Over-riding Fifth Toe
Deformity
5th toe adducted & overrides 4th toe
- extended, adducted & laterally rotated at MTPJ
Pathology
Toe arises more dorsally than it should
Contracture of EDL tendon
Contracted dorsal skin & dorsal MTPJ capsule
Aetiology
Usually congenital deformity
- toe usually hypoplastic
Clinical Features
Cosmetic deformity
Problems with footwear
Usually bilateral
Usually needs surgery (compared with underriding or curly)
Non-operative Management
Strapping & taping ineffective
Broad toe box
Operative Management
Mild / Moderate - Butler procedure
- racquet shaped incision dorsally
- dorsal limb over extensor tendon
- circumferential limb must preserve NV bundle
- EDL and dorsal capsule divided
- toe swung back into position and sutured
Severe - Lapidus procedure
- EDL transfer to AbDM
- curvilinear incision
- cut EDL over mid MT proximally leaving attached distally
- capsule release MTPJ
- tendon transferred medial, plantar and laterally around P1
- sutured to abductor digit minimi
Underriding fifth toe
Opposite deformity of above
Thompson excisional arthroplasty
- Z incision laterally over P1
- proximal phalanx resection and capsule imbrication
- K wire
Cock Up Deformity
Deformity
- of MTP
- realign at MTPJ & IPJ
- usually hammer toe deformity as well
Surgical Algorithm
Mild to moderate
- extensor tenotomy & fixed hammer toe repair
Severe
- Ruiz-Mora procedure
- resection arthroplasty of proximal phalanx
- elliptical plantar incision with proximal phalyngectomy
Salvage
- end up with floppy toe
- syndactylisation may be salvage
- but swapping one deformity for another