Updated: 6/15/2021

Congenital Hallux Varus (Atavistic Great Toe)

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  • summary
    • Congenital Hallux Varus, also known as Atavistic Great Toe, is a rare idiopathic condition caused by a firm, band-like abductor hallucis muscle that occurs in children after walking age and presents with varus deformity of the big toe. 
    • Diagnosis is made clinically with varus deformity of the first toe with radiographs showing a short, thick 1st metatarsal.
    • Treatment is usually operative with abductor hallucis muscle release for mild resistant cases or excision of the central portion of epiphyseal bracket in cases with a bracket causing the deformity.
  • Epidemiology
    • Demographics
      • presents in children after walking age
    • Risk factors
      • longitudinal epiphyseal bracket of the first metatarsal or proximal phalanx
  • Etiology
    • Pathophysiology
      • deformity at metatarsophalangeal joint due to
        • imbalance between the great toe abductor and adductors
      • pathoanatomy
        • firm, fibrous, band-like abductor hallucis muscle
        • short, thick first metatarsal
        • longitudinal bracket epiphysis of the 1st metatarsal
        • underlying skeletal dysplasia (diastrophic dwarfism)
      • do not confuse with metatarus primus varus
        • varus deformity of the 1st metatarsal (no deformity at MTP joint)
    • Associated conditions
      • often associated with polydactyly
  • Presentation
    • Symptoms
      • cosmetic deformity
        • difficult to put on shoes
        • usually painless
    • Deformity
      • can vary in severity
        • few degrees to 90 degress
  • Imaging
    • Radiographs
      • recommended views of the foot
        • AP
        • lateral
        • oblique
      • findings
        • short, thick 1st metatarsal
  • Differential
    • Must be differentiated from metatarsus adductus
  • Treatment
    • Nonoperative
      • observation alone
        • indication
          • rare as deformity is thought to worsen with age
          • surgical correction often proposed in infancy
    • Operative
      • abductor hallucis muscle release
        • indication
          • mild and resistant deformities
      • excision of central portion of epiphyseal bracket
        • indication
          • if epiphyseal bracket found to be the cause of Hallux Varus
        • resumption of longitudinal growth common if performed at a young age
        • secondary corrective realignment or lengthening is sometimes needed
      • Farmer technique
        • indication
          • moderate to severe deformities
        • technique creates syndactyly between the 2nd toe and hallux
        • maintains deformity correction
  • Complications
    • Recurrence of deformity
    • Incomplete correction of deformity

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