Fifth-Toe Deformities
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Since the advent of shoes, the fifth toe has been a source of discomfort for many people. Complaints typically involve poorly fitting shoes that create friction, irritation, and pain with each step. The problem can typically be solved conservatively with shoe modifications or proper foot maintenance; however, structural deformities of the toe often require surgical correction.
Fifth-toe deformities comprise several congenital and developmental problems that affect the fifth digit. Most are associated with contractures at the metatarsophalangeal (MTP) joint (MTPJ) and the proximal interphalangeal (PIP) joint (PIPJ), with or without varus rotation. [1]
Although fifth-toe deformities have long been recognized, correction of these deformities did not become prevalent until the early 20th century, when many authors began describing different aspects of the problem, along with surgical procedures to help correct them (see Treatment).
For patient education resources, see Corns and Calluses.
Three bones make up the fifth toe: the distal, middle, and proximal phalanges. They articulate together to make the distal interphalangeal (DIP) joint (DIPJ) and the PIPJ. The proximal phalanx then articulates with the fifth metatarsal to make the fifth MTPJ. Medial and lateral condyles are present at the base of each phalanx, and epicondyles are present at the heads of the proximal and middle condyles.
A two-boned (biphalangeal) fifth toe has been reported in 37-76% of the population and involves a union of the distal and middle phalanges. When this occurs, the fifth toe is less flexible and often unable to accommodate pressure from standard shoes. This variant is more susceptible to irritation and may develop into a painful deformity. [2]
In a descriptive prospective study of 2494 feet in 1247 people, Gallart et al reported that a biphalangeal fifth toe was present in 46.3% of the feet and was bilateral in 97.4% of these cases. [3] The percentage of pathologic toes was significantly higher in patients with triphalangeal fifth toes (29.91%) than in those with biphalangeal toes (15.60%). The authors suggested that there may be an association between pathologic deviations and the greater mobility of triphalangeal fifth toes and that the greater rigidity of biphalangeal fifth toes may lead to lesser accommodation inside the shoe, which might result in less painful feet and decreased need for surgery.
The MTPJ has an extensor wing-and-sling mechanism that aids in extension of the digit. A slip of the extensor digitorum longus (EDL) to the fifth toe travels deep to the extensor wing and sling to insert into the dorsal aspect of the distal phalanx. No slip occurs from the extensor digitorum brevis (EDB) to the fifth toe; however, an occasional anomaly takes place in which an offshoot from the peroneus brevis tendon travels distal to insert into the dorsal-lateral aspect of the fifth MTPJ.
The fourth lumbrical muscle inserts into the plantar-medial fibers of the extensor wing to help adduct and plantarflex the proximal phalanx. The intrinsic third plantar interosseous and flexor digiti quinti brevis muscles insert into the plantar-medial and lateral aspects of the proximal phalanx respectively and function to stabilize the MTPJ against the stronger extrinsic flexor digitorum longus (FDL) and EDL. The abductor digiti minimi originates from the calcaneus and inserts into the plantar-lateral aspect of the proximal phalanx to place an abductory force on the toe.
The final two muscles to affect the fifth digit are the FDL and the flexor digitorum brevis (FDB), both of which plantarflex the toe. The FDL is deep to the FDB until the PIPJ, where the FDB splits, allowing the FDL to become superficial and continue distally to insert into the plantar portion of the distal phalanx. The FDB then rejoins to insert into the plantar aspect of the middle phalanx.
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Simões R, Alves C, Tavares L, Balacó I, Cardoso PS, Ling TP, et al. Treatment of the overriding fifth toe: Butler’s arthroplasty is a good option. J Child Orthop. 2018 Feb 1. 12 (1):36-41. [Medline]. [Full Text].
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Stephen M Schroeder, DPM, FACFAS Foot and Ankle Surgeon, Sports Medicine Oregon
Stephen M Schroeder, DPM, FACFAS is a member of the following medical societies: American College of Foot and Ankle Surgeons
Disclosure: Nothing to disclose.
Raymond O’Hara, DPM Chief Resident, Department of Orthopedic Surgery, Yale-New Haven Hospital
Disclosure: Nothing to disclose.
Peter A Blume, DPM, FACFAS Assistant Clinical Professor of Surgery, Department of Surgery, Yale University School of Medicine; Assistant Clinical Professor of Orthopedics and Rehabilitation, Department of Orthopedics and Rehabilitation, Section of Podiatric Surgery, Yale University School of Medicine
Peter A Blume, DPM, FACFAS is a member of the following medical societies: American Association of Hospital and Healthcare Podiatrists, American College of Foot and Ankle Surgeons, American Podiatric Medical Association, International College of Angiology, American Diabetes Association
Disclosure: Nothing to disclose.
Enzo Sella, MD Chief, Orthopedic Foot and Ankle Surgery, Yale-New Haven Hospital; Associate Clinical Professor, Department of Orthopedics and Rehabilitation, Yale University School of Medicine
Enzo Sella, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Foot and Ankle Society, Eastern Orthopaedic Association, North American Spine Society, Academy of Medical Royal Colleges
Disclosure: Nothing to disclose.
Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Received salary from Medscape for employment. for: Medscape.
Vinod K Panchbhavi, MD, FACS Professor of Orthopedic Surgery, Chief, Division of Foot and Ankle Surgery, Director, Foot and Ankle Fellowship Program, Department of Orthopedics, University of Texas Medical Branch School of Medicine
Vinod K Panchbhavi, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, Orthopaedic Trauma Association, Texas Orthopaedic Association
Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Styker.
John S Early, MD Foot/Ankle Specialist, Texas Orthopaedic Associates, LLP; Co-Director, North Texas Foot and Ankle Fellowship, Baylor University Medical Center
John S Early, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Medical Association, American Orthopaedic Foot and Ankle Society, Orthopaedic Trauma Association, Texas Medical Association
Disclosure: Received honoraria from AO North America for speaking and teaching; Received consulting fee from Stryker for consulting; Received consulting fee from Biomet for consulting; Received grant/research funds from AO North America for fellowship funding; Received honoraria from MMI inc for speaking and teaching; Received consulting fee from Osteomed for consulting; Received ownership interest from MedHab Inc for management position.
Fifth-Toe Deformities
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