1. Feet – Hallux Valgus, Claw & Hammer Toes and Mortons Neuroma’s
Neil Davies
Consultant Orthopaedic Surgeon
October 2004

2. Hope to Cover! Definition Aetiology
Pathology / muscle function / anatomy
Treatment
Outcomes

3. Hallux Valgus & Bunions
Bunio – to enlarge
Common
Unclear cause
Female predominant
Barefoot protection
Degenerative
Acquired
Familial
Hypermobile 1st MTC
Metatarsus Primus Varus
Hyperpronated 1st Ray
Medial slanted 1st MTC

4. Choo – Blahniks Disease!

5. Footwear

6. Pathology Lateral deviation of hallux Medial bunion
Metatarsus primus varus
Sesamoid subluxation
Pronation of the hallux

7. Signs and Symptoms Asymptomatic Pain Tenderness Infection Aesthetic
‘It might get worse’

8. Signs

9. Radiologically 15 10 9

11. Move Over Jimmy Choo

12. Differentials

13. Non Operative Measures

14. Surgery Wilsons McBride Modified McBride Kellers Chevron Silver SCARF
Akin
Basal
Opening Wedge
BRT
Arthrodesis

15. Post Operative Stable osteotomy Heel weight bear Flexible correction
Light dressing
Back to work

16. Outcomes of surgery Stable 70-80% satisfaction Good correction
Low risk AVN
Low risk #
Poor for the Juvenile
Contra indications –
Spasticity
Equinus contracture
Marfans
Vascular insufficiency
Short 1st Metatarsal

17. Hammer Toe

18. Normal Toe Positioning

19. In Shoes!

20. Hammer Toe

21. Incidence Incidence 2-20% population Female : male = 4:1
Mallet:Hammer = 1:9
Increase at years old

22. Hammer Toe - causes Multifactorial Footwear
Trauma - compartment syndrome (tight FDL - dynamic)
Muscle imbalance - Friedreich’s, C.P, M.S, Myelodysplasia, degenerative disk disease
Diabetes
Hansen’s disease
RA/Psoriatic arthropathy

23. Long Toes - Mallet/Hammer

24. Treatment - Hammer Flexible Rigid MTP hyperextension FDL tight
Associated H/Valgus

25. Treatment - Hammer

26. Treatment - surgical DuVries arthroplasty - rigid F.E.T.T - flexible
Partial phalangectomy & syndactylisation
Amputation
Silicon arthroplasty

27. DuVries Arthroplasty

28. DuVries Arthroplasty

29. Post Operative Care Compression bandage Mobilise in cast R/O wire 3/52
Support toe further 4/52

30. Treatment - Dynamic Hammer
Flexible/Dynamic deformity
FDL contracture
Only present on standing
Treat by FDL tendon transfer

31. Flexor to Extensor Tendon Transfer

32. Flexor to Extensor Tendon Transfer

33. Flexor to Extensor Tendon Transfer

34. Results High Fusion - bony/fibrous 50-80% satisfactory
Excellent pain relief
54% correction of MTP subluxation

35. Complications Swelling Transient numbness PIP joint stiffness
Residual angulation
Continuing pain
Pin tract infection
MTP hyperextension
Moulding

36. Claw Toes

37. Claw Toes - causes Unclear Associated with muscle imbalance RA
Collagen deficiency syndromes
Cavus foot
Idiopathic

38. Muscle Action - at rest

39. Muscle Action - EDL

40. Muscle Action - FDL

41. Muscle Action - EDL/FDL

42. Clinical Examination Neurological Vascular Flexible/ Rigid Callosity
Nail problems
Space locally

43. Radiological Assessment
Bony deformity seen
Subluxation or dislocation
Gun Barrel Sign

44. Claw Toes

45. Treatment - Claw Toes Depends on pathology, i.e. cavus Conservative
Surgical
Again flexible/rigid
Treat both Hammer and MTP joint components

46. Treatment - Claw Toe

47. Results & Complications - Claw
70-90% Fair/good post operation
Recurrence of deformity a problem
Persistent metatarsalgia

48. Mortons/Interdigital Neuroma
Difficult to diagnose
Pain into toes
Aggrevated by activity
Tingling in toes
Non descript burning
Metatarsalgia
Stress #
MT bursae

49. Morton’s
45%
25%

50. Mulders Click

51. Ultrasound in Mortons

52. Diagnosis & Treatment Clinical USS LA injection MRI Wide fitting shoes
Many settle
Steroid
Excision
Neurolysis
Intermetatarsal release

53. Outcomes
Dependant on diagnosis
80% satisfaction