Congenital Curly Toe

Introduction

Common congenital deformity
- flexion and varus deformity of the interphalangeal joints
- contracture of the flexor digitorum longus (FDL) or flexor digitorum brevis (FDB) is the most common cause
True incidence and natural history unknown
- usually involves lateral three toes
- usually bilateral

Presentation

Symptoms
- usually asymptomatic

Imaging

Radiographs
- not indicated

Treatment

Nonoperative
- observation
  - indications
    - usually asymptomatic and requires no treatment
  - toe strapping not found to be beneficial
Operative
- surgical soft tissue release
  - indications
    - FDL release reserved for severe toe deformity or nail bed deformity in children typically > 3 years old
  - outcomes
    - 85-90% effective

Techniques

Surgical soft tissue release
- open tenotomy of both slips of the flexor digitorum brevis (FDB) and FDL tendon
- open tenotomy of one slip of the flexor digitorum brevis (FDB) tendon only
- flexor digitorum longus (FDL) transfer to the extensor hood

TAG

(OBQ09.226) An 8 month-old girl is brought in to your clinic for a second opinion for her daughter's congenital deformity seen in Figures A and B. The mother reports that the first surgeon recommended an open tenotomy of one slip of the flexor digitorum brevis (FDB) tendon, dissection of the collateral ligament and the volar plate, and reconstruction of the plantar skin defect. What is your recommendation to the patient's mother for treatment of the congenital curly toe? Topic

Review Topic

FIGURES: A

1. Flexor digitorum longus (FDL) transfer to the extensor side
2. Open tenotomy of one slip of the flexor digitorum brevis (FDB) tendon only
3. Toe strapping with tape
4. Open tenotomy of both slips of the flexor digitorum brevis (FDB) and FDL tendon
5. Observation

PREFERRED RESPONSE ▶

DISCUSSION: Curly toe is a common congenital deformity characterized by flexion and varus deformity of the interphalangeal joints. Third and fourth toes are frequently affected and most patients don't have symptoms. Sweetnam stated that treatment was unnecessary because of the lack of symptoms and self-corrective nature. He indicated that 25% of his patients showed
spontaneous improvement, even if untreated. He stated observation had the same success rate as treatment with toe strapping and was less painful. Answers 1, 2, and 4 are all surgical techniques discussed but are not the gold standard for initial treatment. Surgery is considered if symptoms are present (pain, difficulty with shoe wear, nail problems) after age 3 years.

REFERENCES:

1. Sweetnam R. Congenital curly toes; an investigation into the value of treatment. Lancet. 1958 Aug 23;2(7043):398-400 PMID:13576819 (Link to Abstract)

Question Authors:

Michael Hughes MD, Eric Shirley MD,

Please Rate Educational Value!

3.0

Average 3.0 of 10 Ratings

Level of Evidence 4 (Case Series)

Sweetnam R. Congenital curly toes; an investigation into the value of treatment. Lancet. 1958 Aug 23;2(7043):398-400 PMID:13576819 (Link to Abstract)

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

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