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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
What is the epidemiology of synovitis of 2nd MTP?
* Most frequent **monoarticular synovitis of the MTPJ** * risk factors * **Elongated 2nd MT relative to 1st MT** * **Morton foot** * **Hallux valgus deformity**
26
Describe the pathoanatomy?
* **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
What are the signs and symptoms of 2nd MT synovitis?
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
What investigations are helpful in dx of 2nd MT synovitis?
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
DDX of pain 2nd webspace?
* **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
What is the tx of 2nd MT synovitis?
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
What are the complications of 2nd MT synovitis surgery?
* **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
What are the features of MTP dislocation?
* **Multiplanar instability of MTPJ** * often seen with cross over toe * dosral medial subluxation
33
What are the pathoantomic stages of MTP dislocations?
* **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
Describe the anatomy of the plantar plate?
* 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
What are the signs and symptom of dislocated MTPJ?
Symptoms * walking on marbles * Pain Signs * Callus under Mt head * Dorsimedial deviation of toe * Hammer toe- flexion PIPj ,extensionDIPJ
36
What investigations are useful for MT dislocation?
Xray * Ap and lateral foot standing * dislocation of proximal phalanx * Hyperextension and dorsal dislocation of proximal phalanx MRI * Rule out other pathology
37
What are the tx for MT dislocation?
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
what are the complications of MT surgery?
* 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
What is this?
* Bunionette deformity * characterised by lateral prominence of 5th Mt head * aka as Tailors bunion
40
What is a bunionette caused by?
* A widened 4-5 intermetarsal angle * abnormal transverse metatarsal angle
41
What is a bunionette associated with?
* **Varus MTPJ** * **Pes planus**
42
Describe the classification of bunionette's and tx plan?
* **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
Describe the signs and symptoms of bunionette?
symptoms * Painful lateral callus Signs * Plantar keratosis * pain with shoe wear
44
What investigaitons are helpful in dx of bunionette?
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
What is the tx of bunionette?
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
What are the complications of bunionette surgery?
* **Reoccurrance** * especially with condylectomy alone * **Transfer metatarsalgia** * with _isolated MT head resection_ * **Claw toe**
47
What is this?
* **Freiberg disease** * aka Freiberg's infraction - infraction and fracture * **AVN of the 2nd MT head**
48
Describe the epidemiology of Freiberg's disease?
* Most common in adolescents 13-18 yrs * Most common in female adolescent atheletes Risk Factors * More common in **patients with long 2nd MT**
49
What is the pathophysiology of Freiberg's disease?
* 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
What is the classification system of freiberg's disease?
* **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
What are the signs and symptoms of freiberg's disease?
Symptoms * **Forefoot pain localised to head of 2nd MT** * worse with weight bearing Signs * Swelling and limitation of motion in 2nd MTPJ
52
What investigations are helpful in dx of freigberg's disease?
* 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
What are the tx of freigberg's disease?
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
Describe the surgical approach to tx Freigberg's disease?
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
What are the complciations of Freigberg's disease?
* **Degenerative joint disease of 2nd MT joint in adulthood**

Foot and Ankle FRCS (31 decks)

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