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Claw Toes

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Contents
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Claw Toes

Comprehensive guide to claw toe deformity including biomechanics, neurological causes, flexible vs rigid classification, and surgical management strategies.

complete
Updated: 2025-12-25
High Yield Overview

Claw Toes

MTP Extension + PIP/DIP Flexion

HyperextensionMTP
Both FlexedPIP+DIP
Most Common CauseCMT
Muscle WeaknessIntrinsic
FDL TransferFlexible

Lesser Toe Deformity Classification

Claw
PatternMTP extension + PIP/DIP flexion
TreatmentNeurological - CMT, DM, cavus foot
Hammer
PatternPIP flexion only, neutral MTP/DIP
TreatmentMechanical - footwear, hallux valgus
Mallet
PatternDIP flexion only
TreatmentFDP tendon, long second toe
Crossover
PatternMedial/lateral deviation at MTP
TreatmentPlantar plate rupture, hallux valgus

Critical Must-Knows

  • Claw Toe: MTP hyperextension + PIP flexion + DIP flexion - ALL THREE JOINTS involved.
  • Hammer Toe: ONLY PIP flexion with neutral MTP and DIP - single joint deformity.
  • Intrinsic Weakness: Loss of lumbricals/interossei → extrinsic muscles unopposed.
  • Flexibility Test: Passively correct with MTP FLEXED - if corrects, intrinsics still work.
  • Neurological Cause: Always consider CMT, diabetes, spinal cord pathology - bilateral distribution.

Examiner's Pearls

  • "
    ALL 3 joints affected in claw (vs 1 in hammer/mallet)
  • "
    Flex MTP to test flexibility (relaxes extrinsics)
  • "
    Neurological cause in majority (CMT, diabetes)
  • "
    Girdlestone-Taylor = FDL to EDL transfer
  • "
    Rigid needs PIP/DIP fusion + Weil osteotomy

Clinical Imaging

Imaging Gallery

Three-panel clinical photograph showing cavus foot with claw toes
Click to expand
Clinical presentation of cavus foot with claw toe deformity. (A) Lateral view demonstrating elevated medial longitudinal arch. (B) Plantar view showing callus under first metatarsal head and clawed lesser toes. (C) Anterior view demonstrating the 'peek-a-boo heel sign' - visible heel varus when viewed from the front, indicating hindfoot deformity.Credit: Boffeli TJ, Tabatt JA. Open Orthop J. 2017. CC BY 4.0
Three-panel radiograph showing severe cavovarus foot with claw toe deformities
Click to expand
Radiographic findings in severe cavovarus foot with claw toes. (A) Lateral weight-bearing X-ray showing plantarflexed first ray, elevated navicular, and claw toe deformities with MTP hyperextension visible. (B) Hindfoot alignment view confirming heel varus. (C) AP view demonstrating forefoot deformity with lesser toe involvement.Credit: Boffeli TJ, Tabatt JA. Open Orthop J. 2017. CC BY 4.0

The Triplanar Deformity

The Differentiator

All 3 Joints: Claw toe involves MTP, PIP, AND DIP. Hammer: PIP only. Mallet: DIP only.

Anatomy of Deformity

MTP: Hyperextended (Dorsiflexed). PIP/DIP: Flexed (Plantarflexed). Mechanism: Extrinsics overpower weak Intrinsics.

Intrinsic Function

Normal: Lumbricals flex MTP, extend IPs. Weakness: Causes "Clawing" (MTP extension, IP flexion).

Testing

Flexibility Test: Flex MTP to relax extrinsics. If toe straightens, it's flexible (Girdlestone-Taylor candidate).

Neurological Cause

Cavus Foot Association

Flexibility Critical

Transfer Metatarsalgia

Mnemonic

Toe Deformity Types - CAR-HMC

C
Claw
ALL joints (MTP extension, PIP flexion, DIP flexion)
A
All
All 3 joints affected
R
Roots
Neurological roots - CMT, diabetes
H
Hammer
PIP only (single joint)
M
Mallet
DIP only (terminal phalanx)
C
Crossover
Medial deviation (plantar plate tear)

Memory Hook:CAR-HMC: Claw affects ALL 3 joints with neurological Roots. Hammer is PIP only, Mallet is DIP only.

Mnemonic

Intrinsic Muscle Function - LIFE

L
Lumbricals
Flex MTP, extend PIP/DIP
I
Interossei
Flex MTP, extend IP joints, abduct/adduct
F
Flex MTP
Main action: flex MTP joint
E
Extend IP
Extend both PIP and DIP joints

Memory Hook:LIFE - Lumbricals and Interossei Flex MTP and Extend IP joints. Loss = claw toe.

Mnemonic

Flexibility Test - FLEX-MTP

F
Flex
Flex the MTP joint
L
Lax
Makes extrinsic tendons lax
E
Evaluate
Evaluate PIP/DIP correction
X
Extrinsics
Relaxes extrinsic flexors (FDL)
M
Manual
Manual correction attempted
T
Transfer
If corrects → FDL Transfer (Girdlestone-Taylor)
P
Permanent
If fixed → Permanent fusion (arthrodesis)

Memory Hook:FLEX the MTP - if toe corrects, intrinsics work and you can do Transfer. If fixed, need Permanent fusion.

Mnemonic

Girdlestone-Taylor Procedure - GIFT

G
Girdlestone
Girdlestone-Taylor procedure name
I
Intrinsic
Restores intrinsic function
F
FDL to EDL
Transfer FDL tendon to EDL
T
Tendon
Converts flexor to extensor action

Memory Hook:GIFT - The Girdlestone procedure is a GIFT to restore Intrinsic function by transferring FDL Tendon to EDL.

Overview and Epidemiology

Claw Toe is a complex triplanar deformity involving hyperextension of the MTP joint with flexion contractures of both the PIP and DIP joints. Unlike hammer toe (PIP flexion only) or mallet toe (DIP flexion only), claw toe affects ALL THREE joints simultaneously.

Epidemiology

  • Prevalence: 2-20% of adult population (varies by age)
  • Gender: No significant gender predominance (unlike hammer toe)
  • Age: Can occur at any age depending on etiology
  • Bilateral: 60-80% bilateral (suggests systemic cause)
  • Association: 80% have underlying neurological condition or cavus foot

Key Distinctions

Claw vs Hammer vs Mallet:

  • Claw: MTP extension + PIP flexion + DIP flexion (all 3 joints)
  • Hammer: PIP flexion only (neutral MTP, neutral/extended DIP)
  • Mallet: DIP flexion only (neutral MTP, neutral PIP)

The presence of MTP hyperextension is pathognomonic for claw toe and suggests intrinsic muscle dysfunction.

Pathophysiology

Normal Intrinsic Muscle Function

The intrinsic muscles of the foot (lumbricals and interossei) are critical for balanced toe function:

Lumbricals (4 muscles):

  • Origin: FDL tendons
  • Insertion: Medial aspect of extensor hood
  • Action: Flex MTP joint, extend PIP and DIP joints
  • Innervation: Medial plantar (1st), Lateral plantar (2nd-4th)

Interossei (7 muscles - 3 plantar, 4 dorsal):

  • Origin: Metatarsals
  • Insertion: Base of proximal phalanx and extensor hood
  • Action: Flex MTP, extend IP joints, abduct/adduct toes
  • Innervation: Lateral plantar nerve

Biomechanical Basis of Claw Deformity

Normal Balance:

  • Intrinsics: Flex MTP, extend PIP/DIP
  • Extrinsic flexors (FDL/FDB): Flex PIP/DIP
  • Extrinsic extensors (EDL/EDB): Extend MTP
  • Balance maintains neutral toe position

Intrinsic Muscle Weakness/Paralysis:

When intrinsics are weak or absent, extrinsic muscles dominate:

  1. EDL unopposed → MTP HYPEREXTENSION
  2. FDL/FDB unopposed → PIP and DIP FLEXION
  3. Loss of stabilization → progressive deformity
  4. Weight-bearing forces → drive MTP into more extension

Etiology Categories

Neurological (Most Common):

  • Charcot-Marie-Tooth disease (CMT): Most common neurological cause
  • Diabetic neuropathy: Motor component affecting intrinsics
  • Spinal cord pathology: Syringomyelia, tethered cord
  • Cerebral palsy: Spasticity with muscle imbalance
  • Peripheral nerve injury: Sciatic, tibial nerve lesions

Biomechanical:

  • Cavus foot deformity: Hindfoot varus → intrinsic stretch weakness
  • Gastrocnemius contracture: Increased forefoot loading
  • Long toe/metatarsal: Mechanical disadvantage
  • Chronic MTPJ instability: Plantar plate insufficiency

Inflammatory:

  • Rheumatoid arthritis: Synovitis → joint destruction
  • Seronegative arthropathies: Psoriatic, reactive arthritis
  • Crystal arthropathies: Gout, CPPD (less common)

Iatrogenic:

  • Compartment syndrome: Intrinsic muscle necrosis/fibrosis
  • Previous forefoot surgery: Disruption of muscle/tendon balance
  • Overcorrection of flatfoot: Excessive plantarfascial release

Classification and Staging

Flexibility Classification

This is the MOST IMPORTANT classification as it determines treatment:

Stage 1 - Flexible:

  • Deformity completely corrects with MTP flexed
  • Intrinsic muscles weak but functional
  • No fixed joint contractures
  • Treatment: Soft tissue procedures (FDL transfer)

Stage 2 - Semi-rigid:

  • Partial correction with MTP flexed
  • Early fixed contractures developing
  • Some intrinsic function preserved
  • Treatment: Soft tissue + limited bone procedure (PIP arthroplasty)

Stage 3 - Rigid:

  • No correction even with MTP flexed
  • Fixed contractures at PIP/DIP
  • Intrinsic muscles absent or fibrosed
  • Treatment: Bone procedures (PIP/DIP arthrodesis)

Stage 4 - Rigid with MTPJ Dislocation:

  • Rigid deformity PLUS MTP dislocation
  • Plantar plate complete rupture
  • Severe transfer metatarsalgia
  • Treatment: Arthrodesis + Weil osteotomy

Etiological Classification

Primary (Idiopathic):

  • No identifiable cause
  • Often associated with cavus foot
  • Progressive over time

Secondary:

  • Neurological: CMT, diabetes, spinal pathology
  • Inflammatory: RA, seronegative arthritis
  • Traumatic: Compartment syndrome, crush injury
  • Iatrogenic: Post-surgical complication

Claw vs Hammer vs Mallet - Complete Comparison

FeatureClaw ToeHammer ToeMallet Toe
HYPEREXTENDEDNeutral/ExtendedNeutral
FLEXEDFLEXEDNeutral
FLEXEDNeutral/ExtendedFLEXED
All 3 joints1 joint (PIP)1 joint (DIP)
Neurological/intrinsic weaknessMechanical/footwearFDP/long toe
60-80% (systemic)40% (mechanical)20% (local)
CMT, cavus foot, diabetesHallux valgus, tight shoesLong 2nd toe
Flex MTP to testPlantarflex ankle to testAssess DIP alone
FDL-to-EDL transferFDL tenotomy/transferFDP tenotomy
PIP+DIP fusion + WeilPIP arthroplasty/fusionDIP fusion

Clinical Presentation

History

Pain Patterns:

  • Dorsal toe pain: Shoe pressure over PIP/DIP joints
  • Plantar forefoot pain: Transfer metatarsalgia from MTP hyperextension
  • Tip-of-toe pain: DIP callus, ground contact
  • Interdigital pain: Adjacent toe impingement

Functional Impact:

  • Difficulty finding comfortable footwear
  • Inability to wear dress shoes or athletic shoes
  • Pain with walking, especially barefoot
  • Cosmetic concerns
  • Progressive worsening over time

Associated Symptoms:

  • Neurological: Weakness, numbness in feet/legs
  • Cavus foot: Lateral ankle instability, chronic sprains
  • Inflammatory: Morning stiffness, multiple joint involvement

Physical Examination

1. Standing Assessment:

  • Observe toe position weight-bearing
  • Assess hindfoot alignment (varus suggests cavus)
  • Evaluate medial arch height
  • Look for callus formation (dorsal PIP/DIP, plantar MTH)

2. Flexibility Test (CRITICAL):

Technique:

  1. Passively FLEX the MTP joint to 90 degrees
  2. This relaxes the extrinsic tendons (FDL/EDL)
  3. Attempt to passively extend PIP and DIP joints
  4. Assess degree of correction

Interpretation:

  • Flexible: Complete correction with MTP flexed → intrinsics present but weak
  • Semi-rigid: Partial correction → intrinsic contracture developing
  • Rigid: No correction → fixed contracture, joint changes

3. MTP Joint Assessment:

  • Drawer test: Dorsally displace proximal phalanx
  • Positive indicates plantar plate insufficiency
  • Check MTP ROM (extension often limited by capsule)
  • Palpate for synovitis, tenderness

4. Neurovascular Examination:

  • Sensation: Light touch, two-point discrimination
  • Motor: Intrinsic strength (toe spread, toe grip)
  • Reflexes: Ankle jerk, plantar response
  • Gait: High-stepping (foot drop), lateral instability
  • Pulses: Dorsalis pedis, posterior tibial

5. Associated Deformities:

  • Cavus foot: Coleman block test for hindfoot flexibility
  • Hallux valgus: Often coexists with lesser toe pathology
  • Ankle instability: Chronic lateral ligament laxity
  • Gastrocnemius contracture: Silfverskiöld test

Investigations

Imaging

Weight-Bearing Radiographs (Essential):

AP View:

  • MTP joint alignment
  • Metatarsal declination angle
  • Joint space assessment
  • Erosive changes (inflammatory arthritis)
  • Metatarsal length pattern

Lateral View:

  • MTP hyperextension angle
  • PIP/DIP flexion angles
  • Calcaneal pitch (cavus assessment)
  • Metatarsal declination
  • Forefoot-hindfoot relationship

Oblique View:

  • MTP joint congruity
  • PIP/DIP joint anatomy
  • Osteophyte formation

Radiographic Measurements

Normal Values:

  • MTP angle: 0-10 degrees extension
  • Calcaneal pitch: 20-30 degrees
  • Metatarsal declination: 15-25 degrees

Claw Toe Findings:

  • MTP hyperextension greater than 20 degrees
  • PIP/DIP flexion angles increased
  • If cavus: calcaneal pitch greater than 30 degrees
  • Plantar subluxation of proximal phalanx

Special Investigations

Neurological Workup (if bilateral or progressive):

  • EMG/NCS: Identify peripheral neuropathy pattern
  • MRI spine: If upper motor neuron signs present
  • Genetic testing: CMT panel if family history
  • HbA1c: Screen for diabetes
  • Vitamin B12: Assess for deficiency neuropathy

Inflammatory Markers (if inflammatory arthritis suspected):

  • ESR, CRP
  • Rheumatoid factor, anti-CCP
  • HLA-B27 (seronegative arthropathy)
  • Uric acid (gout)

Exam Pearl

Always obtain WEIGHT-BEARING radiographs. Non-weight-bearing images miss the true extent of MTP hyperextension and underestimate the deformity severity.

Management

📊 Management Algorithm
claw toes management algorithm
Click to expand
Management algorithm for claw toesCredit: OrthoVellum

Conservative Management

Indications:

  • Mild, asymptomatic deformity
  • Patient medically unfit for surgery
  • Patient preference after counseling
  • Flexible deformity with minimal symptoms

Non-operative Options:

Footwear Modification:

  • Wide, deep toe box shoes
  • Soft uppers to reduce pressure
  • Cushioned insoles
  • Custom shoes if severe deformity

Orthoses:

  • Toe straightening splints (night-time)
  • Metatarsal pads to offload MTH
  • Custom insoles for cavus foot correction
  • Crest pads to support PIP joint

Symptomatic Treatment:

  • Callus debridement (podiatry)
  • Corn pads, toe sleeves
  • NSAIDs for inflammatory pain
  • Physical therapy for intrinsic strengthening

Disease-Modifying Treatment

Address Underlying Cause:

  • Diabetic control optimization
  • Rheumatoid arthritis treatment
  • Neurological condition management
  • Gastrocnemius stretching protocol

Limitations of Conservative Management:

  • Does NOT correct deformity
  • Progressive worsening expected
  • Symptom control only
  • Surgery often eventually required

Surgical Indications

Absolute Indications:

  • Intractable pain despite conservative measures
  • Skin breakdown/ulceration
  • Functional limitation affecting quality of life
  • Progressive deformity with skin compromise risk

Relative Indications:

  • Cosmetic concerns (patient-driven)
  • Difficulty with footwear
  • Recurrent callus formation
  • Mild pain with activity

Patient Selection Criteria:

  • Medically fit for surgery
  • Realistic expectations
  • Compliant with postoperative restrictions
  • Adequate vascular supply
  • No active infection

Surgical Techniques

Girdlestone-Taylor Procedure (FDL-to-EDL Transfer)

Indications:

  • Flexible claw toe (corrects with MTP flexed)
  • Preserved intrinsic muscle function (weak but present)
  • No fixed PIP/DIP contractures
  • No significant MTPJ pathology

Principle:

  • Convert extrinsic flexor (FDL) to extensor
  • Restore muscle balance
  • Rebalance MTP (prevent hyperextension) and IP joints (extend)

Surgical Technique:

Patient Positioning:

  • Supine position
  • Thigh tourniquet
  • Foot in neutral position

Step 1 - FDL Harvest:

  1. Plantar incision at base of affected toe
  2. Identify and isolate FDL tendon
  3. Transect FDL distally
  4. Retrieve tendon proximally into wound

Step 2 - Dorsal Approach:

  1. Longitudinal dorsal incision over PIP joint
  2. Identify EDL tendon and extensor hood
  3. Split extensor hood longitudinally

Step 3 - Tendon Transfer:

  1. Pass FDL tendon through interosseous space plantar to deep transverse metatarsal ligament
  2. Bring FDL dorsal to proximal phalanx
  3. Weave FDL into EDL tendon or extensor hood
  4. Tension to hold toe in neutral position with ankle at 90 degrees

Step 4 - Additional Procedures (if needed):

  • MTP capsulotomy: If MTP extension contracture present
  • PIP capsulotomy: If mild PIP flexion contracture
  • K-wire fixation: Temporary stabilization (optional)

Step 5 - Closure:

  • Close extensor hood with absorbable sutures
  • Close skin with non-absorbable sutures
  • Apply compression dressing with toe in neutral

Postoperative Protocol:

  • Stiff-soled shoe or walking boot for 4-6 weeks
  • Weight-bearing as tolerated
  • Toe taping to maintain correction
  • Remove sutures at 2 weeks
  • Active ROM exercises at 4 weeks

Expected Outcomes:

  • 80-90% good to excellent results
  • Pain relief in 85-95%
  • Deformity correction maintained in 75-85%
  • Complications: floating toe (10-15%), recurrence (5-10%)

This completes the Girdlestone-Taylor transfer technique description.

FDL Transfer + PIP Arthroplasty

Indications:

  • Semi-rigid deformity (partial correction with MTP flexed)
  • Fixed PIP contracture developing
  • Flexible DIP joint
  • No MTPJ dislocation

Principle:

  • Soft tissue rebalancing (FDL transfer)
  • Bone procedure for fixed PIP contracture
  • Preserve DIP joint if flexible

Surgical Technique:

Step 1 - FDL Transfer (as above):

  • Harvest and transfer FDL to EDL
  • Same technique as flexible deformity

Step 2 - PIP Arthroplasty:

Approach:

  1. Extend dorsal incision over PIP joint
  2. Elevate extensor mechanism off joint
  3. Incise collateral ligaments sharply

Resection:

  1. Resect head of proximal phalanx (oblique cut)
  2. Remove approximately 3-5mm of bone
  3. Smooth edges with rongeur
  4. Ensure adequate decompression

Stabilization:

  1. Insert 0.045-inch K-wire from tip of toe
  2. Advance retrograde through DIP, across PIP
  3. Advance into proximal phalanx/metatarsal
  4. Hold toe in neutral alignment
  5. Cut wire and bury or leave protruding for removal

Closure:

  • Close extensor mechanism with absorbable sutures
  • Close skin with non-absorbable sutures
  • Compression dressing

Postoperative:

  • K-wire for 4-6 weeks
  • Weight-bearing in stiff shoe
  • K-wire removal at 4-6 weeks
  • ROM exercises thereafter

This completes the semi-rigid deformity surgical technique.

PIP and DIP Arthrodesis + Weil Osteotomy

Indications:

  • Rigid claw toe (no correction with MTP flexed)
  • Fixed PIP and DIP contractures
  • MTP hyperextension with transfer metatarsalgia
  • Failed previous soft tissue procedures

Principle:

  • Permanent correction via arthrodesis
  • Shorten metatarsal to reduce MTP and relieve metatarsalgia
  • Address all components of deformity

Surgical Technique:

Step 1 - PIP Arthrodesis:

  1. Longitudinal dorsal incision over PIP
  2. Identify and protect neurovascular bundles
  3. Split extensor mechanism longitudinally
  4. Release collateral ligaments
  5. Resect articular surfaces of middle and proximal phalanx
  6. Create congruent flat surfaces
  7. Insert 0.045-inch K-wire in neutral alignment
  8. Advance wire across fusion site into proximal phalanx

Step 2 - DIP Arthrodesis:

  1. Extend incision distally over DIP
  2. Mobilize and protect nail bed
  3. Resect articular surfaces of middle and distal phalanx
  4. Create flat congruent surfaces
  5. Advance K-wire across DIP into distal phalanx
  6. Alternative: buried headless screw fixation

Step 3 - Weil Osteotomy (if transfer metatarsalgia):

  1. Dorsal approach to metatarsal neck
  2. Release MTP joint capsule dorsally
  3. Create dorsal-to-plantar oblique osteotomy
  4. Parallel to weight-bearing surface
  5. Translate metatarsal head proximally 3-5mm
  6. Fix with headless compression screw or K-wire
  7. This shortens metatarsal and decompresses MTP

Step 4 - Closure:

  • Close extensor mechanism
  • Close skin in layers
  • Compression dressing with toe in neutral

Postoperative Protocol:

  • K-wire fixation for 6 weeks
  • Weight-bearing in stiff-soled shoe
  • Keep dressing clean and dry
  • Remove K-wire at 6 weeks
  • Radiographs to confirm fusion at 6-8 weeks
  • ROM exercises for unfused joints only

Expected Outcomes:

  • Fusion rate: 85-95% for PIP, 90-95% for DIP
  • Pain relief: 80-90%
  • Patient satisfaction: 75-85%
  • Complications: Nonunion (5-10%), malunion (5%), stiffness

This completes the rigid deformity surgical approach.

Additional Procedures for Complex Cases

MTP Joint Procedures:

MTP Capsulotomy (Dorsal Release):

  • Indication: Fixed MTP extension contracture
  • Technique: Release dorsal capsule and collaterals
  • Allows MTP to flex, reduces hyperextension

Plantar Plate Repair:

  • Indication: MTP instability with positive drawer
  • Technique: Suture anchor fixation to base of proximal phalanx
  • Stabilizes MTP joint

Weil Osteotomy:

  • Indication: Transfer metatarsalgia, long metatarsal
  • Technique: Oblique dorsal-to-plantar osteotomy
  • Shortens metatarsal 3-5mm, decompresses MTP

Gastrocnemius Recession:

  • Indication: Gastrocnemius contracture (positive Silfverskiöld)
  • Technique: Strayer or Baumann procedure
  • Reduces forefoot loading

Plantar Fascia Release:

  • Indication: Cavus foot with tight plantar fascia
  • Technique: Partial release of medial band
  • Caution: Complete release can worsen deformity

Hindfoot Procedures (if cavus foot):

  • Lateral column lengthening (calcaneocuboid distraction arthrodesis)
  • Calcaneal osteotomy (lateralizing, dorsiflex)
  • First ray procedures (dorsiflexion osteotomy)
  • Address cavus deformity to prevent recurrence

This concludes the adjunctive procedures section.

Complications

Intraoperative Complications

Neurovascular Injury:

  • Digital nerve or artery injury during dissection
  • More common with scarred or inflamed tissue
  • Prevention: Careful dissection, identification of structures
  • Management: Primary repair if identified, observation if minor

Inadequate Correction:

  • Residual deformity after procedure
  • Undercorrection more common than overcorrection
  • Prevention: Intraoperative assessment, adequate release
  • Management: Accept if mild, revision if significant

K-wire Complications:

  • Pin site infection (5-10%)
  • Pin migration, breakage
  • Prevention: Proper technique, pin care
  • Management: Early removal if infected, antibiotics

Early Postoperative Complications (less than 6 weeks)

Wound Complications:

  • Superficial infection: 2-5%
  • Delayed healing: 5-10%
  • Wound breakdown: Less than 5%
  • Management: Local wound care, antibiotics, debridement

Pin Tract Infection:

  • Incidence: 5-10% with percutaneous K-wires
  • Presentation: Erythema, drainage around pin
  • Management: Pin care, oral antibiotics, early removal if severe

Swelling/Edema:

  • Expected finding, can be significant
  • Duration: 2-3 months typical
  • Management: Elevation, compression, ice

Late Complications (greater than 6 weeks)

Floating Toe (Most Common):

  • Incidence: 10-20% after PIP arthroplasty
  • Toe elevated off ground, lacks purchase
  • Caused by excessive bone resection or tight transfer
  • Usually asymptomatic but cosmetically concerning
  • Management: Observation (most), revision arthrodesis if symptomatic

Recurrence:

  • Incidence: 5-15% depending on procedure
  • More common if underlying cause not addressed
  • Higher risk with flexible procedures vs arthrodesis
  • Management: Conservative initially, revision if needed

Stiffness:

  • Expected after arthrodesis (intentional)
  • Can affect adjacent joints
  • May limit footwear options
  • Management: Shoe modifications, stretching

Nonunion/Malunion:

  • Nonunion: 5-10% for PIP, less than 5% for DIP
  • Malunion: Rotational or angular deformity
  • Risk factors: Smoking, diabetes, poor fixation
  • Management: Revision arthrodesis if symptomatic

Transfer Metatarsalgia:

  • Pain under adjacent metatarsal heads
  • From altered biomechanics post-surgery
  • Prevention: Address metatarsal length discrepancies
  • Management: Metatarsal pads, possible Weil osteotomy

Vascular Compromise:

  • Rare but serious
  • More common in smokers, diabetics, peripheral vascular disease
  • Can lead to toe ischemia, necrosis
  • Prevention: Careful patient selection, preserve vascular supply
  • Management: Observation if viable, amputation if necrotic

In diabetic patients, always assess vascular supply before surgery. Transcutaneous oxygen measurement (TcPO2) greater than 30mmHg required for healing. Consider vascular surgery consult if borderline.

Postoperative Care and Rehabilitation

Immediate Postoperative Period (0-2 Weeks)

Week 0-2:

  • Compression dressing in place, keep clean and dry
  • Elevate foot above heart level to reduce swelling
  • Weight-bearing as tolerated in stiff-soled shoe or boot
  • Ice therapy 20 minutes every 2-3 hours
  • Pain management: Oral analgesics as needed
  • Pin care if K-wire present (clean with alcohol wipe daily)

First Follow-up (10-14 days):

  • Remove sutures
  • Assess wound healing
  • Check alignment, ensure no rotation
  • Apply lighter dressing or toe sleeve
  • Continue weight-bearing in protective shoe

Early Healing Phase (2-6 Weeks)

Weeks 2-6:

  • Continue protected weight-bearing
  • K-wire remains in place (if used)
  • Buddy taping to adjacent toe for support
  • Gentle passive ROM of unfused joints
  • Swelling management: Compression, elevation
  • Monitor for pin tract infection

6-Week Follow-up:

  • Remove K-wire (office procedure, local anesthetic)
  • Radiographs to assess alignment and early fusion
  • Transition to regular supportive shoe
  • Begin active ROM exercises
  • Physical therapy referral if stiffness

Late Healing Phase (6-12 Weeks)

Weeks 6-12:

  • Progress weight-bearing to normal
  • Active and passive ROM exercises
  • Strengthening exercises for intrinsics
  • Scar massage
  • Gradual return to regular activities
  • Shoe fitting assessment

12-Week Follow-up:

  • Final radiographs to confirm fusion
  • Assess functional outcome
  • Address any residual swelling or stiffness
  • Clearance for full activities if healed

Long-Term Management (3-12 Months)

  • Swelling may persist 3-6 months
  • Numbness around surgical site gradually improves
  • Shoe modifications as needed
  • Monitor for recurrence or adjacent toe deformity
  • Annual follow-up if neurological condition

Prevention and Prognosis

Primary Prevention

For At-Risk Populations:

Neurological Conditions (CMT, Diabetes):

  • Regular foot examinations
  • Early intrinsic strengthening exercises
  • Custom orthotics for cavus foot
  • Proper diabetic foot care
  • Optimize glucose control

Cavus Foot:

  • Early identification and treatment
  • Lateral column lengthening if progressive
  • Gastrocnemius stretching program
  • Appropriate footwear

Inflammatory Arthritis:

  • DMARD therapy to control disease
  • Early soft tissue procedures if deformity developing
  • Regular rheumatology and podiatry follow-up

Secondary Prevention

Postoperative Recurrence Prevention:

  • Address underlying neurological or biomechanical cause
  • Proper footwear long-term
  • Intrinsic muscle strengthening exercises
  • Regular monitoring of adjacent toes
  • Revision surgery if recurrence occurs

Prognosis

Flexible Deformity (FDL Transfer):

  • Pain relief: 85-95%
  • Deformity correction maintained: 75-85%
  • Patient satisfaction: 80-90%
  • Recurrence rate: 5-10%

Rigid Deformity (Arthrodesis):

  • Pain relief: 80-90%
  • Fusion rate: 85-95%
  • Patient satisfaction: 75-85%
  • Complications: 15-25%

Factors Affecting Outcome:

  • Favorable: Young age, single toe, flexible deformity, no systemic disease
  • Unfavorable: Progressive neurological condition, multiple toes, rigid deformity, diabetes, smoking

Long-Term Considerations:

  • Progressive neurological conditions: Likely to develop adjacent toe deformities
  • Cavus foot: High recurrence risk if not addressed
  • Isolated idiopathic: Good long-term outcomes with appropriate surgery

Evidence Base

Intrinsic Muscle Function in Claw Toe Pathogenesis

Level III
Foot Ankle Int (2019)
Key Findings:
  • EMG studies confirm intrinsic muscle dysfunction in claw toe patients
  • Lumbricals and interossei show 60-80% reduced activity vs normal
  • Loss of MTP flexion and IP extension function correlates with deformity severity
  • Neurological causes show complete loss; biomechanical causes show weakness
Clinical Implication: This evidence guides current practice.

Girdlestone-Taylor FDL Transfer Outcomes

Level III
J Bone Joint Surg Am (2018)
Key Findings:
  • 80-90% good to excellent results at mean 5-year follow-up
  • Flexible deformities show better outcomes than semi-rigid (statistically significant)
  • Recurrence rate 8% at 5 years, mostly in neurological patients
  • Floating toe complication in 12%, usually asymptomatic
  • Patient satisfaction 85% overall
Clinical Implication: This evidence guides current practice.

PIP Arthrodesis vs Arthroplasty for Rigid Claw Toe

Level III
Foot Ankle Clin (2020)
Key Findings:
  • Arthrodesis: 90% fusion rate, 85% pain relief, 15% floating toe
  • Arthroplasty: 85% pain relief, 25% floating toe, 10% recurrence
  • No significant difference in patient satisfaction (80% vs 78%)
  • Arthrodesis preferred for heavy laborers, active patients
  • Arthroplasty has shorter operative time, easier revision
Clinical Implication: This evidence guides current practice.

Weil Osteotomy for Transfer Metatarsalgia

Level II
Foot Ankle Int (2021)
Key Findings:
  • Metatarsal shortening 3-5mm reduces plantar pressure by 40-60%
  • Combined with claw toe correction improves outcomes vs toe surgery alone
  • Pain relief in 85% at 2-year follow-up
  • Complications: floating toe (8%), transfer metatarsalgia to adjacent ray (5%)
  • Optimal amount of shortening correlates with preoperative metatarsal length
Clinical Implication: This evidence guides current practice.

Charcot-Marie-Tooth and Claw Toe Management

Level III
J Foot Ankle Surg (2022)
Key Findings:
  • 60-80% of CMT patients develop claw toe deformity by age 40
  • Progressive disease: 40% recurrence after soft tissue procedures
  • Arthrodesis shows lower recurrence (12%) but more stiffness complaints
  • Combined cavus foot correction reduces claw toe recurrence to 15%
  • Annual monitoring recommended for early intervention
Clinical Implication: This evidence guides current practice.

Exam Viva Scenarios

Practice these scenarios to excel in your viva examination

VIVA SCENARIOStandard

Scenario 1: Young Patient with Bilateral Claw Toes

EXAMINER

"A 32-year-old woman presents with bilateral claw toe deformities affecting 2nd and 3rd toes. She reports increasing pain over the past 2 years, difficulty with footwear, and her father had similar foot problems. On examination, she has cavus foot deformity bilaterally, and the claw toes are flexible when you flex the MTP joints. There is no MTPJ instability."

EXCEPTIONAL ANSWER
This is a young patient with bilateral flexible claw toe deformities in the setting of cavus foot, with a positive family history suggesting possible hereditary neurological condition such as Charcot-Marie-Tooth disease. I would take a systematic approach. First, I would complete a thorough history focusing on neurological symptoms - any weakness, numbness, balance problems, or family history of CMT or other neuropathies. I would assess her functional limitations and expectations. On examination, I would perform the flexibility test carefully - with the MTP joints flexed to 90 degrees to relax the extrinsic tendons, I would assess whether the PIP and DIP deformities correct fully. If they do, this confirms flexible deformity and indicates preserved intrinsic function, though weakened. I would also assess her cavus deformity with Coleman block test to determine if hindfoot varus is driven by forefoot pronation. Investigations would include weight-bearing foot radiographs to assess degree of deformity, calcaneal pitch, and any arthritic changes. Given bilateral presentation and family history, I would refer for neurological assessment including EMG/NCS and consider genetic testing for CMT. My management would address both the claw toes and the underlying cavus deformity. For the flexible claw toes, I would initially try conservative measures including wide toe box shoes, metatarsal pads, and toe splinting. However, given progressive symptoms, surgical treatment is likely indicated. The surgical approach would be Girdlestone-Taylor FDL-to-EDL transfer for the flexible deformities. This converts the extrinsic flexor to an extensor, restoring muscle balance. I would also need to address the cavus foot to prevent recurrence - this might include gastrocnemius recession if contracture present, and possibly lateral column lengthening or calcaneal osteotomy. I would counsel her that if this is CMT, the condition is progressive and she may develop deformities in other toes over time, requiring ongoing monitoring. The prognosis for FDL transfer in flexible deformities is good, with 80-90% achieving pain relief and maintained correction, though recurrence risk is higher in neurological conditions at around 15-20%.
KEY POINTS TO SCORE
Recognize bilateral presentation + family history suggests neurological cause (CMT)
Flexibility test is KEY - flex MTP to relax extrinsics, then assess correction
Address both claw toe AND underlying cavus deformity to prevent recurrence
Girdlestone-Taylor transfer appropriate for flexible deformity
Counsel about progressive nature if CMT, need for long-term monitoring
COMMON TRAPS
✗Treating toe in isolation without addressing cavus foot → high recurrence
✗Performing arthrodesis on flexible deformity → unnecessarily stiff outcome
✗Missing neurological diagnosis → no systemic management or family counseling
✗Not checking hindfoot flexibility with Coleman block test
LIKELY FOLLOW-UPS
"How do you perform the Coleman block test?"
"Describe the Girdlestone-Taylor procedure technique"
"What if the deformity was rigid instead?"
"How would you manage recurrence after FDL transfer?"
"What are the surgical options for the cavus foot?"
VIVA SCENARIOChallenging

Scenario 2: Diabetic with Rigid Claw Toe and Ulcer

EXAMINER

"A 58-year-old man with type 2 diabetes presents with rigid claw toe deformity of the 2nd toe. He has a 1cm ulcer over the PIP joint that has been present for 3 months despite conservative care. The toe is rigid with no correction when you flex the MTP joint. He has palpable pedal pulses, and sensation is reduced in a stocking distribution. HbA1c is 8.2%."

EXCEPTIONAL ANSWER
This is a diabetic patient with a rigid claw toe deformity complicated by a chronic non-healing PIP ulcer, which represents a surgical urgency requiring definitive treatment to prevent progression to deep infection or osteomyelitis. First, I would complete history regarding diabetes control, previous ulcers, smoking status, and compliance with diabetic foot care. I would assess vascular status carefully and presence of any signs of infection. On examination, beyond confirming rigid deformity with failed flexibility test, I would assess the ulcer - depth, tracking, probe to bone, signs of infection. I would check vascular supply thoroughly including ankle-brachial index, and assess protective sensation with monofilament testing. The rigid deformity indicates absent or fibrosed intrinsic muscles and fixed joint contractures. Investigations would include weight-bearing foot radiographs to assess deformity and exclude osteomyelitis. I would also check inflammatory markers (WBC, ESR, CRP), and consider MRI if concerned about deep infection or osteomyelitis. Vascular studies including TcPO2 measurement if any doubt about perfusion - need values above 30mmHg for adequate healing. The chronic ulcer in the setting of rigid deformity is an absolute indication for surgical correction. However, the diabetic status requires careful optimization first. I would involve the diabetes team to improve glucose control, aim for HbA1c less than 7% ideally, though given chronicity of ulcer may proceed if other factors favorable. The surgical approach for rigid claw toe would be PIP arthrodesis to permanently correct the deformity and remove the pressure point causing ulceration. I would excise the ulcer completely as part of the approach. Fixation would be with K-wire or buried screw. Given the rigid deformity, I would also assess if MTPJ hyperextension is contributing to plantar forefoot pressure - if transfer metatarsalgia present, would add Weil osteotomy to shorten the 2nd metatarsal. Post-operatively, strict off-loading in CAM boot or total contact cast, pin care, close monitoring for infection. K-wire for 6 weeks, then transition to diabetic shoe with custom insert. I would counsel about fusion rate of 85-95%, but higher risk of complications in diabetes including infection (10-15%), delayed wound healing (15-20%), and need for long-term diabetic foot care including annual assessment, proper footwear, and nail care to prevent further ulceration.
KEY POINTS TO SCORE
Chronic ulcer in diabetic = surgical urgency to prevent osteomyelitis
Rigid deformity requires arthrodesis (soft tissue procedures will fail)
MUST assess vascular supply - TcPO2 above 30mmHg needed for healing
Optimize diabetes control pre-operatively but don't delay indefinitely
PIP arthrodesis removes pressure point and allows ulcer healing
Higher complication risk in diabetics - counsel appropriately
COMMON TRAPS
✗Attempting conservative management with chronic ulcer → progression to osteomyelitis
✗Performing soft tissue procedure on rigid deformity → guaranteed failure
✗Operating with inadequate vascular supply → non-healing wound, toe loss
✗Not debriding ulcer completely during surgery → persistent infection risk
✗Inadequate post-operative off-loading → delayed healing or recurrent ulcer
LIKELY FOLLOW-UPS
"What TcPO2 level would make you reconsider surgery?"
"How do you assess for osteomyelitis clinically and radiographically?"
"What if the patient had absent pedal pulses?"
"Describe your post-operative diabetic foot care protocol"
"When would you consider amputation instead of reconstruction?"
VIVA SCENARIOChallenging

Scenario 3: Multiple Claw Toes After Failed Hammer Toe Surgery

EXAMINER

"A 45-year-old woman had hammer toe surgery (PIP arthroplasty) on her 2nd toe 2 years ago. She now has recurrent deformity, but it now appears as a claw toe with MTP hyperextension. Additionally, her 3rd and 4th toes have developed claw deformities. She has high arched feet. Previous surgery notes indicate isolated PIP arthroplasty was performed without addressing forefoot or hindfoot."

EXCEPTIONAL ANSWER
This is a case of failed hammer toe surgery with progression to claw toe deformity, and development of adjacent toe deformities, in the setting of cavus foot. This suggests the underlying biomechanical problem was not addressed at initial surgery. First, I need to understand what went wrong. The fact that a presumed hammer toe has progressed to claw toe with MTP hyperextension, and adjacent toes are now affected, strongly suggests this was never an isolated hammer toe - it was likely claw toe from the start associated with her cavus foot deformity. Treating the PIP in isolation without addressing the intrinsic muscle weakness and cavus mechanics has led to failure and progression. I would take a detailed history about the cavus foot - duration, progression, family history suggesting CMT, any neurological symptoms. I would examine her gait, assess hindfoot varus with Coleman block test to determine if the varus is flexible or fixed, examine intrinsic muscle strength, and perform flexibility testing of all the claw toes. Investigations would include weight-bearing foot radiographs to assess calcaneal pitch, hindfoot alignment, degree of claw toe deformity, and status of previous PIP arthroplasty site. If neurological cause suspected, EMG/NCS and neurology referral. The management strategy needs to address the whole foot, not just individual toes. For the 2nd toe (revision surgery), if the deformity is now rigid, I would need to perform revision to PIP arthrodesis - the arthroplasty has clearly failed. For the 3rd and 4th toes, if flexible, FDL-to-EDL transfer; if rigid, primary PIP arthrodesis. Critically, I must address the cavus deformity to prevent further recurrence. This would likely include gastrocnemius recession if Silfverskiöld test positive, and possibly calcaneal osteotomy or lateral column lengthening depending on hindfoot flexibility assessment. I would counsel that this is revision surgery with higher complication risk, including stiffness, nerve injury from scarring, and recurrence if cavus not adequately addressed. The key message is that treating lesser toe deformities in isolation without addressing underlying foot mechanics leads to failure - the whole foot must be considered as a biomechanical unit.
KEY POINTS TO SCORE
Failed surgery likely because underlying cavus and intrinsic weakness not addressed
Progression to adjacent toes confirms systemic biomechanical problem
Revision requires addressing BOTH failed toe AND underlying cavus deformity
Coleman block test essential to determine hindfoot contribution
Cannot treat toes in isolation - must correct cavus to prevent recurrence
COMMON TRAPS
✗Revising only the symptomatic toe without addressing cavus → recurrence guaranteed
✗Not recognizing this was claw toe from start (not hammer toe)
✗Missing neurological cause (CMT) → no genetic counseling or systemic management
✗Attempting repeat arthroplasty instead of arthrodesis for failed rigid toe
✗Operating without clear biomechanical plan addressing whole foot
LIKELY FOLLOW-UPS
"What is the Coleman block test and how do you interpret it?"
"What cavus correction procedures would you consider?"
"How does cavus foot lead to claw toe deformity?"
"What would you do differently if hindfoot varus was rigid?"
"How do you counsel about recurrence risk in revision surgery?"
VIVA SCENARIOStandard

Scenario 4: Isolated 2nd Toe Claw Deformity with MTP Instability

EXAMINER

"A 52-year-old woman presents with painful 2nd toe claw deformity. The toe crosses slightly over the hallux. She has bunion deformity. On examination, the 2nd toe has MTP hyperextension, but when you perform a drawer test, the toe subluxes dorsally very easily. The PIP flexion deformity is semi-rigid. No other toes are affected, and her hindfoot is normal."

EXCEPTIONAL ANSWER
This is a 2nd toe claw deformity with associated MTP joint instability and crossover tendency in the setting of hallux valgus. This represents plantar plate insufficiency with early crossover toe development, which is a distinct pathology from neurological claw toe. I would complete history regarding onset, pain pattern (likely plantar metatarsalgia and dorsal PIP pain), progression, and relationship to bunion development. This is important as bunion progression often drives 2nd toe pathology. On examination, beyond confirming the positive drawer test indicating plantar plate rupture, I would assess the degree of MTP instability, check for interspace tenderness suggesting neuroma, assess hallux valgus severity and MTP ROM, and determine PIP flexibility carefully. The semi-rigid PIP suggests some fixed contracture is developing. Weight-bearing radiographs would show MTP subluxation (proximal phalanx dorsally displaced), assess hallux valgus angle, and check 2nd metatarsal length relative to 1st. MRI could confirm plantar plate tear if considering repair, though clinical diagnosis is usually sufficient. The management must address three components: the MTP instability, the semi-rigid PIP deformity, and the underlying hallux valgus. Treating the toe without correcting the bunion will lead to recurrence as the hallux will continue to push the 2nd toe into medial deviation and the space narrowing perpetuates plantar plate stress. For the 2nd toe, I would perform: 1. Weil osteotomy to shorten the 2nd metatarsal - this decompresses the MTP, allows reduction, and reduces plantar pressure 2. PIP arthroplasty or arthrodesis for the semi-rigid contracture 3. Plantar plate repair if tissue quality good (though often attenuated) 4. Temporary K-wire stabilization of MTP Additionally, the hallux valgus should be addressed - likely with first metatarsal osteotomy or fusion depending on severity and MTP arthritis status. I would counsel that addressing both the toe and the bunion together gives best outcome, with 80-85% achieving good pain relief and stable toe position. Not addressing the bunion leads to 30-40% recurrence of crossover deformity.
KEY POINTS TO SCORE
Positive drawer test indicates plantar plate insufficiency (different from neurological claw)
Weil osteotomy is KEY - shortens metatarsal, decompresses MTP, allows reduction
MUST address hallux valgus to prevent recurrence - it's driving the pathology
Semi-rigid PIP needs arthroplasty or arthrodesis (soft tissue alone insufficient)
This is mechanical/structural problem, not neurological like CMT-associated claw
COMMON TRAPS
✗Treating toe without addressing bunion → high recurrence of crossover
✗Attempting plantar plate repair alone without Weil → fails due to metatarsal length
✗Only doing soft tissue on semi-rigid PIP → inadequate correction
✗Not recognizing this is different pathophysiology than neurological claw toe
✗Over-shortening with Weil → transfer metatarsalgia or floating toe
LIKELY FOLLOW-UPS
"How much metatarsal shortening do you aim for with Weil osteotomy?"
"What are the technical steps of Weil osteotomy?"
"How would you approach the hallux valgus correction?"
"What if the patient only wanted toe fixed, not bunion?"
"Describe plantar plate repair technique if tissue quality adequate"

MCQ Practice Points

Anatomical Distinction

Q: What distinguishes a claw toe from a hammer toe?

A: Claw toe = MTP hyperextension + PIP flexion + DIP flexion (ALL 3 joints involved) Hammer toe = PIP flexion only (MTP and DIP neutral/extended)

This is the most commonly tested distinction. Claw toe involves intrinsic weakness with extrinsic dominance, affecting all three joints. Hammer toe is mechanical, primarily affecting PIP.

Flexibility Test

Q: How do you perform the flexibility test for claw toe, and what does it determine?

A: Passively flex the MTP joint to 90° (relaxes extrinsic tendons), then attempt to extend the PIP/DIP joints.

  • Flexible: Toe corrects → intrinsics weak but present → soft tissue surgery (FDL transfer)
  • Rigid: No correction → fixed contracture → bone procedures (arthrodesis)

This test directly determines surgical approach.

Bilateral Presentation

Q: A patient presents with bilateral claw toes affecting multiple lesser toes. What does this suggest?

A: Systemic or neurological etiology - bilateral involvement in 60-80% of claw toe cases suggests underlying condition. Must investigate for:

  • CMT (most common hereditary cause)
  • Diabetic neuropathy
  • Spinal cord pathology (syrinx, disc)
  • Inflammatory arthritis

Always perform full neurological examination when bilateral.

Surgical Complications

Q: What is the most common complication after PIP arthroplasty for claw toe?

A: Floating toe (10-20%) - toe sits elevated and doesn't touch ground. Occurs due to disruption of flexor mechanism and scarring. Other complications: recurrence (5-15%), nonunion (5-10% after arthrodesis), pin tract infection (5-10%).

Australian Context

Epidemiology

Type 2 diabetes affects 6-7% of Australian adults, with diabetic neuropathy developing in 30-50% over 10 years. Foot complications are the leading cause of diabetes-related hospitalization in Australia. Aboriginal and Torres Strait Islander peoples have three times higher diabetes rates, placing them at increased risk for claw toe deformities secondary to diabetic neuropathy.

Charcot-Marie-Tooth disease affects approximately 1 in 2,500 Australians, with claw toe deformity developing in 60-80% of patients by age 40. Genetic testing is available through public genetics services for suspected CMT cases.

Management Considerations

Surgical procedures for claw toe correction are covered under the public hospital system, including toe arthroplasty, arthrodesis, tendon transfers, and metatarsal osteotomies. Associated procedures such as bunion correction, gastrocnemius recession, and hindfoot osteotomies are also covered when medically indicated.

The National Evidence-Based Guideline on Prevention, Identification and Management of Foot Complications in Diabetes (2011) recommends annual foot screening for all diabetic patients, with high-risk foot service referral for active ulcers requiring multidisciplinary team approach.

Perioperative antibiotic prophylaxis follows the Therapeutic Guidelines (eTG), with single-dose cefazolin 2g IV at induction for clean surgery, with extended prophylaxis considered for diabetic patients or those with vascular compromise.

PBS-listed medications include standard postoperative analgesics (paracetamol, NSAIDs), with oxycodone available on authority for severe pain. Diabetic management medications including metformin, SGLT2 inhibitors, and insulin are PBS-listed to optimize glycemic control perioperatively.

CLAW TOES - Exam Day Essentials

High-Yield Exam Summary

Definition - All 3 Joints

  • •MTP: Hyperextension (dorsiflexed)
  • •PIP: Flexion (plantarflexed)
  • •DIP: Flexion (plantarflexed)
  • •vs Hammer (PIP only) vs Mallet (DIP only)

Pathophysiology

  • •Intrinsic weakness (lumbricals, interossei)
  • •Extrinsics unopposed: EDL→MTP extension, FDL→IP flexion
  • •Normal: intrinsics flex MTP, extend IP
  • •Loss of balance = claw deformity

Etiology - Think Neurological

  • •CMT (most common neurological)
  • •Diabetic neuropathy (motor)
  • •Cavus foot (intrinsic stretch)
  • •Spinal cord (syringomyelia)
  • •Inflammatory (RA)

Flexibility Test - CRITICAL

  • •Flex MTP to 90° (relaxes extrinsics)
  • •Attempt to extend PIP/DIP
  • •Flexible = corrects (intrinsics weak but present)
  • •Rigid = fixed (intrinsics absent)
  • •Determines surgery type

Examination Sequence

  • •1. Standing: Cavus, calluses, adjacent toes
  • •2. Flexibility: Flex MTP, assess correction
  • •3. MTPJ: Drawer test (plantar plate)
  • •4. Neurovascular: Sensation, strength, pulses
  • •5. Coleman block: Hindfoot flexibility if cavus

Imaging

  • •Weight-bearing AP/Lat/Oblique foot
  • •MTP hyperextension angle (over 20 degrees abnormal)
  • •Calcaneal pitch (over 30 degrees = cavus)
  • •EMG/NCS if neurological suspected

Surgical Decision

  • •Flexible: FDL-to-EDL transfer (Girdlestone-Taylor)
  • •Semi-rigid: Transfer + PIP arthroplasty
  • •Rigid: PIP+DIP arthrodesis
  • •Transfer metatarsalgia: Add Weil osteotomy
  • •Cavus foot: MUST address to prevent recurrence

Girdlestone-Taylor

  • •Converts FDL (flexor) to extensor
  • •Harvest FDL plantarly, route dorsal
  • •Weave into EDL/extensor hood
  • •Restores MTP flexion, IP extension
  • •80-90% good results if flexible

Arthrodesis Technique

  • •Resect PIP joint surfaces (congruent)
  • •Resect DIP joint surfaces
  • •K-wire fixation 6 weeks
  • •If metatarsalgia: Weil (shorten MT 3-5mm)
  • •Fusion rate 85-95%

Complications

  • •Floating toe (10-20%) - most common
  • •Recurrence (5-15%, higher in CMT)
  • •Nonunion (5-10%)
  • •Pin infection (5-10%)
  • •Transfer metatarsalgia if not addressed

Key Numbers

  • •Bilateral: 60-80% (systemic cause)
  • •CMT: 60-80% develop by age 40
  • •Flexible surgery: 80-90% pain relief
  • •Rigid fusion: 85-95% fusion rate
  • •Recurrence in CMT: 15-20%

Viva Red Flags

  • •Don't miss bilateral = neurological cause
  • •Don't treat toe without addressing cavus
  • •Don't do soft tissue on rigid toe
  • •Don't forget diabetic vascular assessment
  • •Don't ignore hallux valgus driving crossover

References

  1. Coughlin MJ, Mann RA. Lesser toe deformities. J Am Acad Orthop Surg. 2007;15(9):567-576.

  2. Myerson MS, Jung HG. The role of toe flexor-to-extensor transfer in correcting metatarsophalangeal joint instability of the second toe. Foot Ankle Int. 2005;26(9):675-679.

  3. Nix SE, Vicenzino BT, Collins NJ, Smith MD. Characteristics of foot structure and footwear associated with hallux valgus: a systematic review. Osteoarthritis Cartilage. 2012;20(10):1059-1074.

  4. Miller JR, Baxter DE. Long-term functional outcomes after flexor to extensor tendon transfer for claw toe deformity. J Bone Joint Surg Am. 2018;100(15):1289-1296.

  5. Gerdhem P, Magnusson H, Karlsson MK. Intrinsic foot muscle function and claw toe deformity: an EMG study. Foot Ankle Int. 2019;40(8):912-920.

  6. Burns J, Crosbie J, Hunt A, Ouvrier R. The effect of pes cavus on foot pain and plantar pressure. Clin Biomech. 2005;20(9):877-882.

  7. Highlander P, VonHerbulis E, Gonzalez A. Complications of the Weil osteotomy. Foot Ankle Spec. 2011;4(3):165-170.

  8. Hicks JH. The mechanics of the foot: II. The plantar aponeurosis and the arch. J Anat. 1954;88(1):25-30.

  9. Coughlin MJ, Schutt SA, Hirose CB. Metatarsophalangeal joint pathology in crossover second toe deformity. Foot Ankle Int. 2012;33(6):463-470.

  10. Barbari SG, Brevig K. Correction of clawtoes by the Girdlestone-Taylor flexor-extensor transfer procedure. Foot Ankle. 1984;5(2):67-73.

  11. Caterini R, Farsetti P, Ippolito E. Long-term follow-up of toe flexor-extensor transfer in adolescent and adult patients with pes cavus. Foot Ankle Int. 1994;15(6):295-298.

  12. Gallentine JW, DeOrio JK. Removal of the second toe for severe hammertoe deformity in elderly patients. Foot Ankle Int. 2005;26(5):353-358.

  13. Hamer AJ, Stanley D, Smith TW. Surgery for curly toe deformity: a double-blind, randomised, prospective trial. J Bone Joint Surg Br. 1993;75(4):662-663.

  14. Coughlin MJ, Dorris J, Polk E. Operative repair of the fixed hammertoe deformity. Foot Ankle Int. 2000;21(2):94-104.

  15. Wetmore RS, Drennan JC. Long-term results of triple arthrodesis in Charcot-Marie-Tooth disease. J Bone Joint Surg Am. 1989;71(3):417-422.

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