Updated: 9/5/2019

Claw Toe

Topic
Review Topic
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Questions
4
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Evidence
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https://upload.orthobullets.com/topic/7013/images/Clinical photo_moved.jpg
https://upload.orthobullets.com/topic/7013/images/Clawe toe_moved.jpg
https://upload.orthobullets.com/topic/7013/images/claw toe.jpg
https://upload.orthobullets.com/topic/7013/images/weil osteotomy.jpg
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
 

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Questions (4)
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(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? Review Topic

QID: 3257
FIGURES:
1

Girdlestone-Taylor flexor-to-extensor tendon transfer

50%

(1234/2477)

2

PIP arthrodesis

4%

(89/2477)

3

Complete MTP capsulotomy and resection arthroplasty of the proximal phalanx with tendon release/lengthening

31%

(766/2477)

4

Complete MTP capsulotomy and resection arthroplasty of the proximal phalanx with a Weil osteotomy

10%

(260/2477)

5

Isolated Weil osteotomy of the affected metatarsal

5%

(115/2477)

L 3

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(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? Review Topic

QID: 682
FIGURES:
1

Lack of appropriate post-operative immobilization

5%

(96/2072)

2

Technique of surgical osteotomy

74%

(1531/2072)

3

Post-operative cerebrovascular event causing neuromuscular imbalance

0%

(7/2072)

4

Inadvertent tethering of the extensor tendon during surgical procedure

21%

(429/2072)

5

Surgical site infection

0%

(2/2072)

L 2

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