Claw Toe

Definition

 

Hyperextension of MTPJ and PIPJ / DIPJ flexion

- usually all toes affected 

 

Claw Toes

 

DDx

 

1.  Complex hammer

- hammer toe with MTPJ extension

- hammer usually affects second toe

 

2.  Curly toe

- normal MTPJ

- flexed PIPJ and DIPJ

 

Associations

 

Cavus foot 

Compartment syndrome

Diabetic neuropathy

Rheumatoid arthritis

 

Pathology

 

Imbalance between intrinsics and extrinsics

- intrinsic weak (MCPJ flexion and IPJ extension)

- extrinsics strong

 

MTPJ  

- extension strong

- flexion weak

 

IPJ

- extension weak

- flexion strong

 

P1 subluxes dorsally

- it pushes the MT head plantar-ward 

- leading to metatarsalgia

 

Cavus foot 

- claw occurs not only due to intrinsic weakness but because of plantar flexed MT's 

- lead to dorsiflexion at MTPJ's 

- results in flexion of IPJ's as seen above

- If claw flexible may correct if reduce MT's

 

History

 

Pain & callosities under MT heads (metatarsalgia)

 

Examination

 

Hindfoot

- cavus

- coleman block

 

Forefoot

- characteristic deformity

 

Calluses

- dorsum PIPJ

- bleow MTPJ

 

Mobile or fixed of MTPJ / PIPJ crucial

 

Flexible

- claw disappears with ankle PF 

- returns with DF ankle (tight long flexors)

 

Cavus foot

- when DF to correct MT claw actually improves (tight plantar fascia) 

 

Management

 

Non-operative

 

Extra width and depth toe box shoe 

MT dome

 

Operative

 

Significant deformity of the hindfoot ± a cavus foot should be addressed first if symptomatic

 

Surgical Algorithm

 

1.  Flexible Deformity PIPJ / MCPJ

 

Girdlestone Taylor FETT 

- divide FDL in two and suture dorsally over P1

- +/- Extensor tenotomy & Dorsal MTPJ capsulotomy

 

2.  Fixed PIPJ Deformity / Flexible MCPJ

 

A.  Du Vries Excisional Arthroplasty PIPJ

- resection of head & neck of P1 

- stabilise with K wire

- aiming for fibrous union

- ROM 15o

 

B.  Extensor tenotomy + PIPJ Fusion

 

+/- Dorsal MTP capsulotomy MP joint

 

3.  Fixed PIPJ / MCPJ 

 

PIPJ arthrodesis + Extensor tendon tenotomy 

+ dorsal MTPJ capsulotomy

+ MT neck osteotomy

  

4.  Great toe involved

 

Jones procedure

- arthrodesis of IPJ

- EHL to MT neck 

 

Metatarsal options

 

Persistent MTPJ DF main cause of failure

 

Options

1. Excision of MT head (Keller's)(RA)

2. Distal metatarsal oblique osteotomy (Weil)

3. Hibbs (if from cavovarus)

 

Techniques

 

1.  FETT Technique / Modified Girdlestone Taylor

 

A.  Release FDL distally / divide into two

- 2 plantar incisions P2 and P3

- transverse incision plantar aspect P3

- divide FDL, protect NV bundles

- transverse incision plantar aspect P2

- harvest FDL and split in two

- can do single longitudinal plantar incision

 

B. Pass FDL over plantar aspect P1

- dorsal incision over P1

- place clamp each side of hood

- don't trap digital nerve

- bring tendon through incision slot in extensor tendon over P1 on each side 

- if over P2 will not work

- toe placed in approximately 20 degrees of plantar flexion at the MTP joint

- suture to each other & ED

- if varus or valgus take whole FDL either side

 

2.  PIPJ fusion 

 

Principles

- important to shorten the toe

 

Technique

- Ellipse of skin excised over dorsum PIPJ

- Extensor tendon taken in the ellipse

- release the collaterals so that P1 subluxes into operative field 

- elevate volar plate off P1

- bone cutters to resect P1 condyles

- resect base P2

- retrograde K wire out through P2 and P3 first

- back through P1, rest against subchondral bone

- bend wire over and tape

 

Risk

- check blood supply at end of case

- if problematic

- release dressings / warm / increase BP

- can use antispasmodic

- will usually reperfuse over 5 minutes

- keep patient asleep in meantime

- need to have ischaemia as part of consent

 

3.  Weil Osteotomy 

 

Technique

- Dorsal metatarsal exposed

- web space incisions if doing multiple toes

- homan retractors each side of MT

- saw enters at edge of articular surface dorsally

- Blade angled as low / horizontal as possible

- When osteotomy complete the MT head slides back

- Needs to slide back at least 5mm

- Then fix with screw from dorsal to distal plantar

- Amputate leading edge of proximal fragment

- if have valgus or varus deformity then can correct for this

 

Weil Ostetomy PIPJ FusionWeil Osteotomy PIPJ Fusion Lateral