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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
Hallux Valgus
Treatment:
In adolescence : conservative due to high recurrence rate (20 to 40%)
wear shoes with deep toe-boxes, soft upper & lower heels
if deformity progresses, then corrective osteotomy
In adults :
Excision of bunion
Metatarsal osteotomy & soft tissue rebalancing
If first metatarso-phalangeal joint is frankly osteoarthritic, arthrodesis
of joint may be a better option
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. If the
joint starts to stiffen, walking can become painful and difficult.
Ends of the bones are covered by a smooth articular cartilage > wear-and-
tear or injury damage the articular cartilage, the raw bone ends can rub
together > bone spur, or overgrowth, 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
Hallux Rigidus
Symptoms
Pain in the joint when you are active, especially as you push-off on the toes
when you walk
Swelling around the joint
A bump, like a bunion or callus, 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, as well as the degree of
degeneration in the joint space and cartilage
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 - fusing the bones together (damaged cartilage is removed and
pins, screws, or a plate are used to fix the joint in a permanent position > the
bones grow together) - not be able to bend the toe
Arthroplasty - joint replacement surgery (joint surfaces are removed >
artificial joint is implanted) - relieve pain and preserve joint motion
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
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, rheumatoid arthritis,
stroke, Charcot-Marie-Tooth disease
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
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.
Sometimes your toes also bend downward at the top joints, curling under the
foot.
Corns may develop over the top of the toe or under the ball of the foot.
Claw Toe
Clinical Features:
Pain in forefoot & under metatarsal heads
Bilateral
Restricted walking
Initially, the joints are mobile & can be passively corrected; 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
Treatment:
If toe can be passively straightened, may obtain relief by wearing a
metatarsal support
If toe cannot be passively straightened, dynamic correction is
achieved by transferring long toe flexor to extensor
If fixed deformity, either accepted & accommodated by special
footwear or treated by interphalangeal joint arthrodesis combined
with tendon transfer
Mallet Toe
Detached or avulsed insertion of extensor tendon to distal
interphalangeal joint of toe
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 - greater or lesser degree
Metatarso-phalangeal joints : hyperextension
Interphalangeal joints : flexion
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