Digital Deformities

Question 1

FLEXOR STABILIZATION

Answer 1

Most common mechanism ~80%
*Occurs in a pronated foot in stance
*FDL and FDB overpower the interossei
*Increased pull of long flexors which gain mechanical advantage
*Flexors fire earlier and longer to help stabilize pronated, hypermobile foot
*Intrinsics can not counter the deforming force

Question 2

EXTENSOR SUBSTITUTION

Answer 2

Swing phase condition due to weak anterior leg muscles
*Secondary to ankle equinus, weak lumbricals, spastic EDL, anterior cavus
*Extensor muscles gain mechanical advantage over the lumbrical muscles

Question 3

FLEXOR SUBSTITUTION

Answer 3

Occurs when the deep posterior and lateral muscle groups
overcompensate for a weak triceps surae
*A supinated high arch foot with contracture of the digits results from
the early and prolonged contracture of the FDL, FHL, tibialis posterior,
and peroneus longus muscles.

Question 4

DIGITAL DEFORMITIES

Answer 4

bnormal contraction of
lesser digits
*They can be flexible, semi-rigid, or rigid in nature

Question 5

HAMMERTOE

Answer 5

Deformity occurs in the sagittal plane
*Proximal phalanx is DF, middle phalanx is PF.
*MPJ may be prominent plantarly

Question 6

MALLET TOE

Answer 6

Sagittal plane deformity in which the distal phalanx is flexed on the
middle phalanx
*Often associated with a long digit

Question 7

CLAW TOE

Answer 7

Deformity where the middle and distal phalanges are
flexed on a dorsiflexed proximal phalanx
*MPJ is prominent plantarly
*Often associated with cavus foot deformity or a
neuromuscular disorder

Question 8

SYMPTOMS: digital deformities

Answer 8

Pain or irritation of the affected toe when wearing shoes
*Corns and calluses on the dorsum of the toe, between the toes, or on the
plantar forefoot secondary to retrograde pressure on the metatarsal head
*Inflammation, redness, or a burning sensation of the digit
*Contracture of the digit
also ulcerations

Question 9

CONSERVATIVE TREATMENT

Answer 9

Wider and deeper toe box
*Padding/offloading
*Orthoses

Question 10

SURGICAL TREATMENT

Answer 10

Exostectomy
*Phalangectomy
*Arthroplasty
*Arthrodesis
*Tendon Transfer
*Capsulotendon Balancing
*MPJ Release
*Weil
*Amputation

Question 11

FIRST METATARSOCUNEIFORM EXOSTOSIS

Answer 11

Excessive motion of 1st met during
propulsive period of gait
*Hypermobile 1st ray
*Trauma

Question 12

SESAMOIDITIS

Answer 12

pain and inflammation sub met 1
*Edematous
*Bipartite versus Fracture
*Contralateral X-rays may help

Question 13

METATARSUS PRIMUS EQUINUS

Answer 13

Excess plantarflexion of 1st Ray
*Can be structural or positional
*Structural (congenital plantarflexion associated with
cavus foot)
*Positional (compensation for supinated foot)

Question 14

MANAGEMENT: first ray deformities

Answer 14

Orthoses
*Padding/offloading
*Surgical intervention
*Dorsiflex the 1st ray

Question 15

METATARSUS PRIMUS ELEVATUS

Answer 15

1st metatarsal is dorsally deviated in the sagittal plane relative to lesser
metatarsals
*Results in Hallux Limitus/Rigidus
*Assess through manual ROM and radiographs (lateral view).
Long or short metatarsal
*Short proximal phalanx
*Hypermobile medial column
*Degenerative arthritis
*Iatrogenic

Question 16

MANAGEMENT: met primus elevatus

Answer 16

Orthoses
*Padding
*Surgical Intervention
*Plantarflex the metatarsal

Question 17

HALLUX LIMITUS

Answer 17

Restriction of 1st MPJ
*Less than 65 degrees
*Leads to hallux rigidus
*Sesamoidal hypertrophy
*May see hallux extensus develop

Hypermobility of 1st ray
*Propulsive phase pronation
*Metatarsus primus elevatus – structural elevation of 1st met
*Congenital, Post-traumatic, Structural
*Iatrogenic – inadvertent DF with CBWO, patient walking s/p 1st ray surgery leading to
failure of fixation

Question 18

HALLUX LIMITUS

Answer 18

Structural
*Intrinsic problem with 1st ray, fixed/rigid position, non-reducible
*Functional
*Secondary to hypermobility, seen only weightbearing/with gait,
reversible/reducible by controlling hyperpronation

Question 19

RADIOGRAPHICALLY: Hallux Limitus

Answer 19

Lateral view XR
*Distal first met will be sitting higher than second
*Seiberg’s index, dorsal exostoses, Flag sign, narrowing of joint space
*Stress lateral hallux DF XR
*Patient raises heel off ground
*First ray is not parallel to 2nd with elevation distally, won’t rotate
up on sesamoid complex/sits behind it

Question 20

HALLUX ABDUCTO VALGUS

Answer 20

Overlying enlargement of first met head
*Sesamoids track laterally
*1st met adducts
*Hallux abducts

Question 21

ETIOLOGY

Answer 21

Developmental
*Shoegear
*Hypermobility at the medial column
*Fully Compensated RF Varus
*RF Valgus
*Fully Compensated FF Varus

Question 22

CLINICAL EVALUATION

Answer 22

Prominent dorsomedial eminence
*Quality of ROM
*Tracking vs. Trackbound
*EHL tendon
*Pain on palpation
*Other associated deformities

Question 23

HALLUX VARUS

Answer 23

Congenital
*Excessive tightness of medial soft tissue structures
*Metatarsus adductus
*Iatrogenic – Most Common!

Question 24

MANAGEMENT: hallux varus

Answer 24

Surgical
*Depends on length of deformity
*Immediate post op HAV complication –
reverse your procedure
*Long term – Fusion or joint destructive
procedure