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Deformities of the Great

Toes

Hallux Valgus
• In those who have never worn shoes, big toe is in line with the first
metatarsus, retaining the slightly fan-shaped appearance of the forefoot
• In those who habitually wear shoes,
the hallus assumes a valgus
position & is only referred as
hallus valgus when the angulation
if excessive
• Hallux Valgus Angle :
- Intersection of longitudinal axis of 1st MT
& proximal phalanx
- Normal < 15 degree
• Intermetatarsal Angle :
- Intersection of 1st & 2nd MT
- Normal < 9 degree

Hallux Valgus • Metatarsus primus varus may be :  congenital  loss of muscle tone in forefoot in the elderly  common in rheumatoid arthritis • Lateral deviation & rotation of hallux. together with hypertrophy (exostosis) of medial part of metartasal head & overlying bursa which together form a prominent bump or (‘bunion’) on the medial side • Lateral deviation of hallux may lead to overcrowding & sometimes overriding of lateral toes .

Hallux Valgus Clinical Features: • Common in women 50-70 • Usually bilateral • Those with strong family history tendency appears during late adolescence • Often there is no symptom • If pain present may be due to :  shoe pressure on large or an inflamed bunion  splaying of forefoot & muscle strain (metatarsalgia)  associated deformities of the lesser toes  secondary osteoarthritis of first metatarso-phalangeal joint .

Hallux Valgus X-ray Findings: • Standing position to show degree of first metatarsus & hallux angulation • The first metatarsal-phalangeal joint may be subluxated or it may look osteoarthritic .

arthrodesis of joint may be a better option . soft upper & lower heels • if deformity progresses.Hallux Valgus Treatment: In adolescence : conservative due to high recurrence rate (20 to 40%) • wear shoes with deep toe-boxes. then corrective osteotomy In adults : • Excision of bunion • Metatarsal osteotomy & soft tissue rebalancing • If first metatarso-phalangeal joint is frankly osteoarthritic.

the raw bone ends can rub together > bone spur. If the joint starts to stiffen.Hallux Rigidus • Arthritis in the foot is at the base of the big toe (metatarsophalangeal joint) • It's important because it has to bend every time you take a step. may develop on the top of the bone > overgrowth can prevent the toe from bending as much as it needs to when you walk > hallux rigidus . • Ends of the bones are covered by a smooth articular cartilage > wear-and- tear or injury damage the articular cartilage. walking can become painful and difficult. or overgrowth.

like a bunion or callus. especially as you push-off on the toes when you walk • Swelling around the joint • A bump. as well as the degree of degeneration in the joint space and cartilage . that develops on the top of the foot • Stiffness in the great toe and an inability to bend it up or down Investigation • Physicians examine your foot > look for evidence of bone spurs > move the toe around to see how much motion is possible without pain > x-rays will show the location and size of any bone spurs.Hallux Rigidus Symptoms • Pain in the joint when you are active.

joint replacement surgery (joint surfaces are removed > artificial joint is implanted) .relieve pain and preserve joint motion .fusing the bones together (damaged cartilage is removed and pins. or a plate are used to fix the joint in a permanent position > the bones grow together) .Hallux Rigidus Treatment • Simple pain killers > stronger pain killers or anti-inflammatory medicines > injecting some steroid mixed with local anaesthetic into the joint • Cheilectomy .removing the bone spurs as well as a portion of the foot bone > toe has more room to bend • Arthrodesis . screws.not be able to bend the toe • Arthroplasty .

Deformities of the Lesser Toes .

Hammer Toe • Isolated flexion deformity of proximal interphalangeal joint with hyperextension of metatarso-phalangeal joint of second or third toe • Distal interphalangeal joint is straight or pulled into hyperextension • May produce a painful corn on dorsally projecting proximal interphalangeal joint when wearing covered shoes .

stroke.Hammer Toe Causes: • Wearing poorly-fit shoes that can force the toe into a bent position as in high-heeled shoes • Toes bent for long time cause intrinsic muscles to shorten • Can also be seen in diabetes mellitus. osteoarthritis. Charcot-Marie-Tooth disease . rheumatoid arthritis.

Hammer Toe Treatment: • Operative correction is indicated for pain or for difficulty with wearing shoes • Toe is shortened & straightened by excising the joint then fusing the proximal & middle phalanges • Alternative treatment is to fix toe in straight position with Kirschner wire .

Claw Toe • All toes can be affected to greater or lesser degree • Metatarso-phalangeal joints are hyperextended & interphalangeal joints are flexed • If all toes are involved. maybe associated with pes cavus or some other cause of intrinsic muscle insufficiency .

curling under the foot. • Corns may develop over the top of the toe or under the ball of the foot. • Sometimes your toes also bend downward at the top joints.Claw Toe Symptoms • Your toes are bent upward (extension) from the joints at the ball of the foot. . • Your toes are bent downward (flexion) at the middle joints toward the sole of your shoe.

later deformities become fixed & metatarso-phalangeal joints subluxed or dislocated • Painful corns & callosities develop • In very severe cases. skin ulcerates at press sites .Claw Toe Clinical Features: • Pain in forefoot & under metatarsal heads • Bilateral • Restricted walking • Initially. the joints are mobile & can be passively corrected.

dynamic correction is achieved by transferring long toe flexor to extensor • If fixed deformity. may obtain relief by wearing a metatarsal support • If toe cannot be passively straightened. either accepted & accommodated by special footwear or treated by interphalangeal joint arthrodesis combined with tendon transfer .Claw Toe Treatment: • If toe can be passively straightened.

Mallet Toe • Detached or avulsed insertion of extensor tendon to distal interphalangeal joint of toe .

greater or lesser degree  Metatarso-phalangeal joints : hyperextension  Interphalangeal joints : flexion .Hammer Toe vs Claw Toe Hammer Toe  Second or third toe  Metatarso-phalangeal joint : hyperextension  Proximal interphalangeal joint : flexion  Distal interphalangeal joint : straight/hyperextension Claw Toe  All toes can be affected .

Hammer Toe vs Mallet Toe Hammer Toe  Second or third toe  Metatarso-phalangeal joint : hyperextension  Proximal interphalangeal joint : flexion  Distal interphalangeal joint : straight/hyperextension Mallet Toe  Detached or avulsed insertion of extensor tendon to distal interphalangeal joint of toe .