claw toe
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toe
[to]
claw toe
Management Conservative, tendon resection, joint resection
claw toe
(klaw tō)toes
lesser toes (LT) and hallux (great toe) see Table 1absent toe congenital/traumatic/surgical toe loss, with resultant pathomechanical forefoot shape changes and overall foot dysfunction
claw toe mobile/fixed LT sagittal plane deformity, characterized by proximal phalanx dorsiflexion at metatarsophalangeal joint, intermediate phalanx plantarflexion at proximal interphalangeal joint, distal phalanx plantarflexion at distal interphalangeal joint, with weight-bearing apex and nail-free margin (weight-bearing dorsal nail plate in severe cases)
curly toe mobile, transverse-plane LT deformity, characterized by abduction of proximal phalanx, neutral intermediate phalanx and adduction of distal phalanx (in relation to intermediate phalanx)
flexed toe fixed congenital sagittal-plane LT deformity, characterized by plantarflexion of proximal and distal interphalangeal joints, contracture of plantar soft tissues of toe, and weight-bearing dorsal nail plate and eponychium
hammer toe symptomatic/non-symptomatic, fixed/mobile sagittal-plane LT deformity characterized by dorsiflexion of proximal phalanx at metatarsophalangeal joint, plantarflexion of intermediate phalanx relative to proximal phalanx and (variably) neutral, dorsiflexion or plantarflexion of distal phalanx relative to intermediate phalanx; associated metatarsal head may become plantarflexed and load-bearing due to pressure from dorsal orientation of base of proximal phalanx; associated with hallux abductovalgus, local trauma, pathology of associated metatarsal head (e.g. Freiberg's disease), inflammatory joint disease (e.g. rheumatoid arthritis) or congenital malformation; typical associated hyperkeratotic lesions include apical and dorsal interphalangeal joint lesions (callosity/corn formation), nail pathologies (onychauxis, onychophosis, subungual corn/callosity), plantar hyperkeratotic lesions of associated metatarsophalangeal joints, metatarsalgia secondary to subluxation of associated metatarsophalangeal joint
lesser toes; LTs all toes other than hallux
mallet toe fixed (e.g. joint pathology)/flexible (e.g. soft-tissue contracture) sagittal plane LT deformity characterized by neutral proximal phalanx at metatarsophalangeal joint, neutral position of intermediate phalanx at proximal interphalangeal joint, marked plantarflexion of distal phalanx at distal interphalangeal joint, weight-bearing at apex, free nail margin and sometimes dorsal nail plate; leads to apical corn/callosity, subungual corn formation and local nail hypertrophy
retracted toe mobile/fixed sagittal-plane LT deformity, characterized by dorsiflexion of proximal phalanx at metatarsophalangeal joint, plantarflexion/neutral intermediate phalanx at proximal interphalangeal joint, plantarflexion/neutral distal phalanx at distal interphalangeal joint; neither apex nor pulp is weight-bearing
sausage toe; dactylitis acute sero-negative inflammatory arthropathy affecting joints of one toe in patients with psoriasis; characterized by generalized soft-tissue inflammation (swelling, heat, redness and pain) in affected toe, characteristic erosions and/or new bone formation around affected joints, 'pencil in cup' metatarsophalangeal joint and interphalangeal joint formation and phalangeal resorption (see Table 2)
tennis toe chronic traumatic toenail injury leading to subungual haematoma and/or nail plate hypertrophy, caused by rapid pivotal movements of the toe against shoe box; also seen in netball players and joggers
trigger toe mobile/fixed sagittal-plane first-ray deformity characterized by plantarflexion of first metatarsal head (i.e. plantarflexed metatarsal), dorsiflexion of hallux proximal phalanx relative to support surface, and plantarflexion of distal phalanx relative to orientation of proximal phalanx; medial apex of hallux and free margin may become weight-bearing
turf toe episode of hallux limitus/rigidus caused by direct trauma/stubbing hallux; characterized by local inflammation, first metatarsophalangeal joint pain especially on movement, hallux plantarflexion at first metatarsophalangeal joint and protective spasm of flexor hallucis brevis muscle; treated by RICE(P) (see Table 3), non-steroidal anti-inflammatory drugs, rest (using soft splintage and/or fan strapping; see Table 4) and orthoses as necessary
valgus toe rotational transverse LT deformity characterized by abduction and external rotation (pronation) of proximal phalanx, neutral intermediate phalanx and abduction and external rotation (pronation) of distal phalanx in relation to intermediate phalanx; medial pulp and nail fold area are weight-bearing
varus toe rotational, transverse LT deformity characterized by abduction and supination of proximal phalanx, neutral intermediate phalanx, adduction and supination of distal in relation to intermediate phalanx, with weight-bearing of lateral nail fold and lateral area of nail plate; toe is prone to Durlacher's corn at lateral sulcus (secondary to pressure and friction of transverse-plane movement occurring at toe off)
Deformity | Clinical features |
Hammer toe | Sagittal-plane deformity • Hyperextension at MTPJ • Hyperflexion at PIPJ • Hyperextension/neutral/flexion at DIPJ |
Mallet toe | Sagittal-plane deformity • Neutral MTPJ • Neutral PIPJ • Hyperflexion at DIPJ • Apical skin weight-bearing |
Clawed toe | Sagittal-plane deformity • Hyperextension at MTPJ • Hyperflexion at PIPJ • Hyperflexion at DIPJ • Apical skin weight-bearing |
Hyperflexed toe | Sagittal-plane deformity • Hyperextension at MTPJ • Hyperflexion at PIPJ • Hyperflexion at DIPJ • Dorsum of nail and terminal segment bearing |
Retracted toe | Sagittal-plane deformity • Hyperextension at MTPJ • Hyperflexion at PIPJ • Hyperflexion at DIPJ • Apical skin non-weight-bearing |
Curly toe | Transverse-plane deformity • Adduction/neutral or abduction at MTPJ • Adduction at PIPJ • Adduction at DIPJ |
Varus toe (adductovarus toe) | Transverse and frontal-plane deformity • Abduction ± inversion of digit at MTPJ, or neutral MTPJ • Adduction or neutral at PIPJ • Adduction at DIPJ • ± Frontal plane (inversion) rotation of terminal segment of digit |
Valgus toe (abductovalgus toe) | Transverse and frontal-plane deformity • Adduction ± eversion of digit at MTPJ, or neutral MTPJ • Abduction or neutral at PIPJ • Abduction at DIPJ • ± Frontal plane (eversion) rotation of terminal segment of digit |
Overriding toe | Sagittal and transverse-plane deformity • Adduction and extension at MTPJ • Neutral PIPJ • Neutral DIPJ |
Underriding toe | Sagittal and transverse-plane deformity • Abduction and flexion at MTPJ • Neutral PIPJ • Neutral DIPJ |
The main types of lesser-toe deformity (LTD) are listed in this table; some presenting LTDs may show the features of more than one type. LTDs may be fixed (due to joint pathology) or flexible (due to soft-tissue contracture). LTDs may characterize neurological and skeletomuscular diseases, hallux abductovalgus, hallux limitus/rigidus, compensation for excess pronation at the subtalar and midtarsal joint, and pathomechanical anomalies in the foot and lower limb. Hyperkeratotic skin lesions develop in areas of exposed digital or interdigital skin that are subject to excess pressure and/or friction, as the result of the toe deformity and shoe trauma. MTPJ, metatarsophalangeal joint; PIPJ, proximal interphalangeal joint; DIPJ, distal interphalangeal joint. |
Feature | Comment |
Leukocyte antigen type | 90% of patients with sero-negative arthritis test positive for human leukocyte antigen (HLA) B27 |
Skeletal involvement | Axial skeleton/spinal involvement; with back pain (common presenting first symptom) |
Enthesopathy | Inflammation at insertions of ligaments/tendons (posterior calcaneum, plantar calcaneum, base of fifth metatarsal, forefoot) |
Soft-tissue swellings | Localized swelling at Achilles tendon insertion Bursitis of congenital/adventitious bursae |
Synovitis | Dactylitis/'sausage' toe Generalized swelling of fore foot |
Vasculitis | Note: Does not tend to affect foot in sero-negative arthritides |
Radiographs | Bone/periosteal fluffy/'whiskery' proliferation New bone/spur formation at entheses, secondary to inflammation |
RICE(P) | Feature |
R Rest | The patient is advised to reduce/abstain from weight-bearing on the affected foot/limb until all symptoms subside Joint immobilization is achieved by:
|
I Ice packs | The application of ice within 48-72 hours of the initial injury/onset of symptoms, to reduce swelling, minimize pain and control inflammation Ice (cubes wrapped in a towel; packet of frozen peas; cool pack) is applied at least twice a day Ice is not indicated >72 hours after injury; patients should be advised to apply gentle heat twice a day (immersion in water bath at 45°C for 10 minutes, infrared lamp, hot-water bottle) |
C Compression | Compression bandaging (crepe bandage; Coban, 'figure of eight') controls soft-tissue oedema and reduces unwanted movement |
E Elevation | The limb should be fully supported along its length, with the heel of the foot above hip height to minimize oedema |
P Pain control | Rest, ice (or heat), compression and elevation all help minimize pain, reduce inflammation and oedema |
Non-steroidal anti-inflammatory drugs (e.g. 400 mg ibuprofen every 4 hours, or equivalent for 5 days) both reduce inflammation and control pain |
Strapping | Application |
Church door | Three lengths of strapping applied around the periphery of a pad, as a triangle |
Goal post | Four lengths of strapping applied around the periphery of a pad, as a rectangle |
Shiplap | Several lengths of strapping that are applied transversely across the pad from proximal to distal so that each subsequent strap overlaps the previous by one-third |
Fan | Several lengths of strapping that are applied longitudinally across a joint (to form a soft splint), so that one end of each subsequent strap overlies the previous strap but the other end lies adjacent to the previous strap, so that the whole assemblage resembles a fan |
Top strap | The distal transverse bar of goal post strapping, whose distal margin is shaped to reflect the line of the plantar webbing, allowing maximum plantar adhesion but minimal restriction of the toes |
Flask | A strap cut to the shape of a bottle or flask, so that the 'neck' is applied to the pad, and the 'belly' to the skin |
Banana | A strap cut into the shape of a banana |
Bow/false plantar fascia | Lengths of strapping applied longitudinally along the sole of the foot from the heel to the plantar web line Figure 1 |
Mask | Several layers of strapping laid one on another with a central hole cut to match the size of a lesion Figure 2 |
Stirrup | Lengths of strapping applied to the ankle/subtalar joint area, applied from the medial to lateral malleolus (for a medial ankle sprain) or from the lateral to medial malleolus (for a lateral ankle sprain) |
Metatarsal | Strapping applied transversely across the plantar and dorsal surfaces of the forefoot to restrict metatarsal movement |
Note: To aid retention, strapping should always be cut to create a smooth outline (e.g. corners are rounded) and applied firmly allowing for digital movement - unless the intention is to provide a soft splint to rest the part. |
