Primary care physicians frequently see infants, children, and adolescents with abnormalities involving the toes. Typically, it is parental concern that brings youngsters with these conditions to medical attention. Regardless of the motivation for the office visit, however, a basic familiarity with the most common toe deformities in young patients can help you decide whether to manage the problem yourself or refer the patient for further evaluation and possible surgery.
Not all toe problems are serious or require surgical intervention. Some are primarily cosmetic; others may cause pain, lead to abnormal shoe wear, or produce functional impairment. It is, therefore, important to understand the cause, natural history, methods of evaluation, indications for treatment, and options for treatment of these various conditions.
Pediatric toe problems are classified according to whether they involve the great toe or the lesser toes. In this article, we will outline the key points in recognizing important disorders in both categories. Then we will describe the most frequently employed corrective measures, emphasizing when surgery can be avoided and when surgical referral is necessary. To enhance the practical value of the article, most of the conditions are illustrated, either grossly or roentgenographically or in both ways.
THE GREAT TOE
Problems commonly affecting the great toe in the young patient include bunions, ingrown toenails, subungual exostoses, and congenital hallux varus.
A hallux valgus deformity, or bunion, is the lateral displacement of the great toe resulting from mal-alignment with the first metatarsal head. Although no statistics are available, bunions are common in adolescents. They are usually bilateral, are more common in girls, and tend to run in families.
Bunions in adolescents are qualitatively different from those that develop in adults. In the young patient, the deformity is less severe, the medial eminence of the metatarsal head is not as prominent, and there is no osteoarthrosis of the metatarsophalangeal joint.
Bunions have both intrinsic and extrinsic causes. Intrinsic factors associated with bunion development include metatarsus primus varus (an angulation of the first metatarsal bone toward the midline of the body), an oblique articulation between the first metatarsal and the medial cuneiform bone, a long first metatarsal bone, and generalized ligamentous laxity with foot pronation (flat feet). Extrinsic factors include the wearing of shoes with narrow toe boxes and elevated heels and the presence of neurologic disorders, such as cerebral palsy, that may present in a subtle manner.
Recognition. Medical help for bunions is usually sought during early adolescence. Complaints include pain over the medial aspect of the first metatarsophalangeal joint, difficulty in finding appropriate shoes, and concerns about cosmetic appearance. In the evaluation, determine whether the pain is related to activity or to the wearing of shoes and ascertain the effect of the pain on function. In particular, look for shoes that are too narrow or that have high heels.
In the physical examination, assess alignment of the great toe and the foot under weight-bearing conditions and with the patient walking barefoot. Note also the mobility of the first metatarsophalangeal joint and the presence or absence of calluses. In addition, determine the range of motion of all joints of the foot and identify areas of pain and tenderness.
A careful neurologic examination is also performed to assess for a subtle neurologic deficit. This examination should include testing of muscle strength, sensation, deep tendon reflexes, and pathologic reflexes (Babinski’s reflex).
Roentgenographic evaluation is necessary to confirm the diagnosis and document the severity of the deformity. Obtain anteropostenor and lateral films under weight-bearing conditions. In addition to assessing the standard joint angles, the alignment of the first metatarsal-medial cuneiform joint and the length of the first metatarsal bone need to be evaluated. The degree of pesplanus is assessed on the lateral view.
Management. An integral aspect of management is an open discussion of the patient’s (and the parents’) concerns about the deformity and realistic expectations from treatment. Nonoperative treatment with shoe modifications can usually relieve symptoms but will not correct the deformity. Wide-toed shoes with low heels are recommended. For pes planus, an orthotic device that restores the medial longitudinal arch may be beneficial.
The efficacy of most nonoperative approaches to hallux valgus in adolescents is limited by poor compliance. It may be difficult to get the teenage patient to wear shoes that are not deemed stylish or to cooperate in the use of an orthotic device.
Surgical treatment is indicated when nonoperative treatment, such as shoe modification for 6 to 12 months, has failed or the deformity progresses. Concern over cosmetic appearance alone is not an indication for surgery because the operated foot rarely achieves normal appearance. The goals of surgery are to relieve pain, restore articular congruency of the first ray joints, and improve alignment.
There is no standard surgical procedure for bunions in adolescents. The severity of the deformity, as determined by the hallux valgus angle, is the general guide for appropriate operation. An angle of less than 25° is considered a mild deformity, an angle between 25° and 40° is a moderate deformity, and an angle greater than 40° is a severe deformity. The intermetatarsal angle is used as a general guide for selection of the appropriate operation.
In adolescents, mild and moderate deformities occur more commonly than severe deformities. They are usually corrected by some type of first-metatarsal osteotomy combined with a distal soft-tissue procedure. Medial cuneiform osteotomy or metatarsal cuneiform arthrodesis, in combination with distal soft-tissue realignment, is reserved for severe deformities. Satisfactory result is achieved in 80% of patients.
Corrective surgery is seldom necessary on an urgent basis, and it should be delayed until early adolescence because the recurrence rate is higher in young children. Complications following bunion surgery are common and include recurrent deformity, hallux varus, pronation deformity, and pain. Recurrence of the deformity is the most common.
A benign bone tumor of the distal phalanx, a subungual exostosis appears as a cartilage-capped reactive bone spur. It develops beneath or adjacent to the toenail. The great toe is the most common site, but it can also occur on the lesser toes. The cause may be trauma to the fibro cartilaginous tuft of the distal phalanx. Subungual exostosis may be distinguished clinically from an osteochonctroma by the fact that the latter occurs proximally on the phalanx. The two lesions are similar histologically.
Recognition. The lesion is usually painful and may simulate an ingrown toenail. On physical examination, a firm mass is palpable under the toenail. Roentgenographic evaluation will demonstrate the lesion, especially in the lateral view.
Management. There is no effective nonoperative treatment for subungual exostosis. The procedure of choice involves excision of the lesion and repair of the nail bed. The recurrence rate is low – approximately 10%. Surgery should be done as soon as the diagnosis has been confirmed to avoid excessive damage to the nail or nail bed. This is performed under general anesthesia in an outpatient setting. The nail bed usually heals within 1 to 2 weeks and the nail re-grows within several months.
This lesion is common, especially in adolescents. The lateral border of the great toe is the most common site. Some nail shape abnormalities are associated with ingrown toenail, but a causal relationship is not certain. Persons with elevated lateral nail margins may be at lower risk for this problem. Ingrown toenail may be preventable or rendered less likely by proper toenail cutting: the nail should be trimmed straight across.
Recognition. Pain is a common complaint, especially when wearing shoes. On physical examination, the toe appears irritated and may be secondarily infected. Hypertrophic granulation tissue is common. There is no need for roentgenographic evaluation.
Management. For infants and young children, nonoperative treatment is usually effective. It includes shoe modification, warm soaks, topical antibiotics, nail-edge elevation, and proper nail-cutting technique. Shoe modification includes avoidance of shoes with a narrow toe box that would put increased compression over the medial margin of the nail. Warm soaks for 15 minutes two or three times a day will decrease inflammation. Occasionally, topical or oral antibiotics may be necessary, if there is an associated cellulitis.
It is important that the ingrown part of the nail be removed from the soft tissue so that it no longer acts as a foreign body. This is usually done with a nail cleaner. Once the ingrown toenail has resolved, cutting the toenail square rather than rounding it on the medial and lateral borders helps prevent recurrence.
When surgery is necessary, wedge resection of the involved nail border (including the matrix) is the procedure of choice. It is performed in an outpatient setting under general anesthesia. A digital block can also be considered, but this requires a mature patient; this procedure is usually performed in a hospital. Nail bed cauterization with phenol during surgery may lower the recurrence rate in adolescents. This step is not necessary in infants and young children.
Congenital hallux varus
This deformity involves a varus or medial angulation of the great toe associated with partial duplication of the first metatarsal. It is present at birth and is not associated with metatarsus adductus.
Recognition. Congenital hallux yams is diagnosed on clinical evaluation and confirmed radiographically. Clinically, there may be a tight band over the medial aspect of the forefoot that appears to tether the great toe in its medially deviated position. The great toe frequently will appear short and broad. Radiographs will confirm the partial duplication of the first metatarsal. Occasionally, there will be only a short, broad first metatarsal.
Management. This deformity causes shoe fitting problems and, for this reason, treatment is indicated. Nonoperative management is ineffective. Surgical treatment is usually delayed until the infant is 9 to 12 months of age, so that the extent of the anatomic abnormalities can be accurately recognized and treated.
THE LESSER TOES
Some common problems of the lesser toes in the young patient include curly toe, hammer toe, overlapping fifth toe, mallet toe, claw toe, polydactyly, syndactyly, congenital constriction band syndrome, and macrodactyly.
One of the most common lesser toe problems, curly toe is a flexion deformity of the proximal interphalangeal joint with lateral rotation and varus alignment of the toe. It is usually familial. The deformity is caused by congenital contracture of the flexor digitorum longus and brevis muscles.
Recognition. Curling is bilateral and symmetric Most children with curly toe will be asymptomatic when first seen. The deformity is usually recognized by parents, or it may be seen on a routine examination. The third and fourth toes are most frequently involved. The contractures can be demonstrated with a simple maneuver: passive dorsiflexion of the foot increases the curling while plantar flexion diminishes it.
While initially the lesion is painless and the foot flexible, the deformity eventually becomes painful and renders the foot stiff. Corns or calluses may develop. Roentgenographic evaluation is not needed for diagnosis.
Management. The deformity in infants and young children should simply be observed over time, because approximately 25% to 50% of curly toes will improve with growth. Nonoperative treatment by splinting or taping is usually ineffective. Pain at any age and moderate or severe deformities in a young child are indications for operative treatment.
Open release (tenotomy) of the flexor digitorum longus and flexor digitorum brevis tendons is the procedure of choice. Partial improvement can be seen immediately after surgery; further correction occurs with growth. Good to excellent results are achieved in 95% of patients. Unsatisfactory outcomes are usually the result of poor surgical technique.
This abnormality is similar to curly toe, but without malrotation of the digit. There is a flexion deformity of the proximal interphalangeal joint, with or without flexion at the distal interphalangeal joint.
Recognition. Hammer toe is usually bilateral and symmetric, and the second toe is most frequently affected. A long metatarsal bone is a commonly associated finding.
During the physical examination, the deformity can be relieved (temporarily) by passive plantar flexion of the foot. Success of this maneuver indicates tight flexor digitorum muscles. As the metatarsophalangeal joint becomes hyperextended, the metatarsal head can appear to be depressed.
Although asymptomatic initially, the deformity may cause the toe to stiffen by adolescence. Painful corns may develop over the dorsum of the proximal interphalangeal joint. Roentgenographic evaluation is not needed.
Management. Nonoperative treatment, such as passive stretching and taping, is rarely successful, even in infants and young children. The indications for operative treatment are severe deformity and such symptoms as pain and nail bed irritation. The procedure of choice is open release (tenotomy) of the flexor digitorum longus and possibly the flexor digitorum brevis tendons. Surgery can be performed at any age provided the appropriate indications are met. However, symptoms usually are not present until late childhood and early adolescence.
Satisfactory results are obtained in 95% of operated toes. Unsatisfactory results are due to poor surgical technique. After skeletal maturation, the deformity may become rigid, making arthroplasty or arthrodesis of the involved joint the treatment of choice.
Overlapping fifth toe
In this condition, the fifth toe is extended and adducted, dorsally overriding the fourth toe. There is an extension contracture of the metatarsophalangeal joint, and the toe is adducted and externally rotated. The deformity is a result of a shortened and medially displaced extensor digitorum longus tendon. It is familial and commonly bilateral.
Recognition. The diagnosis is essentially visual. On physical examination, it is possible to passively correct the deformity, but normal anatomy will not be maintained. Roentgenographic evaluation is not needed.
The deformity in young children is usually asymptomatic. Concerns in this age group are mainly cosmetic. Up to 50% of patients, however, will have pain over the dorsum of the fifth toe in adolescence.
Management. Symptomatic patients are treated operatively. Nonoperative treatment is ineffective. The surgical approach includes tenotomy of the extensor digitorum longus tendon and release of the dorsal metatarsophalangeal joint capsule (Butler’s operation). Good results are achieved in most patients.
This is a flexion deformity of the distal interphalangeal joint. The second toe is most commonly affected. The condition is associated with a long second metatarsal bone and the abnormality is the result of a shortened flexor digitorum brevis muscle.
Recognition. Diagnosis is visual, and the condition by itself may not cause symptoms. Dorsal corns or toenail irritation, however, may become bothersome, especially during adolescence. Roentgenographic evaluation is not needed.
Management. Symptomatic relief can be achieved by callosity shaving or use of pads inside shoes, but only operative treatment will correct the deformity. Operative correction is obtained by release of the flexor digitorum longus tendon. Occasionally, arthroplasty is necessary in order to correct rigid deformities.
The components of claw toe deformity are extension contracture of the metatarsophalangeal joint and flexion deformity of the proximal interphalangeal joint. Occasionally, there may also be flexion deformity of the distal interphalangeal joint. All four lesser toes are usually involved. Pes cavus is a common associated finding.
Imbalance between the intrinsic and extrinsic foot muscles is the cause of claw toe. The deformity may be idiopathic, but it is commonly caused by an underlying neurologic disorder, such as Charcot-Marie-Tooth disease, or by sequelae of deep posterior compartment syndrome.
Recognition. Diagnosis is visual. The patient is usually asymptomatic but may have metatarsalgia due to depression of the metatarsal heads into the plantar aspect of the foot. Corns on the dorsal aspect of the proximal interphalangeal joints can result from shoe rubbing. Roentgenographic evaluation of the feet, with weight-bearing anteroposterior and lateral views, is necessary for diagnosis.
Management. Nonoperative approaches may be tried first. The aim of nonoperative treatment is to redistribute pressure away from the metatarsal heads. Orthotic devices and corrective shoes with an adequate toe box can be used to support the foot.
Operative treatment is recommended for progressive and severe deformities. The goal of operative treatment is to achieve a relatively normal-appearing foot with balanced musculature. This allows comfortable shoe wear and maximizes function. Flexible toe deformities are corrected by soft-tissue releases and tendon transfers. Correction of more rigid deformities, especially in adolescents, requires bone procedures, such as osteotomies, as well.
Supernumerary toes are found in approximately 3 per 1,000 live births and are more common in blacks than whites. Polydactyly is usually an isolated disorder with an autosomal dominant inheritance. Approximately 30% of patients have a positive family history for this abnormality.
Polydactyly of the feet can be associated with polydactyly of the hands and with metatarsal disorders. It is classified as preaxial (involving the great toe), central (involving the second, third, and fourth toes), or postaxial (involving the fifth toe). Seventy-nine percent of supernumerary toes are postaxial, 15% are preaxial, and only 6% are central. Thus, 85% involve the lesser toes.
The deformity can be further divided into articulated (type A) and rudimentary (type B). The first are more complex and have an articulation of the metatarsal and the duplicated toe; these frequently have common neurovascular structures that must be preserved. Rudimentary deformities have only a small skin tag and no structural stability.
Recognition. Usually, the diagnosis is obvious on inspection. The deformity can cause pain, create difficulties when wearing shoes, and impair cosmetic appearance. Anteroposterior and lateral roentgenographic views of both feet under weight-bearing conditions (or under simulated weight-bearing conditions for the younger patient) are needed for accurate evaluation.
Management. The treatment of polydactyly is surgical. Distinguishing between rudimentary and articulated duplication and assessing any accompanying metatarsal abnormalities are essential steps in treatment planning. Rudimentary toes can be ligated at birth and allowed to undergo autoamputation.
Articulated digits require excision and reconstruction when the patient is approximately 1 year old. This includes saving the digit with best axial alignment, capsular repair, and soft-tissue balancing. Any metatarsal anomalies can be repaired simultaneously. The long-term functional results of operative treatment are satisfactory, although the foot and toes may not appear entirely normal.
Persistence of the webbing between adjacent toes is a common failure-of-separation deformity that may be familial. There are two types of deformity: zygosyndactyly and polysyndactyly. In the former, there is complete or incomplete webbing, usually between the second and third toes. In the latter, there is duplication of the fifth toe, with syndactyly between the duplicated toes, and sometimes between the fourth toe and the duplicated toes as well.
Recognition. The distinction between zygosyndactyly and polysyndactyly is usually made on clinical examination by both the appearance of the toes and the location. Radiographs are necessary to rule out an associated metatarsal duplication or other abnormality.
Management. Zygosyndactyly is almost never symptomatic and should not be treated. Polysyndactyly usually necessitates operative treatment, which is similar to the treatment of polydactyly. Surgery is usually delayed until the patient is 1 year old. The results of operative treatment are usually good, enabling the forefoot to be more narrow and helping the patient avoid shoe wear problems.
Congenital constriction band syndrome
This manifestation of defective postembryonic development is a result of early amniotic rupture. Temporary oligohydramnios leads to intrauterine fetal compression and subsequent constriction of fetal appendages by cords or bands of the torn amnion. Toe involvement is common and includes amputations, hypoplasia, and acrosyndactyly (the fusion of the terminal portions of digits, with clefts or sinuses between the proximal phalanges). Other musculoskeletal abnormalities that occur with this syndrome include clubfoot, pseudarthrosis, peripheral nerve palsy, and limb-length discrepancy.
Recognition. Diagnosis is visual, and symptomatology depends on the precise nature of the lesion. A 4group clinical classification exists for this syndrome: simple (superficial) ring constriction, ring constriction accompanied by distal part deformities with or without lymphedema, ring constriction accompanied by distal fusion, and intrauterine amputation.
Management. The goal of treatment for constriction band syndrome is to achieve a functional limb. Bands causing distal lymphedema may be considered for surgical excision and Z-plasty closure. Toe deformities usually do not need operative treatment.
THE PRIMARY CARE ROLE
The primary care physician is in an ideal position to identify the problems of toes in infants, children, and adolescents. This can be done during routine evaluations of asymptomatic patients or in response to the question of a concerned parent who sees something that looks unusual.
The primary care physician can also provide nonoperative management, refer for possible surgery at the appropriate time, and observe for progressive deformity and functional loss that may indicate the need for surgery sooner rather than later. The primary care physician is also in an ideal position to educate and reassure patients and families about the nature of the problem and its correction.