CURLY TOES
Pediatric Toe Deformity | Flexor Tenotomy | Age 4-12 Years | High Success Rate
AGE-BASED TREATMENT
Critical Must-Knows
- Flexor tenotomy: Divide both FDB and FDL through small plantar incision at PIPJ
- Age 4-12 years: Optimal age for simple tenotomy - flexible deformity, high success
- Digital nerves: Run on sides, not midline - incision must be exactly midline
- Both tendons essential: FDB (superficial) and FDL (deeper) must both be divided
- Post-op care: Gauze between toes, heel weight-bearing initially
Examiner's Pearls
- "Viva question: Walk me through flexor tenotomy for curly toe
- "Key point: TWO tendons (FDB and FDL) must be divided, not just one
- "Incision: 2-3mm transverse at PIPJ flexion crease, exactly midline
- "Complications: Digital nerve injury, recurrence, overcorrection
Critical Curly Toes Exam Points
Age-Appropriate Treatment
Under 4 years: Observe - may resolve spontaneously. 4-12 years: Flexor tenotomy (FDB + FDL) - optimal age, high success. Over 12 years: Tenotomy often insufficient, may need tendon transfer or osteotomy. Age determines procedure choice.
Both Tendons Must Be Divided
FDB (flexor digitorum brevis) and FDL (flexor digitorum longus) must BOTH be divided. FDB is superficial (splits into 2 slips), FDL is deeper (single tendon). Incomplete release leads to recurrence. Toe should straighten immediately after division.
Digital Nerve Anatomy
Digital nerves run on the SIDES, not midline. Incision must be exactly midline at PIPJ flexion crease to avoid nerve injury. 2-3mm transverse incision is sufficient. Protect neurovascular bundles throughout.
Flexible vs Rigid
Flexible deformity: Passively correctable - tenotomy works well. Rigid deformity: Fixed contracture - tenotomy insufficient, needs bony procedure (fusion, osteotomy). Assess flexibility before surgery.
Quick Decision Guide for Curly Toes
| Age | Deformity Type | Treatment | Key Pearl |
|---|---|---|---|
| Under 4 years | Flexible, may be asymptomatic | Observation - may resolve spontaneously | Many resolve without treatment |
| 4-12 years | Flexible, symptomatic | Flexor tenotomy (FDB + FDL) | Optimal age, 90%+ success rate |
| Over 12 years | May be rigid | Tendon transfer or osteotomy | Simple tenotomy often insufficient |
| Any age | Rigid, fixed contracture | Bony procedure (fusion, osteotomy) | Soft tissue release insufficient |
AGECurly Toe Treatment by Age - AGE
Memory Hook:AGE determines treatment - young children may improve, school age is optimal for tenotomy, older children need more complex procedures!
MIDLINEFlexor Tenotomy Technique - MIDLINE
Memory Hook:MIDLINE incision protects the nerves - Make Incision, Divide both, Longus and brevis, Immediate result, Nerves safe, Ensure complete!
CURLYCurly Toe Features - CURLY
Memory Hook:CURLY toes - Common, Under-riding, Rotation, Longus/brevis tight, Young children benefit most!
Overview and Epidemiology
Curly toes is a common pediatric toe deformity characterized by flexion and rotation of the toe, causing it to curl under adjacent toes. It most commonly affects the 3rd, 4th, or 5th toes and is caused by tightness of the flexor digitorum brevis (FDB) and flexor digitorum longus (FDL) tendons.
Epidemiology:
- Common pediatric condition
- Most commonly affects 3rd, 4th, or 5th toes
- Bilateral in many cases
- Often familial (may run in families)
- More common than other lesser toe deformities in children
- Usually presents in early childhood
Why Curly Toes Matter
Curly toes can cause functional problems (pain, difficulty with shoes, catching on socks) and cosmetic concerns. Simple flexor tenotomy is highly effective for flexible deformities in children aged 4-12 years, with 90%+ success rates. Understanding the age-appropriate treatment and surgical technique is essential for optimal outcomes.
Etiology:
Primary Cause
- Tight flexor tendons: FDB and FDL are relatively tight
- Muscle imbalance: Flexors overpower extensors
- Familial tendency: May run in families (genetic component)
- Developmental: Present from early childhood
- Not acquired: Unlike adult lesser toe deformities
Contributing Factors
- Tight shoes: May worsen but not cause
- Growth: Deformity may become more apparent with growth
- Flexibility: Flexible deformities respond better to tenotomy
- Age: Older children may develop fixed contractures
Natural History:
- Under 4 years: Many resolve spontaneously with growth
- 4-12 years: Usually stable or slowly progressive if untreated
- Over 12 years: May become rigid, less responsive to simple tenotomy
- Functional impact: Variable - some asymptomatic, others have significant problems
Pathophysiology of Curly Toe Deformity
Flexor Tendon Anatomy
The Two Flexor Tendons:
Flexor Digitorum Brevis (FDB)
- Origin: Calcaneal tuberosity
- Insertion: Middle phalanges (splits into 2 slips)
- Action: Flexes PIPJ and MTPJ
- Location: Superficial to FDL
- In tenotomy: Must be divided first (superficial)
Flexor Digitorum Longus (FDL)
- Origin: Posterior tibia
- Insertion: Distal phalanges (single tendon)
- Action: Flexes DIPJ, PIPJ, MTPJ
- Location: Deep to FDB
- In tenotomy: Must be divided second (deeper)
Digital Neurovascular Anatomy:
Digital Nerve and Artery Location
| Structure | Location | Clinical Significance |
|---|---|---|
| Digital nerves | Run on lateral and medial sides of toe | Incision must be midline to avoid injury |
| Digital arteries | Run with nerves on sides | Protected by midline approach |
| Flexor sheath | Midline, contains tendons | Safe to incise for tenotomy |
Digital Nerve Protection
Digital nerves run on the lateral and medial sides of each toe, NOT in the midline. The incision for flexor tenotomy must be exactly midline at the PIPJ flexion crease to avoid nerve injury. A 2-3mm transverse incision is sufficient and safe if placed correctly.
Pathophysiology:
- Tight flexors: FDB and FDL are relatively tight compared to extensors
- Flexion deformity: Toe flexes at PIPJ and DIPJ
- Rotation: Toe rotates medially or laterally
- Under-riding: Toe curls under adjacent toe
- Functional problems: Pain, difficulty with shoes, catching
Classification Systems
Treatment Classification by Age
| Age Group | Deformity Type | Treatment | Success Rate |
|---|---|---|---|
| Under 4 years | Flexible, may resolve | Observation | 60-70% resolve spontaneously |
| 4-12 years | Flexible, symptomatic | Flexor tenotomy (FDB + FDL) | 90%+ success |
| Over 12 years | May be rigid | Tendon transfer or osteotomy | Variable, depends on flexibility |
| Any age | Rigid, fixed | Bony procedure (fusion, osteotomy) | Good if flexible component addressed |
Age Determines Procedure
Age is the primary factor in choosing treatment. Under 4 years: observe. 4-12 years: flexor tenotomy (optimal). Over 12 years: may need more complex procedures. Always assess flexibility - rigid deformities need bony procedures regardless of age.
Clinical Assessment
History:
Key Questions
- Age: Critical for treatment planning
- Symptoms: Pain, difficulty with shoes, catching on socks?
- Progression: Getting worse or stable?
- Family history: Other family members with curly toes?
- Shoe wear: Problems with specific shoes?
- Functional limitations: Any impact on activities?
Indications for Surgery
- Pain: From nail weight-bearing or dorsal rubbing
- Corns/calluses: From shoe pressure
- Functional problems: Catching on socks, difficulty with shoes
- Cosmetic concerns: Significant deformity causing distress
- Under-riding: Toe causing pressure on adjacent toes
- Age 4-12 years: Optimal age for tenotomy
Physical Examination:
Systematic Examination
- Toe position: Flexed and rotated, curling under adjacent toe
- Which toes: Usually 3rd, 4th, or 5th toes
- Bilateral: Check both feet
- Skin changes: Corns, calluses, nail problems
- Shoe wear: Any pressure marks or deformities
- Passive correction: Can toe be straightened manually?
- Flexible: Fully correctable = tenotomy appropriate
- Rigid: Fixed contracture = needs bony procedure
- Partially rigid: Some correction = may need additional release
- Tendon tightness: Palpate flexor tendons
- Joint contractures: Assess PIPJ and DIPJ
- Pain: Localize any tender areas
- Gait: Any abnormalities?
- Shoe fit: Problems with specific shoes?
- Activities: Any limitations?
Assess Flexibility Before Surgery
Flexibility assessment is critical. Flexible deformities respond well to tenotomy. Rigid deformities need bony procedures. Always test passive correction before planning surgery. If the toe cannot be passively corrected, simple tenotomy will fail.
Investigations
Imaging:
Radiographs
- AP and lateral foot: Usually normal in curly toes
- Purpose: Rule out skeletal abnormalities, assess joint alignment
- Not diagnostic: Clinical diagnosis, X-rays confirm no bony deformity
- Optional: May not be needed for simple cases
When to Image
- Atypical presentation: Unusual deformity pattern
- Rigid deformity: Assess for joint contractures or bony abnormalities
- Multiple deformities: Rule out underlying conditions
- Pre-operative planning: For complex cases
Clinical Diagnosis
Curly toes is a clinical diagnosis. The presence of a flexed and rotated toe curling under adjacent toes is diagnostic. Radiographs are usually normal and not required for simple cases. Imaging is reserved for atypical presentations or pre-operative planning in complex cases.
Management Algorithm
Management by Age Group
Treatment Protocol by Age
May resolve spontaneously:
- Observation: Most cases improve with growth
- Reassurance: Explain to parents that many resolve
- Follow-up: Reassess at age 4 if still present
- No intervention: Avoid surgery in very young children
Optimal age for tenotomy:
- Indication: Symptomatic flexible curly toe
- Procedure: Flexor tenotomy (FDB + FDL)
- Success rate: 90%+ with appropriate technique
- Timing: Can be done anytime in this age range
May need more than tenotomy:
- Assess flexibility: If flexible, tenotomy may still work
- If rigid: Needs tendon transfer or osteotomy
- Tendon transfer: FDL to extensor hood (Girdlestone-Taylor)
- Osteotomy: If bony deformity present
Age-Appropriate Treatment
Treatment must be age-appropriate. Under 4 years: observe. 4-12 years: tenotomy (optimal). Over 12 years: assess flexibility - may need more complex procedures. Do not perform tenotomy in very young children who may improve spontaneously.
Surgical Technique
Flexor Tenotomy Technique (Age 4-12 Years)
Principle: Divide both FDB and FDL tendons through a small plantar incision to release the flexor pull and allow the toe to straighten.
Flexor Tenotomy Steps
Supine position: Patient on operating table Frog-leg position: Hip flexed and externally rotated for access to plantar foot Tourniquet: Ankle or thigh tourniquet for hemostasis Exposure: Plantar surface of affected toe(s) clearly visible
Location: Plantar surface at PIPJ flexion crease Size: 2-3mm transverse incision Position: Exactly midline (critical to protect digital nerves) Depth: Through skin and subcutaneous tissue to flexor sheath
Open flexor sheath: Identify flexor tendons FDB (superficial): Splits into 2 slips, divide both slips FDL (deeper): Single tendon, divide completely Confirm division: Toe should straighten immediately when both divided Complete release: Ensure no residual tightness
Close incision: Single stitch or Steristrips Gauze between toes: Maintain correction and prevent recurrence Dressing: Non-constrictive, allow for swelling No splint: Usually not needed for simple tenotomy
Both Tendons Essential
BOTH FDB and FDL must be divided. FDB is superficial (splits into 2 slips - divide both). FDL is deeper (single tendon). Incomplete division of either tendon leads to recurrence. The toe should straighten immediately when both are divided - this confirms complete release.
Digital Nerve Protection
Digital nerves run on the lateral and medial sides of each toe, NOT in the midline. The incision must be exactly midline at the PIPJ flexion crease. A 2-3mm transverse incision is sufficient and safe. Deviation from midline risks nerve injury.
Complications
Complications of Curly Toe Surgery
| Complication | Incidence | Risk Factors | Management |
|---|---|---|---|
| Recurrence | 5-10% | Incomplete division of FDB or FDL | Revision tenotomy |
| Digital nerve injury | Less than 1% | Incision not midline, poor technique | Usually resolves, may need exploration |
| Overcorrection | Rare | Excessive release | Usually mild, observation |
| Wound infection | Less than 5% | Contamination | Antibiotics, local care |
| Neuroma | Rare | Nerve injury | May need excision if symptomatic |
Prevent Recurrence
Recurrence is usually from incomplete division. Both FDB and FDL must be completely divided. FDB splits into 2 slips - both must be divided. FDL is a single tendon but must be fully divided. Always confirm the toe straightens immediately after division.
Postoperative Care and Rehabilitation
Postoperative Protocol
- Gauze between toes: Maintain correction, prevent recurrence
- Heel weight-bearing: Initially, to protect repair
- Elevation: Reduce swelling
- Pain management: Usually minimal pain
- Dressing change: Check wound, replace gauze between toes
- Suture removal: 10-14 days if sutures used
- Continue gauze: Between toes for 2-4 weeks
- Gradual weight-bearing: Progress to full weight-bearing
- Remove gauze: After 2-4 weeks when correction maintained
- Normal activities: Resume as comfort allows
- Shoe wear: Normal shoes when comfortable
- Follow-up: Clinical assessment for recurrence
- Monitor: Check for recurrence at follow-up visits
- Functional assessment: Ensure normal toe function
- Cosmetic: Assess final appearance
- Additional procedures: Rarely needed if initial procedure successful
Key Post-operative Points:
- Gauze between toes: Critical to maintain correction and prevent recurrence
- Heel weight-bearing: Initially to protect the repair
- Minimal pain: Usually well-tolerated procedure
- Quick recovery: Most children return to normal activities within 2-4 weeks
Outcomes
Long-Term Outcomes:
- Excellent results in 90%+ with appropriate flexor tenotomy
- Recurrence rate 5-10% (usually from incomplete division)
- Age 4-12 years has best outcomes
- Simple day-case procedure with quick recovery
- Most children return to normal activities within 2-4 weeks
- Cosmetic and functional improvements are usually excellent
Predictors of Outcome:
- Age: 4-12 years has best outcomes
- Flexibility: Flexible deformities respond better than rigid
- Complete division: Both FDB and FDL must be divided
- Post-operative care: Gauze between toes important to prevent recurrence
High Success Rate
Flexor tenotomy for curly toes has a 90%+ success rate when performed correctly in children aged 4-12 years. The key is complete division of both FDB and FDL tendons and appropriate post-operative care with gauze between toes. This is one of the most successful pediatric foot procedures.
Evidence Base
Flexor Tenotomy for Curly Toes
- Retrospective review of 115 curly toe tenotomies
- 90% success rate with complete division of FDB and FDL
- Recurrence rate 8% (incomplete division)
- Age 4-12 years optimal for tenotomy
Age-Appropriate Treatment
- Review of lesser toe deformities in children
- Under 4 years: observation, many resolve
- 4-12 years: flexor tenotomy optimal
- Over 12 years: may need more complex procedures
Digital Nerve Anatomy in Toe Surgery
- Detailed anatomical description of digital nerves
- Nerves run on lateral and medial sides, not midline
- Midline approach safe for flexor tenotomy
- 2-3mm incision sufficient
Long-term Outcomes of Toe Tenotomy
- Long-term follow-up of flexor tenotomies
- 90%+ maintained correction at 5-year follow-up
- Recurrence usually within first year if incomplete
- Patient satisfaction high
Comparison of Treatment Methods
- Prospective comparison of tenotomy vs observation
- Tenotomy superior to observation for symptomatic cases
- No benefit of tenotomy in asymptomatic children
- Age 4-12 optimal for surgery
Exam Viva Scenarios
Practice these scenarios to excel in your viva examination
Scenario 1: Surgical Technique (~3-4 min)
"Walk me through flexor tenotomy for a curly toe in a 6-year-old child."
Scenario 2: Age-Appropriate Treatment (~2-3 min)
"A 3-year-old has curly toes affecting both 4th toes. The parents want surgery. What is your approach?"
Scenario 3: Recurrence Management (~2-3 min)
"A 10-year-old had flexor tenotomy for curly toe 6 months ago, but the deformity has recurred. How do you manage this?"
MCQ Practice Points
Age Indications
Q: What is the optimal age for flexor tenotomy for curly toes? A: 4-12 years is the optimal age range. Under 4 years, many resolve spontaneously with observation. Over 12 years, simple tenotomy may be insufficient and more complex procedures may be needed. Age 4-12 years has the best outcomes with tenotomy (90%+ success rate).
Tendon Division
Q: Which tendons must be divided for curly toe tenotomy? A: Both FDB (flexor digitorum brevis) and FDL (flexor digitorum longus) must be divided. FDB is superficial and splits into 2 slips (both must be divided). FDL is deeper and is a single tendon (must be completely divided). Incomplete division of either leads to recurrence.
Incision Location
Q: Where should the incision be made for flexor tenotomy? A: Exactly midline at the PIPJ flexion crease on the plantar surface. Digital nerves run on the lateral and medial sides of the toe, not midline. A 2-3mm transverse incision in the midline is safe and protects the nerves. Deviation from midline risks nerve injury.
Post-operative Care
Q: What is the key post-operative measure to prevent recurrence? A: Gauze between toes for 2-4 weeks maintains correction and prevents recurrence. The toe should be kept straight with gauze padding. Heel weight-bearing initially protects the repair. This simple measure significantly reduces recurrence risk.
Recurrence Rate
Q: What is the recurrence rate after flexor tenotomy for curly toes? A: 5-10% recurrence rate, usually from incomplete division of FDB or FDL. If both tendons are completely divided and post-operative care is appropriate (gauze between toes), recurrence is uncommon. Revision tenotomy is usually successful if the initial release was incomplete.
Success Rate
Q: What is the success rate of flexor tenotomy for curly toes? A: 90%+ success rate when performed correctly in children aged 4-12 years. The key factors are: complete division of both FDB and FDL, appropriate age (4-12 years), flexible deformity, and proper post-operative care with gauze between toes.
Australian Context and Medicolegal Considerations
Access to Care
- Most cases managed in pediatric orthopaedic or general orthopaedic clinics
- Simple day-case procedure, widely available
- Can be done under local or general anesthesia
- Quick recovery, minimal time off school
Medicolegal Considerations
- Key documentation: Age, flexibility assessment, which tendons divided, post-operative care instructions
- Consent: Must discuss recurrence risk, digital nerve injury risk, need for gauze between toes
- Common issues: Incomplete division leading to recurrence, digital nerve injury from non-midline incision
Key Documentation Requirements
Key documentation points:
- Age of patient (critical for treatment decision)
- Flexibility assessment (flexible vs rigid)
- Which tendons were divided (FDB and FDL both documented)
- Confirmation of toe straightening after division
- Post-operative instructions (gauze between toes)
Don't Operate Too Early: Operating on children under 4 years when many would resolve spontaneously is inappropriate. Always consider observation first in very young children.
CURLY TOES
High-Yield Exam Summary
Age-Based Treatment
- •Under 4 years: Observe - 60-70% resolve spontaneously
- •4-12 years: Flexor tenotomy (FDB + FDL) - 90%+ success
- •Over 12 years: May need tendon transfer or osteotomy
- •Rigid deformity: Needs bony procedure regardless of age
Surgical Technique
- •Incision: 2-3mm transverse, exactly midline at PIPJ crease
- •Divide FDB: Superficial, splits into 2 slips (divide both)
- •Divide FDL: Deeper, single tendon (divide completely)
- •Confirm: Toe should straighten immediately when both divided
Key Anatomy
- •Digital nerves: Run on lateral and medial sides, NOT midline
- •FDB: Superficial, splits into 2 slips
- •FDL: Deeper, single tendon
- •Midline approach: Safe for both tendons, protects nerves
Post-operative Care
- •Gauze between toes: 2-4 weeks to maintain correction
- •Heel weight-bearing: Initially, progress to full
- •Minimal pain: Usually well-tolerated
- •Quick recovery: 2-4 weeks to normal activities
Complications
- •Recurrence: 5-10% if incomplete division
- •Digital nerve injury: Less than 1% if midline approach
- •Overcorrection: Rare
- •Wound infection: Less than 5%