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Duke Orthopaedics
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Wheeless' Textbook of Orthopaedics

Claw Toes


- See:
      - Hallux Claw Toe
      - Hammer Toes
      - Muscles of Foot
      - Polio: Claw Toes

- Anatomy and Discussion:
    - claw toe consists of hyperextension at the metatarsophalangeal joint, and flexion at the proximal (and distal interphalangeal joints);
           - all of the toes are usually affected, although contracture of the great toe can be the most severe;
           - there is an imbalance between the extrinsic extensor tendons (which indirectly extend the MP joint and the intrinsics which flex the MP joint);
    - claw toes result from simultaneous contraction of extensors & flexors with weak or insufficient intrinsic muscles;
           - hyperextension deformity of the MP joint is caused by excessive relative pull of the extensor tendons;
           - PIP hyperflexion is caused by excessive pull of the long flexors;
    - hyperextension of the MT joints and flexion of the IP joints, are common features of a neuropathic clawfoot or pes cavus;
    - dorsiflexion of the MP joint causes the metatarsal fat pad to be pulled distally through its attachments to the proximal phalanx;
    - flexed IP joints are constantly irritated by shoe, & painful metatarsal callosities develop;
    - deformity will become permanent;
    - diff dx:
          - hammer toes
                 - characteristics include: MPT joints extended, flexed at the PIP joint, and hyperextended at the distal interphalangeal joint;
                 - in contrast to hammer toes which may or may not have MPT joint hyper-extension, a claw toe is always associated w/ MTP hyperextension;
    - inciting conditions:
          - rheumatoid arthritis
          - advanced age (decreased muscle tone and reliance of toe gripping for balance)
          - diabetes
          - compartment syndrome involving deep posterior compartment;
          - polio: claw toes:
          - Charcot Marie Tooth
          - stroke
          - cavus foot
                 - when the claw toe deformities are associated with a cavus deformity, tarsal deformity should be corrected first, since clawing of toes may correct spontaneously;


- Exam:
    - note presence of pes cavus deformity;
    - determine degree of MTP hyperextension and PIP flexion;
    - note presence of metatarsalgia w/ associated skin changes (plantar keratosis);
    - determine whether claw toes are flexible or fixed;
         - assess flexibility of toes w/ ankle in plantar flexion and dorsiflexion;
               - if the claw toe deformity disappears w/ plantar flexion then the deformity is considered flexible;
         - apply pressure underneath the metatarsal heads and note degree of correction;
    - assessment during gait:
         - note whether the clawing becomes worse during gait (stance phase vs swing phase);
         - clawing during swing phase: may indicate weak ankle dorsiflexors and over-compensation of toe extensors;
         - clawing during stance phase: may indicate weak triceps surae and over-compensation of long toe flexors;

- Radiographs:
    - subluxation is indicated on AP radiographs by narrowing of the apparent joint space (which occurs from the overlap of the proximal phalanx over the metatarsal;


- Non Operative Treatment:
    - includes corn padding, soft metatarsal pads (when metatarsalgia is present), & shoe w/ high, wide toe box, often succeeds;


- Flexible Claw Toes:
    - implies that there is no contraction of MTP or PIP joints;
    - Girdlestone-Taylor Procedure:
           - indicated for flexible claw toes w/ dorsally subluxated MP joints;
           - transfers long flexor to extensor hood over proximal phalanx) is performed along with extensor tenotomies and dorsal capsulodesis of MTP;
    - clawed hallux:
           - authors carried out a cross-sectional study in 51 patients (81 feet) with a clawed hallux in association with a cavus foot after a modified Robert Jones tendon transfer;
           - in all feet, concomitant procedures had been undertaken, such as extension osteotomy of the first metatarsal and transfer of the tendon of the peroneus longus to peroneus brevis, to correct the underlying foot deformity;
           - overall rate of patient satisfaction was 86%, and the deformity of the hallux was corrected in 80 feet;
           - catching of the big toe when walking barefoot, transfer lesions and metatarsalgia, hallux flexus, hallux limitus and asymptomatic nonunion of the interphalangeal joint were the most frequent complications;
           - hallux limitus was more likely when elevation of the first ray occurred (p = 0.012);
           - additional transfer of the tendon of peroneus longus to peroneus brevis was a significant risk factor for elevation of the first metatarsal (p < 0.0001);
           - deforming force of extensor hallucis longus is effectively eliminated by the Jones transfer, but the mechanics of the first metatarsophalangeal joint are altered;
           - ref: Function after correction of a clawed great toe by a modified Robert Jones transfer.   


- Fixed Claw Toe Deformity:
    - inform pt that toe ischemia sometimes follows correction of severe deformity;
    - w/ neurologic disorder such as Charcot Marie Tooth disease, consider transfer of the long extensors to the neck of  metatarsals along with fusion of the PIP joints;
    - MTP Joint Subluxation:
           - often associated with metatarsalgia;
           - once MP joint is dislocated, result is never entirely satisfactory, & joint is always slightly stiff;
           - contracted extensor tendons (which are the main deforming force) may have to be tenotomized to allow correction of dorsal subluxation of MP joints;
                 - first extend EDL, then EDB;
           - if MP joint is still extended, then release collateral ligaments;
           - note that reduction of MP joint, may cause ischemia of the digit, due to stretching of the N/V bundle across contracted soft tissues;
                 - hence, toe cannot be relocated w/o bone resection;
           - shortening at base of proximal phalanx;
                 - resection of base of proximal phalanx may lead to instability, which is may require syndactylization to an adjacent toe;
           - shortening at metatarsal head;
                 - resect bone from or distal metatarsal head shaving or partial resection of distal portion of metatarsal head alone;
                 - joint should immobilized for three to four weeks postoperatively;
    - PIP Deformity:
           - deformity at PIP joint is best treated w/ resection arthroplasty, removing distal one third of proximal phalanx;
           - arthrodesis is indicated only in the presence of severe or recurrent deformity, or when associated w/ neurologic disturbance of forefoot;
                 - when performing arthrodesis of the interphalangeal joint, toe should be slightly plantarflexed, because this position is better tolerated than a stiff straight toe



The pathological anatomy of claw and hammer toes

The treatment of clawtoes by multiple transfers of flexor into extensor tendons.   

Subluxation and dislocation of the second metatarsophalangeal joint.  

Modified Resection Arthroplasty for Infected Non-healing Ulcers with Toe Deformity in Diabetic Patients

Flexor Hallucis Longus Tendon Transfer for Hallux Claw Toe Deformity and Vertical Instability of the Metatarsophalangeal Joint 

Muscular Imbalances Resulting in a Clawed Hallux

Comparison of the Results of the Weil and Helal Osteotomies for the Treatment of Metatarsalgia Secondary to Dislocation of the Lesser Metatarsophalangeal Joints

Reversal of toe clawing in the patient with neuropathy by neurolysis of the distal tibial nerve.



Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Wednesday, September 5, 2012 10:32 am