summary Claw toe is a lesser toe deformity characterized by MTP hyperextension and resulting PIP and DIP flexion. Diagnosis is made clinically with presence of MTP hyperextension, PIP flexion and DIP flexion of a lesser toe. Treatment is a trial of nonoperative management with shoe modification and taping. Surgical management is indicated for progressive deformity, fixed contractures, and dorsal toe ulcerations. Epidemiology Anatomic location typically involves multiple toes often bilateral Etiology Pathophysiology MTP hyperextension is the primary pathology chronic MTP hyperextension leads to unopposed flexion of the DIP and PIP by FDL analogous to intrinsic minus deformity in the hand 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 Cause 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 vs. Hammer toe vs. Mallet toe Claw Toe Hammer Toe Mallet toe DIP Flexion Extension Flexion PIP Flexion Flexion Normal MTP Hyperextension 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 Isolated FDL tenotomy indications flexible deformity in a diabetic patient with tip-of-toe ulceration without evidence of infection 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
QUESTIONS 1 of 9 1 2 3 4 5 6 7 8 9 Previous Next Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ19.43) A patient presents to your clinic with minor toe deformities in Figure A. She has been given a recent diagnosis of multiple sclerosis. Which of the following below best fits the description of the associated minor toe deformities? QID: 213945 FIGURES: A Type & Select Correct Answer 1 Flexed metatarsalphalangeal joint with flexed proximal and distal interphalangeal joints 3% (23/678) 2 Neutral metatarsalphalangeal and proximal interphalangeal joint and flexed distal interphalangeal joint 2% (15/678) 3 Neutral metatarsalphalangeal joint, flexed proximal interphalangeal joint and extended distal interphalangeal joint 6% (38/678) 4 Laterally deviated metatarsalphalangeal joint, flexed proximal interphalangeal joint and neutral distal interphalangeal joint 4% (30/678) 5 Extended metatarsalphalangeal joint, flexed proximal and distal interphalangeal joints 84% (568/678) N/A Question Complexity E Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (SBQ12FA.60) A 62-year-old female presents with pain on the plantar surface of her foot. Figure A is a clinical photograph. The patient is scheduled for the osteotomy shown in Figure B. What is the pathophysiologic mechanism of the most common complication caused by this osteotomy method? QID: 3867 FIGURES: A B Type & Select Correct Answer 1 Articular damage 8% (143/1835) 2 Disruption of dorsal capsular artery 18% (323/1835) 3 Lengthening of the metatarsal 12% (220/1835) 4 Conversion of interossei from plantarflexors to dorsiflexors 41% (752/1835) 5 Iatrogenic ligament instability 21% (379/1835) L 3 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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? QID: 3257 FIGURES: A Type & Select Correct Answer 1 Girdlestone-Taylor flexor-to-extensor tendon transfer 49% (1775/3632) 2 PIP arthrodesis 4% (144/3632) 3 Complete MTP capsulotomy and resection arthroplasty of the proximal phalanx with tendon release/lengthening 32% (1147/3632) 4 Complete MTP capsulotomy and resection arthroplasty of the proximal phalanx with a Weil osteotomy 10% (356/3632) 5 Isolated Weil osteotomy of the affected metatarsal 5% (181/3632) L 3 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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? QID: 682 FIGURES: A Type & Select Correct Answer 1 Lack of appropriate post-operative immobilization 5% (126/2760) 2 Technique of surgical osteotomy 74% (2038/2760) 3 Post-operative cerebrovascular event causing neuromuscular imbalance 1% (15/2760) 4 Inadvertent tethering of the extensor tendon during surgical procedure 21% (569/2760) 5 Surgical site infection 0% (2/2760) L 2 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic
All Videos (0) Podcasts (1) Foot & Ankle⎪Claw Toe Foot & Ankle - Claw Toe Listen Now 12:35 min 10/15/2019 526 plays 4.8 (6)