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Less toe deformity Flashcards

Claw toe hammer toe mallet toe synovitis 2nd MT Bunionette Freiberg's disease

1
Q

What is a claw deformity characterised by?

A
  • MTPJ HYPEREXTENSION —> PIPJ AND DIPJ FLEXION similar to intrinsic deformity of the hand
  • combination of hammer and mallet toe
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2
Q

What is claw’s toes epidemiology?

A
  • Bilateral
  • Typically involves multiple toes
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3
Q

What is the pathophysiology of claw toes?

A
  • PRIMARY MCPJ HYPEREXTENSION
  • –> UNOPPOSED FLEXION PIPJ and DIPJ BY FDL
  • MTP PLANTAR PLATE becomes insufficient
  • Base of PROX PHALANX TRANSLATES DORSALLY
  • INTEROSSEI AND LUMBRICALS move DORSALLY
  • shift rotation dorsally
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4
Q

What is the result of the pathophysiology?

A
  • Shifts flexion moment to WRONG SIDE OF CENTRE OF ROATION -> FLEXION
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5
Q

Describe the Aetiology of claw toe?

A
  • SYNOVITIS- most common
  • TRAUMA
  • DELAYED COMPARTMENT SYNDROME- DEEP POST COMPARTMENT
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6
Q

What other conditions are associated with Claw toes?

A
  • Pes CAVUS
  • NEUROMUSCULAR disease- effects intrinsics
  • INFLAMMATORY ARTHROPATHIES- leads to soft tissue attenuation and MTPJ instability
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7
Q

What do patients with Claw toe present with?

A

Symptoms

  • METATARSALGIA
  • PAIN AT LEVEL OF UNSTABLE MTCP

Signs

  • Claw like deformity of toe
  • Depressed metatarsal head with callus formation adn tenderness
  • Flexed IPJ with callosities and tenderness
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8
Q

Describe non operative tx of claw toes?

A

Non operative

  • Taping / Shoe modificaiton
    • ​first line of treatment
    • adequate plantar padding using MT and or crest pads or orthotics to off load plantarly sublused MT heads
    • sling to hold proximal phalanx parallel to the ground
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9
Q

Describe operative tx of claw toes?

A
  • Extensor Digitorium brevis tenotomy, Extensor Digitorium Longus lengthening, FDL flexor to extensor transfer ( girdelstone)
    • for painful , flexible deformities without contractures
    • ulcerations caused by shoe wear
  • Girdlestone, MTP capsulectomy, and proximal phalanx and head resection = fixed contracture
  • Girdelstone and MT shortening osteotomy = Weils
    • clawing of all 4 lesser toes
    • oblique shortening osteotomy
    • translated MT heads PROXIMAL & PLANTAR
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10
Q

What are the complications of surgical correction of claw toes?

A
  • Floating toe
    • most common complx of Weils osteotomy
    • caused by _intrinsics migrating dorsall_y to the joint and acting as MTP extensors
    • avoid by osteotomy parallel to plantar surface if foot or a wafer of bone resected to ensure that joint is not depressed as the mT is shortened- see pic
  • ​Reoccurance
    • _​_Persistent plantar plate dysfunction
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11
Q

decribe the anatomy of extensor digitorium brevis and extensor hallucis?

A

Extensor digitorium brevus

  • orgin- lateral portion of calcaneus
  • inserts- Base prox phlanax 2-4 toes

Extensor hallucis brevis

  • origin- dorsal lateral side of calcaneus
  • inserts- base of prox phalanx great toe
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12
Q

What is this?

A
  • Hammer toe
  • Flexion at PIPJ and extension at DIPJ
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13
Q

What is the epidemiology of hammer toes?

A
  • Most common deformity of lesser toes
  • more common in older women
  • second toe most commonly affected
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14
Q

What is the pathanatomy of hammer toe?

A
  • Overpull of Extensor Digitorium Longus
  • Imbalance of Intrinsics
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15
Q

Describe any associated conditions of hammer toes?

A
  • Painful corns at PIPJ
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16
Q

What are the signs and symptoms of hammer toes?

A

Symptoms

  • Pain on dorsal surface of shoe wear
  • deformity

Signs

  • Flexion deformity of PIPJ of lesser toes with extension of DIPJ
  • PUSH UP TEST- flexible deformity is correctable with dorsal directed pressure on plantar aspect of involved metatarsals
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17
Q

what is the tx for hammer toe deformities?

A

Non operative

  • Shoe with high toe box, foam or silicone gel sleeves
    • pain or corns on dorsal PIP

Operative

  • Flexor tendon (FDL) to extensor Tendon transfer
    • Flexible deformity that failed non op
  • Resection arthroplasty +/- tenotomy and tendon transfers
    • ​Rigid deformity that has failed non op mx
  • Girdlestone procedure with flexor to extensor transfer
    • ​MTP involvement
    • Similar to claw toe tx
  • Arthrodesis
    • ​rigid deformity
    • high non union rate
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18
Q

Describe resection arthroplasty and tenotomy & tendon transfer?

A
  • Resection of head and neck or proximal phalanx to create a fibrous joint
    • ​+/- FDL to EDL transfer
    • hold in place with K wires 2-3 wks
    • post op additional 3 weeks w taping of PIPj in extension
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19
Q

Describe the girdlestone procedure for hammer toes?

A
  • (flexor to extensor transfer)
  • Extensor tendon lengthening Z plasty
  • Preform MTP capsule release
  • +/- Metatarsal shortening with oblique osteotomy
  • FDL to EDL transfer
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20
Q

What is this?

A
  • Mallet deformity
  • Hyperflexion of the DIPJ
  • normal PIPJ and MTPJ

Deformity may be fixed or flexible

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21
Q

What is the pathoanatomy of mallet toe?

A
  • Contracture/ of FDL
  • >70% of patient have a longer
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22
Q

What is the congential mallet toe associated with?

A
  • Flexion and lateral deviation of DIPJ
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23
Q

What is seen on examination of a mallet toe?

A
  • Callosities on toe
    • dorsum of DIPJ
    • Tip of toe
    • Pain results from impacting the ground with gait
24
Q

What is the TX of mallet toes?

A

Non operative

  • Shoes with hogh toe boxes, silicone/foam toe sleeves
    • first line

Operative

  • Percutaneous FDL tenotomy
    • flexible deformity that have failed non op
  • Middle phalangeal distal condylectomy (excision arthroplasty of DIP)
    • ​Rigid deformities that have failed non op mx
    • repair attenuated extensor tendons
    • K wire placement used to hold affected digit in extension
25
Q

What is the epidemiology of synovitis of 2nd MTP?

A
  • Most frequent monoarticular synovitis of the MTPJ
  • risk factors
    • Elongated 2nd MT relative to 1st MT
      • Morton foot
    • Hallux valgus deformity
26
Q

Describe the pathoanatomy?

A
  • Synovitis -> capsuloligamentous apparatus of MTP joint become stretched
    • stretch-> instability
    • instability -> deformity
  • Attenuation of plantar plate
    • extension of MTPJ
    • Sagittal plane deformity
    • assoc cross over toe deformity
  • ​MTP instability -> dorsal dislocation of MTPJ
    • predipose to hammer toe
27
Q

What are the signs and symptoms of 2nd MT synovitis?

A

Symptoms

  • Pain
  • Warmth
  • fullness of joint

Signs

  • Pain and tenderness
    • pain in 2nd webspace
    • tendereness maybe worse plantarly over PLANTAR PLATE or over DORSAL CAPSULE
    • Pressure on interdgitial nerve
  • GLobal swelling of MTP
  • Motion- decreased plantar flexion
  • deformity is passively correctable in predislocation stage
  • distruption to collat log and planatar plate-> cross over toe deformity
28
Q

What investigations are helpful in dx of 2nd MT synovitis?

A

xrays

  • weight bearing ap and lateral of foot
  • widening /medial- lateral joint space imbalance of 2nf MTPJ
    • may appear like joint space narrowing or overlapping of the proximal phalanx on distal metatarsal head
    • varus/valgus deformity of toe

MRI

  • If dx is unclear
  • quantify the extent of plantar plate or ligamentous disruption
29
Q

DDX of pain 2nd webspace?

A
  • Morton’s neuroma
  • 2nd MT synovitis
  • Need to distinguish between synovitis and neuroma as if you inject steriod into synovotis can weakend capsuloligamentous structures at MTPJ-> progressive deformity
30
Q

What is the tx of 2nd MT synovitis?

A

Non operative

  • Activity modifications, NSAIDS, external support of MTPJ
    • first line tx
    • external support crossover taping/ budin -type toe splint
    • non op tx should last 10-12 weeks
    • avoid shoes that aggrevate symptoms

Operative

  • Synovectomy
    • no deformity
    • failure of non op tx
  • Distal oblique shortening MT Osteotomy- Weils procedure
    • ​fixed flexion deformity 2nd MT
    • preserves joint
    • rebalances MT cascade
    • relaxes planar plate and rebalances alignment
  • Girdlestone- taylor: FDL to EDL tendon transfer or MTP capsular release with extensor tendon lengthening
    • ​Fixed deformity and NO long 2nd MT
    • sagittal deformity
31
Q

What are the complications of 2nd MT synovitis surgery?

A
  • Vascular compromise
    • if correcting a dislocated the soft tisse can contract including vasculature
    • stretching can compromise too
    • may need to reverse to save toe
32
Q

What are the features of MTP dislocation?

A
  • Multiplanar instability of MTPJ
    • often seen with cross over toe
    • dosral medial subluxation
33
Q

What are the pathoantomic stages of MTP dislocations?

A
  • Plantar plate disrupted
    • trauma/inflammatory
  • Lateral collateral ligaments fail
    • medial deviation of 2nd toe
    • plantar plate with flexor attachment moves medially
    • medial displacement of prox phalanx cf mt
  • Medial structures become contracted
    • lumbricals, interosseous tendons, MCL & medial capsule become tight
  • Plantar plate fails
34
Q

Describe the anatomy of the plantar plate?

A
  • Broad thick ligamentous structure spans plantar aspect of MTPJ
  • origin MT head
  • inserts plantar base proximal phalanx

function

  • resists tensile loads in sagittal plane
  • cushioned joint and supports weight bearing
35
Q

What are the signs and symptom of dislocated MTPJ?

A

Symptoms

  • walking on marbles
  • Pain

Signs

  • Callus under Mt head
  • Dorsimedial deviation of toe
  • Hammer toe- flexion PIPj ,extensionDIPJ
36
Q

What investigations are useful for MT dislocation?

A

Xray

  • Ap and lateral foot standing
    • dislocation of proximal phalanx
    • Hyperextension and dorsal dislocation of proximal phalanx

MRI

  • Rule out other pathology
37
Q

What are the tx for MT dislocation?

A

Non Operative

  • Taping, Shoe modification, Metatarsal pads, Budin splint, NSAIDS
    • first line
    • Won’t correct deformity

surgery

  • Distal oblique shortening MT osteotomy- Weils
    • sig pain and fixed deformity
    • achieves longitudinal compression thru shortening and allows joit reduction
    • ostetomy alomost parallel to plantar aspect of foot
    • Dorsal & medial capsular release of MT
    • fixation screw perpendicular to osteotomy
  • Plantar plate repair with MT osteotomy
    • suture thru planar plate and proximal phalanx
  • Flexor to extensor tendon transfer
    • Split FDL over Proximal phalanx to stabilise joint
      *
38
Q

what are the complications of MT surgery?

A
  • Cock up deformity of toe
    • inability to flex MTPJ-> 2nd digit dorsiflexion deformity
  • Toe vascular compromise
    • strecthing of tissue can compromise toe
    • procedure may need to be reversed
39
Q

What is this?

A
  • Bunionette deformity
  • characterised by lateral prominence of 5th Mt head
  • aka as Tailors bunion
40
Q

What is a bunionette caused by?

A
  • A widened 4-5 intermetarsal angle
  • abnormal transverse metatarsal angle
41
Q

What is a bunionette associated with?

A
  • Varus MTPJ
  • Pes planus
42
Q

Describe the classification of bunionette’s and tx plan?

A
  • Coughlin
  • Type 1 Enlarged 5th MT head or lateral exostosis
    • tx Condylectomy (excision of lateral bony eminence)
  • ​Type 2 Congential bow of 5th MT, normal 4-5 IMA
    • chevron (distal) osteotomy +/- lateral eminence resection
  • Type 3- Increased 4-5 IMA( >6.2o) most common-see pic
    • Oblique mid- diaphyseal metatarsal osoteotomy
    • shave planatar aspect of 5th MT head if plantar deformity calosity present- never excise 5Th MT head
43
Q

Describe the signs and symptoms of bunionette?

A

symptoms

  • Painful lateral callus

Signs

  • Plantar keratosis
  • pain with shoe wear
44
Q

What investigaitons are helpful in dx of bunionette?

A

Xrays

  • Standing WB ap , lateral and oblique
    • increased 4-5 Intermetarsal angle normal 6.5-8o
    • Increase width of MT head (normal <13mm)
    • Increase lateral deviation angle (normal 0-7o)
45
Q

What is the tx of bunionette?

A

Non operative

  • Shoe wear modification, keratosis padding and shaving
    • initial mode of tx
    • 75-90% success rate

Operative

  • Exostectomy vs Metatarsal osteotomy ( proximal, diaphyseal,distal)
    • poor response to non surgical mx
46
Q

What are the complications of bunionette surgery?

A
  • Reoccurrance
    • especially with condylectomy alone
  • Transfer metatarsalgia
    • with isolated MT head resection
  • Claw toe
47
Q

What is this?

A
  • Freiberg disease
  • aka Freiberg’s infraction - infraction and fracture
  • AVN of the 2nd MT head
48
Q

Describe the epidemiology of Freiberg’s disease?

A
  • Most common in adolescents 13-18 yrs
  • Most common in female adolescent atheletes

Risk Factors

  • More common in patients with long 2nd MT
49
Q

What is the pathophysiology of Freiberg’s disease?

A
  • Thought to be related to a disruption in the blood supply due to microtrauma and stress overloading
  • Leads to eventual collapse of 2nd MT head
50
Q

What is the classification system of freiberg’s disease?

A
  • SMILLIE
  • Stage 1= subchondral fracture visible only on MRI
  • Stage 2= dorsal collapse of articular surface on xray
  • Stage 3= Collapse of dorsal MT head with plantar articular portion intact
  • Stage 4= Collapse of entire MT head, joint space narrowing
  • Stage 5= severe arthritic changes and joint space obliteration
51
Q

What are the signs and symptoms of freiberg’s disease?

A

Symptoms

  • Forefoot pain localised to head of 2nd MT
  • worse with weight bearing

Signs

  • Swelling and limitation of motion in 2nd MTPJ
52
Q

What investigations are helpful in dx of freigberg’s disease?

A
  • standing ap , lateral and oblique foot xrays
    • Sclerosis
    • flattening of involved MT head
    • Joint destruction in late disease
    • defect is usually located in upper half of the articular surface of the MT head
  • MRI
    • can show patchy oedema
53
Q

What are the tx of freigberg’s disease?

A

Non operative

  • Activity limiation, NSAIDS, immobilisation
    • early disease
    • BK walking cast 3-4 weeks
    • Stiff sole shoe with MT bars /pads-post pop

Operative

  • Metatarsophalangeal arthrotomy with removal of loose bodies
    • v rare indication
    • can be combined with drilling MT head, subchondral Bone graft, interpositional graft using EDL
  • Dorsiflexion closing and shortening osteotomy
    • dorsal disease involvement of bone and cartilage
    • ​Shortening reduced stress and load on MT head
    • bring less effective plantar cartilage into contact with proximal phalanx
  • DuVries arthroplasty( partial MT head resection)
    • severe 4-5 stage
    • plantar cartilage not sufficient to reconstruct joint
54
Q

Describe the surgical approach to tx Freigberg’s disease?

A

Supine on table

Incision

  • make 2-3 cm dorsolateral incision parallel to correspinding extensor tendon
  • if 2 adjacent joints need to be exposed - make incision between them

Superifical dissection

  • Incise deep facia in line with incision
  • retract extensor tendon to reveal MTPJ

Deep Dissection

  • Perform Transverse or longitudinal arthrotomy
  • Retract the joint capsule to expose the MTPJ
55
Q

What are the complciations of Freigberg’s disease?

A
  • Degenerative joint disease of 2nd MT joint in adulthood

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