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Underlapping Toes
Deformities of the toes are common in the
pediatric population. Generally they are congenital in nature with both
or one of the parents having the same or similar condition. Many of
these deformities are present at birth and can become worse with time.
Rarely do children outgrow these deformities although rare instances of
spontaneous resolution of some deformities have been reported. Malformation
of the toes in infancy and early childhood are rarely symptomatic. The
complaints of parents are more cosmetic in nature. However, as the
child matures these deformities progress from a flexible deformity to a
rigid deformity and become progressively symptomatic. Many of these
deformities are unresponsive to conservative treatment. Common digital
deformities are underlapping toes, overlapping toes, flexed or contracted toes and mallet toes.
Quite often a prolonged course of digital splitting and exercises may
be recommended but generally with minimal gain. As the deformity
becomes more rigid surgery will most likely be required if correction
of the deformity is the goal. Underlapping Toes Description Underlapping
toes are commonly seen in the adult and pediatric population. The toes
most often involved are the fourth and fifth toes. A special form of
underlaping toes is called clinodactyly or congenital curly toes.
Clinodactyly is fairly common and follows a familial pattern. One or
more toes may be involved with toes three, four, and five of both feet
being most commonly affected. The exact cause of
the deformity is unclear. A possible etiology is an imbalance in muscle
strength of the small muscles of the foot. This is aggravated by a
subtle abnormality in the orientation on the joints in the foot just
below the ankle joint called the subtalar joint. This results in an
abnormal pull of the ligaments in the toes causing them to curl. With
weight bearing the deformity is increased and a folding or curling of
the toes results in the formation of callus on the outside margin of
the end of the toe. Tight fitting shoes can aggravate the condition. Treatment The
age of the patient, degree of the deformity and symptoms determine
treatment. If symptoms are minimal, a wait and see approach is often
the best bet. When treatment is indicated the degree of deformity
determines the level of correction. When the deformity is flexible in
nature a simple release of the tendon in the bottom of the toe will
allow for straightening of the toe. If the deformity is rigid in nature
then removal of a small portion of the bone in the toe may be
necessary. Both of these procedures are common in the adult patient for
the correction of hammertoe deformity. If skin contracture is present a derotational skin plasy may be required. Overlapping Toes - Overlapping Fifth Toe Description This
deformity is characterized by one toe lying on top of an adjacent toe.
The most common toe involved is the fifth toe. When one of the central
toes is involved the second toe is most commonly affected. The etiology
of the condition is not well understood. It is though that it may be
caused by the position of the fetus in the womb during development. The
condition my run in families so there may be a hereditary component to
the deformity. Treatment Effective
conservative treatment depends upon how early the diagnosis is made. In
infancy, passive stretching and adhesive tapping is most commonly used.
This may require 6 to 12 weeks to accomplish and reoccurrence is not
uncommon. Rarely will the deformity correct itself. As the individual
matures the deformity becomes fixed. When surgical correction is
warranted a skin plasty is required to release the contracture of the
skin associated with the deformity. Additionally a tendon release and a
release of the soft tissues about the joint at the base of the fifth
toe may be required. In severe cases the toe may require the placement
of a pin to hold the toe in a straightened position. The pin, which
exits the tip of the toe, may be left in place for up to three weeks.
During this period of time the patient must curtail their activities
significantly and wear either a post-operative type shoe or a removable
cast. Excessive movement at the surgical site can result in a less than
desirable result. The pin can be easily removed in the doctor's office
with minimal discomfort. Following removal of the pin splinting of the
toe may be required for an additional two to three weeks. Hammertoes and Mallet Toes Description Another common digital deformity is contracture of the toes in the formation of hammertoes and mallet toes. Hammertoes are described in depth in another article. Mallet toes
are a result of contracture of the last joint in the toe. In the
pediatric population it is often flexible and not painful. Over time
the deformity becomes rigid and a callus may form on the skin overlying
the joint at the end of the toe. Additionally the toenail may become
thickened and deformed form the repetitive jamming of the toe while
walking. The deformity usually involves one or two toes, with the
second toe most commonly affected. Mallet toes have several etiologies.
Longer toes that are forced against a short toe box in the shoe will,
over time, develop a contracture of the last joint in the toe causing a
mallet toe. Treatment Conservative treatment
consists of padding and strapping the toes into a corrected position.
This treatment may alleviate the symptoms but will not correct the
deformity. Diabetic patients often develop ulcerations on the ends of
their toes secondary to mallet toe deformity and the pressure that
results from the toe jamming into the shoe. When standing, the toe will
demonstrate a contracture, with the tip of the toe facing downward into
the floor. If the deformity is flexible a simple release of the tendon
in the bottom of the toe will allow straightening of the toe. Following
the procedure the patient must avoid shoes that cause jamming of the
toe or the deformity can reoccur. When the deformity is rigid surgical
correction requires the removal of a small section of bone in the last
joint of the toe. On occasion fusion of the last two bones in the toe
may be necessary. This requires removing the cartilage from the last
joint in the toe and pinning the bones together. When the bone heals it
forms a single bone and the toe remains in a straightened position.
Healing time is dependent upon the procedure selected. If a tendon
release is performed the patient my return to a roomy shoe within a
week. If the toe is straightened by removing a section of the bone in
the toe it make ten days to three weeks for a patient to return to
normal shoes. If a fusion is performed to straighten the toe, the
patient may not return to normal shoes for 6 to 8 weeks. Time off from
work will depend upon the type of shoe gear that must be worn and the
level of activity necessary to perform the job. A minimum of three to
four days off from work is generally recommended and longer if the job
responsibilities can not be modified to accommodate the normal healing
time for the surgery.
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