PART II Flashcards
Background
o Consists of
§ Plantarflexion, medial deviation, rotated laterally at the DIPJ
• Lateral rotation of the DIPJ may cause overriding of the adjacent toe
o Commonly seen in the 3rd and 4th toes
o Usually Bilateral
o Often a (+) family history
Etiology
o Contracture of the FDL and occasional FDB
o Hypoplasia of intrinsic muscles (lumbricals that attach to the FDL)
Conservative Treatment
o Observe (it may correct on its own)
o Strappings, tapings, stretching, accommodative shoe gear
Surgery
o Indications – painful corns/blisters, nail complaints
o Percutaneous Tenontomy to the affected toe
§ Toe will fully extend but the medial deviation and rotation may still
persist
digital varus (curly toes)
Background
o Can be isolated or associated w/ an inherent syndrome, especially when
accompanied by syndactyly
§ (30% have a (+) family history, autosomal dominant)
Associated Syndromes
o Trisomy 13 (Patau Syndrome) – cardiac, brain, or spinal cord deformities. Cleft lip, hypotonia
o Ellis-Van Creveld Syndrome – short forearms and legs, narrow chest, cardiac defects
Classifications
o Location of the extra digit to normal structure
§ Pre-axial
• Supernumery digit on medial side of hallux (15-17% of cases)
§ Central
• Duplication of the 2nd, 3rd, or 4th digit (3-6% of cases)
§ Post-axial
• Supernumery digit lateral to the 5th digit (80% of cases)
o A – Extra digit is well formed and articulated w/ the 5th met
o B – Extra digit that is not well formed, it is just a skin tag
o M – Combination of A and B, partially formed digit with some bone
or catrilagenous tissue
o Amount and type of tissue of the extra digit
Polymetatarsia Association o Wide metatarsal head o Y-shaped met o T-shaped met o Metatarsal duplication
Clinical Presentation
o Psychological, painful, functional deformity (ex. cant fit in shoe gear), shoe gear difficulties
Imaging
o Get Radiographs – looking at how well formed the digits are and what the mets look like
Surgical Considerations
o Skin tag w/ post axial type B – put suture around it and tie it off cutting off blood flow and it
falls off
o For all other forms proper age is debatable
§ Delay surgery to at least 1yr so baby can tolerate anesthesia
o General Rule – leave the digit that will give the most normal shape and function
§ If the appearance is similar, excise the lateral or medial most digit
Complications
o Post-axial polydactyly correction is straightforward
o Pre-axial polydactyly is more complicated
§ Hallux varus
§ Short 1st met
§ Forefoot splay
§ Longitudinal epiphyseal bracket
• C-shaped longitudinally oriented growth plate w/ resultant shortening and
angular deformities
§ Acquired hyperkeratotic lesions
§ Failure to debulk tissue can limit shoegear
§ Digit subluxation
polydactyly (more than 5 digits)
Background
o Any degree of webbing or fusion of the toes
§ Due to rapid arrest of the embryonic development btwn 6th and 8th week of intrauterine
life the interdigital tissue fails to degenerate
o Most common btwn the 2nd and 3rd digit (since this is the last webbing to disappear)
o Strong familial incidence, usually autosomal dominant
Associated Genetic Syndromes
o Apert’s Syndrome – premature fusion of skull bones, and syndactyly
o Polands Syndrome – underdevelopment/absence of the pectoral muscles on one side of the body, and syndactyly
Classifications
o Davis-German
§ Incomplete or Complete?
• Incomplete – webbing does not extend to the distal most aspect of involved
digits
• Complete – webbing extends to the distal most aspect of involved digits
§ Simple or Complicated?
• Simple – no phalangeal involvement
• Complicated – phalangeal bones are abnormal
o Temtamy-McKusick
§ Zygodactyly – fancy name for syndactyly involving the 2nd and 3rd toes
Conservative Treatment
o None, it is purely a cosmetic issue
Imaging
o Radiographs – can see if its just skin or bone involvement
Surgical Desyndactylization
o Usually performed after age 1 (ideal is 2-4), skin needs to be mobile
o Procedure Types
§ Flaps
§ Grafts
• Full thickness skin grafts are preferred over split thickness
skin grafts due to less contraction
• Can get skin from medial or lateral submalleolar regions,
dorsum of foot, groin, abdomen
§ Tissue Expansion
• Tissue expanders used to increase the volume under the
skin therefore slowly expanding the skin
o Reduces the need for skin grafts
o Cons – 2 surgeries, leakage of expander, repeated
injections, longer duration to complete
o Post-op Management
§ Do not overtighten bandages and damage vascular supply
§ May utuilize short leg cast or splint
§ Recommended to treat 1 foot at a time if B/L
§ Continue w/ dressings or tapings for compression for up to 2 months to prevent “web
creep”
• Its when the web space continues to grow giving the appearance of incomplete
syndactyly
syndactyly
Background
o Congenital enlargement of all tissue types in an affected ray
§ Phalanges, tendons, nerves, vessels, subQ, nails, skin
o Unilateral, seldom involves the 4th or 5th digits
o May occur w/ syndactyly
o Family genetics most likely DOES NOT play a role in this deformity
Etiologies
o Unknown but may be associated w/
§ AV fistula, increased circulation to the digit, hyperplasia of lymphatics, etc.
NOTE: enlargement of the forefoot or the entire foot is Localized Gigantism
Types
o Static
§ Present at birth and enlarges proportionatly with growth
§ Limited to the digit (doesn’t go back into the met)
o Progressive
§ Disproportionate growth rate of the digit
§ May extend proximal into the met
Imaging
o Radiographs, MRI (may be helpful in surgical planning)
Treatments
o No Gold Standard (its case by case basis)
o Goals – pain free, plantigrade foot, similar size in unaffected foot (so can buy same size shoes)
o BE CREATIVE
§ May need to do staging (do the surgery in stages taking some tissue then seeing what
grows back)
o Salvage Procedures
§ Soft Tissue
• Static type responds best to debulking (careful not to devascularize the tissue,
they suggest doing the medial side then see if any devascularization then do the
lateral side or vise versa)
o Debulk at 3 month stage intervals
§ Osseous
• Phlanagectomy, arthroplasty, arthrodesis, ray resection, amp as last resort
• May need ST work 5-6 weeks after bone work
o Digital Epiphysiodesis
§ Gives the potential for the digit to grow proportionatly as the others digits by arresting
growth
• Resect the entire growth plate w/ a 15 blade or curettage and fixate w/ stable or
K-wire
macrodactyly
Background
o Absence of 2 or 3 central rays or digits
o Cone shaped cleft forefoot
§ Medial deviation of the 5th digit
§ Hallax abductus
o Rearfoot is normal
o Bilateral vs. Unilateral
o Most bilateral defects are inherited as a single gene trait or chromosomal abnormality
§ Autosomal dominant
• May occur w/ cleft hand, cleft lip and palate
o Unilateral
§ Most are caused by amniotic band syndrome and are thus NOT
genetic
Etiology
o Not really known
Model for Understanding Congenital Malformations
o Primary Force
§ Intrinsic genetic defect in the cartilaginous precursor of a specific bone
• Ex. central ray absence
o Secondary Force
§ Effects of external forces, such as muscular attachments on bone
• Ex. splaying seen from asymmetrical pull of the abductor hallucis and abductor
digiti minimi
o Tertiary Force
§ External forces on the bone itself
• Ex. weight bearing
Imaging
o Radiographs, MRI (surgical planning)
Conservative Treatment
o Custom shoes to accommodate the splaying of the forefoot
o Debride hyperkeratotic lesions
Surgical
o Considerations
§ No procedure will cause this cleft foot to have a normal appearance
§ Contraindicated in a child that has a limited life expectancy
o Goals – restore function, provide stable WB foot, alleviate physical and psychological pain to
the best of the surgeons ability
o Procedures
§ Artificial Syndactyly (w/ the aid of metatarsal osteotomies when needed)
• Many different ways to do it
o Complications
§ Pin tract infections, infection, wound dehiscence, skin necrosis, neurovascular
compromise
Ectrodactyly (congenital split, cleft foot, lobster foot, partial adactyly)
