release/lengthening
4. Complete MTP capsulotomy and resection arthroplasty of the proximal phalanx with a Weil osteotomy
5. Isolated Weil osteotomy of the affected metatarsal

PREFERRED RESPONSE ▶

DISCUSSION: Claw toe deformity occurs most commonly in patients with diabetes, alcoholism, or an underlying neuromuscular condition. The classic presentation is a dorsiflexed MTP joint, and hyperflexion at the PIP and DIP joints. Surgical treatment is based on whether or not the PIP joint is flexible or fixed. The Girdlestone-Taylor procedure involves transferring the FDL to the extensor surface of the affected toe, allowing the long toe flexors to behave like intrinsic muscles producing active plantar flexion at the MP joints and extension at IP joints. This is only effective in the presence of a flexible deformity. PIP arthrodesis, MTP capsulotomy, and PIP joint resection arthroplasty are only indicated in varying degrees of a fixed claw toe deformity. A Weil osteotomy can be added in these fixed cases for added correction, or if multiple toes are involved. Illustration A shows a comparison of the different lesser-toe deformities.

Illustrations: A

REFERENCES:

1. Coughlin MJ. Lesser toe deformities. In: Coughlin MJ, Mann RA, Saltzman CL, eds. Surgery of the Foot and Ankle. 8th ed. Philadelphia, PA: Mosby Elsevier; 2007:363-464.

2. Pleimann JH, Ishikawa SN, Sanders M. Lesser toe deformities, intractable plantar keratosis, Freiberg infraction, and bunionette. In: Pinzur MS, ed. Orthopaedic Knowledge Update: Foot and Ankle 4. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2008:257-270.

Question Authors:

Joshua Blomberg MD, Michael Hughes MD, Ben Taylor MD,

Please Rate Educational Value!

3.0

Average 3.0 of 14 Ratings

TAG

(OBQ07.21) A 54-year-old female has struggled with 2nd metatarsalgia that is not relieved with orthotics. She undergoes a metatarsal shortening osteotomy using the technique demonstrated in Figure A. Following surgery she complains that her 2nd toe "floats" above the level of the remaining lesser toes. Which of the following is the most likely cause? Topic

Review Topic

FIGURES: A

1. Lack of appropriate post-operative immobilization
2. Technique of surgical osteotomy
3. Post-operative cerebrovascular event causing neuromuscular imbalance
4. Inadvertent tethering of the extensor tendon during surgical procedure
5. Surgical site infection

PREFERRED RESPONSE ▶

DISCUSSION: Figure A demonstrates a Weil metatarsal shortening osteotomy that results in mild depression of the joint surface in addition to shortening of the metatarsal. This joint depression leads to a dorsiflexion deformity of the MTP. To avoid this complication the osteotomy should be made parallel to the plantar surface of the foot or a wafer of bone should be resected to ensure that the joint is not depressed as the metatarsal is shortened. These techniques are demonstrated in Illustration A.

Trnka et al performed a cadaveric study to evaluate dorsiflexion following Weil osteotomy. They found that plantar depression of the MTP joint following the osteotomy altered the dynamic forces of the interossei converting them from plantarflexors to dorsiflexors.

In another article, Trnka et al reviewed 30 patients with metatarsalgia who were treated with either metatarsal head osteotomy (Weil) or metatarsal shaft osteotomy (Helal). Patients treated with a Weil osteotomy had significantly higher satisfaction, lower incidence of recurrent metatarsalgia, and fewer transfer lesions.

Illustrations: A

REFERENCES:

1. Trnka HJ, Nyska M, Parks BG, Myerson MS. Dorsiflexion contracture after the Weil osteotomy: results of cadaver study and three-dimensional analysis. Foot Ankle Int. 2001 Jan;22(1):47-50. PMID:11206822 (Link to Abstract)

2. Trnka HJ, Mühlbauer M, Zettl R, Myerson MS, Ritschl P. Comparison of the results of the Weil and Helal osteotomies for the treatment of metatarsalgia secondary to dislocation of the lesser metatarsophalangeal joints. Foot Ankle Int. 1999 Feb;20(2):72-9. PMID:10063974 (Link to Abstract)

Question Authors:

John Badylak MD, Ben Taylor MD, Jan Szatkowski MD,

Please Rate Educational Value!

4.0

Average 4.0 of 18 Ratings

Textbooks

Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Coughlin MJ. Lesser toe deformities. In: Coughlin MJ, Mann RA, Saltzman CL, eds. Surgery of the Foot and Ankle. 8th ed. Philadelphia, PA: Mosby Elsevier; 2007:363-464.
Pleimann JH, Ishikawa SN, Sanders M. Lesser toe deformities, intractable plantar keratosis, Freiberg infraction, and bunionette. In: Pinzur MS, ed. Orthopaedic Knowledge Update: Foot and Ankle 4. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2008:257-270.

Undefined

Trnka HJ, Nyska M, Parks BG, Myerson MS. Dorsiflexion contracture after the Weil osteotomy: results of cadaver study and three-dimensional analysis. Foot Ankle Int. 2001 Jan;22(1):47-50. PMID:11206822 (Link to Abstract)
Trnka HJ, Mühlbauer M, Zettl R, Myerson MS, Ritschl P. Comparison of the results of the Weil and Helal osteotomies for the treatment of metatarsalgia secondary to dislocation of the lesser metatarsophalangeal joints. Foot Ankle Int. 1999 Feb;20(2):72-9. PMID:10063974 (Link to Abstract)

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