Valgus deformity of the toe: features of development and treatment of pathology

Hammertoe deformity of the 2nd, 3rd, 4th toes is a deformity (usually the 2nd, 3rd) in which the toes are bent in the shape of a hammer. With this pathology, the proximal phalanx is extended at the metatarsophalangeal joint, and the middle phalanx is bent at the interphalangeal joint.

Isolated hammertoe deformity is rare. More often it is combined with valgus deviation of the first toe and transverse flatfoot.

Claw-shaped (hook-shaped) deformity - the finger is bent in the shape of a hook. The proximal phalanx is extended at the metatarsophalangeal joint, the remaining 2 are bent at the interphalangeal joint.

“Mallet” finger – curvature in the form of a hammer. The nail phalanx is flexed at the distal interphalangeal joint.

All of the above types of curvatures can be soft (unfixed) and fixed (rigid).

Pathogenesis

With valgus deformity of the first toe, the angle between the first and second metatarsal bones becomes larger, and displacement of the first metatarsal bone is observed. The big toe moves outward and the head of the bone protrudes outward, forming a bunion. This bone prevents the thumb from conforming to the norm, and it gradually deviates outward.

The tubercle (bone) interferes with wearing shoes, creates inflammation, friction and leads to bursitis (inflammation of the bursa of the first metatarsophalangeal joint). Gradually the bone becomes swollen, inflamed, and painful. Incorrect position of the joint provokes its premature wear, damage to the cartilage and an increase in the size of the bone growth. This in turn provokes foot trauma and further development of pathology.

As the disease progresses, the big toe displaces the other toes, causing them to develop a hammertoe deformity. As the disease develops, it leads to deforming arthrosis of the metatarsophalangeal joints, inflammation of the joint capsules, joints of the toes, chronic bursitis, internal displacement of the first metatarsal bone, flat feet (chronic and transverse), bone and cartilaginous growths of the heads of the metatarsal bones.

In what cases is surgery necessary?

Surgical treatment is indicated in the following situations:

• severe pain that limits daily activities;
• inflammatory processes, chronic swelling in the joint of the first finger, which are not eliminated by taking medications;
• inability to wear regular shoes;
• restrictions on the movements of the first finger - the inability to bend or straighten it.

Most patients with hallux valgus note significant improvements from conservative treatment methods and selection of the right shoes. But if these methods do not produce an effect, especially in elderly patients, it is necessary to decide on surgical intervention.

Forms

In normal condition, the metatarsal bones are parallel to each other. Under the influence of certain reasons, the first metatarsal bone deviates outward and because of this, a protruding small bump appears on the foot, ligaments and tendons lose their elasticity, and their dysfunction develops.

The disease goes through several stages:

1. Early.

At this stage, the deviation of the big toe is less than 15 degrees.

1. Average.

The deviation of the first finger to the side is from 15 to 20 degrees. At the same time, deformation of the second finger is observed. It rises above the thumb and becomes shaped like a hammer.

1. Heavy.

The thumb deflection is 30 degrees. All the toes are already deformed, and a large bone growth is observed at the base of the first phalanx. In places where there is a lot of stress on the foot, rough calluses appear.

Types of operations

There are 3 types of operations for Hallux Valgus:

• On soft tissues. Effective for grade 1 deformation. The goal is to restore the uniformity of traction of the abductor and adductor muscles.
• On the bones. Indicated for deformity of 2, 3 degrees for the purpose of resection of a painful formation.
• Combined. Carry out in cases of severe impairment of the supporting function of the foot. They consist of a combination of removal of bone growth and plastic surgery of sprained ligaments.

There are more than 300 surgical options to remove the painful growth. In the initial stages of the disease, doctors try to use minimally invasive techniques so that the patient recovers faster. But if the disease is advanced, more complex surgical interventions are required.

Operation McBride

A popular operation on the soft tissues of the foot. Its essence is to move the adductor tendon to the head of the 1st metatarsal bone. Due to this, it is possible to bring the metatarsal bones closer together and restore normal muscle-tendon balance. After surgery, it must be taken into account that the abductor pollicis muscle cannot withstand a constant load for a long time.

If after treatment the patient does not follow the doctor’s recommendations and does not eliminate risk factors for the disease, there is a possibility that the deformity will reoccur. After correction, you must wear orthopedic shoes, avoid heavy physical activity, and avoid wearing heels and tight shoes. Unfortunately, the latter becomes a problem for many women, which is why in 95% of cases they suffer from hallux valgus.

SERI

A minimally invasive technique in which an osteotomy of the first metatarsal bone is performed through a small incision of 1-2 cm. The head of the bone is moved in the desired direction, and the bone fragments are fixed with special knitting needles, which are removed after a month. The operation is used for mild to moderate deformity.

SCARF

Scarf osteotomy is the gold standard for the treatment of hallux valgus. This is a suitable operation for moderate to severe forms of Hallux Valgus and helps to correct the rotation of the thumb around its axis. An incision on the inside of the foot allows access to the bone.

Using a special microsaw, the surgeon cuts out a Z-shaped section of the first metatarsal bone. Next, its head is shifted at the desired angle to the correct position. The bone fragments are fixed with titanium screws for stability of the connection. After complete fusion, they are removed, but if they do not cause discomfort, they can be left in the body. In particularly complex clinical cases, this operation is supplemented with other techniques.

CHEVRON

Chevron osteotomy (Austin operation) is used to correct mild to moderate deformity. Allows you to adjust the angle between the 1st and 2nd metatarsal bones. The operation is named after the V-shaped military patch called a chevron. Another name, Austin osteotomy, is associated with the name of the doctor who first performed it.

The operation begins with a V-shaped cut of the first metatarsal bone near its head. The bone fragment is moved taking into account the configuration of the bones of the foot. Bone fragments are fixed in the required position using a variety of fixators: Brauk intracortical screw, wires, wire, cortical screw, etc. Excess bone tissue on the medial side is removed.

Operation Ludloff

Technique used for moderate deformity. It is based on a wedge-shaped cut of the first metatarsal bone and moving the distal part of the bone inward. It is shifted in such a way as to solve the main problem - too large an angle between the 1st and 2nd metatarsal bones. The bone fragments are stabilized with screws, and the joint capsule is additionally sutured to reduce valgus deviation.

Operation Schede-Brandes

The technique can be called classical, but it is used less and less. The point is to simply remove the protruding part of the head of the first metatarsal bone through an oblong incision about 5 cm long. The attitude of specialists towards this technique is ambiguous, since there are a number of disadvantages. But there are also positive aspects - the operation is simple, does not require complex tools or metal structures. It can be performed without applying tourniquets, which is important for patients with chronic venous insufficiency.

Arthrodesis

It consists of complete immobilization of the metatarsal-wedge joint by fusion of its bones. The operation is aimed at imparting strength by blocking mobility. The bones are firmly secured with metal clamps - pins, knitting needles, screws. After their installation, the surfaces of the joint grow together at a certain angle and the joint becomes motionless.

The operation is carried out in two ways. The first is classic (open), in which manipulations are carried out through incisions. The second is arthroscopic, all actions take place through small incisions using an arthroscope. Without a doubt, arthrodesis is a more traumatic operation, but it helps people live without pain.

Causes

The main provoking factor in the appearance of hallux valgus is the wrong shoes. If a person wears tight shoes with a narrow toe or high heels, then the fingers are constantly in the wrong (compressed) position, which contributes to the development of hallux valgus. But this is not the only reason for the development of the disease.

The following reasons influence the appearance of pathology:

• traumatic injuries of the leg and foot;
• rickets;
• cerebral palsy;
• polyneuropathy;
• low arch of the foot;
• flat feet;
• congenital weakness of the muscular-ligamentous apparatus;
• chronic inflammation of the joints caused by psoriasis;
• arthritis;
• multiple sclerosis (accompanied by damage to the sheath of nerve fibers);
• diabetes;
• gout (deposition of urate in body tissues);
• joint hypermobility observed in Marfan and Down syndrome;
• juvenile foot (rapid increase in foot size during adolescence);
• Charcot-Marie-Tooth disease (hereditary neuropathy accompanied by muscle atrophy of the distal limbs);
• osteoporosis (bone loss);
• overstrain of the feet due to professional activities (waiters, athletes, ballerinas).

In the presence of provoking factors, the disease progresses rapidly.

Rehabilitation and recovery

The duration of the recovery period is individual and depends on the type of surgical intervention. The stronger the deformation, the longer the rehabilitation will take. On the first day, bed rest is indicated. During the following sessions, you can carefully stand on the operated leg.

Most modern methods of surgical treatment avoid the use of plaster splints and crutches, but for some time it will be necessary to bandage the lower leg and foot to prevent swelling. But after arthrodesis, you need to walk with the support of crutches, since the load on the damaged surface is not allowed.

Patients are allowed to walk in special Baruk shoes, which reduce the load on the forefoot when walking. Due to this, the healing of wounds, injuries, and the tightening of sutures occurs at an accelerated rate. Baruk's shoes have a non-slip surface, adjustable clasps, and an openable upper, so they can be worn even with bandages. On average, it is needed for a period of 4-6 weeks, then they switch to regular shoes with orthopedic insoles.

During the rehabilitation period, you must adhere to the following recommendations:

• when at rest, it is advisable to keep your legs elevated by placing bolsters;
• Before removing the sutures, try to protect the wounds from moisture;
• Do not step on your foot completely for at least a month - try to transfer the load to the heel;
• be sure to wear special shoes, use orthopedic insoles, then choose comfortable, wide shoes with flat soles;
• do foot exercises regularly;
• take medications prescribed by your doctor.

Full recovery ends in about six months. During this time, active sports should be excluded, especially those associated with heavy loads.

Symptoms

The symptoms of the pathology depend on the degree of damage to the foot. At the first stage, there is redness, swelling of the tissue in the area where the bone appears, pain in the phalanges of the fingers, which intensifies while walking. At the middle stage of development of the disease, pain, swelling, bone growths in the area of ​​the metatarsal head, and dry callus appear under the middle phalanx of the finger. In the severe stage, severe, debilitating pain occurs in the sole of the foot and in the big toe. Dry calluses form, and keratinization of the skin appears under the second and third phalanges of the fingers.

Conservative treatment and prevention of Taylor deformity

Typically, treatment for tailor's foot begins with non-surgical methods. All conservative methods can only be aimed at relieving pain and reducing inflammation, since the deformity itself can only be removed surgically.

• We adjust to the foot. You need to select shoes based on the cross-sectional size of your own foot. Shoes should have wide toes. Narrow shoes with heels provoke pain, swelling and inflammation. Everyone understands this, but often they cannot refuse dress shoes, especially women. And they resort to surgery, adjusting the foot to fit fashionable shoes.
• Reducing pain and inflammation. Non-hormonal painkillers: “Nise”, “Nimesil”, etc.
• Blockade. In “persistent” cases, local injections of corticosteroids are used to treat inflammation of the tissues around the joint.
• Silicone or fabric inserts into shoes. Protect the area of ​​the head of the fifth metatarsal bone from rubbing with shoes and reduce pain.

• Local hypothermia. To reduce pain and inflammation, you can apply an ice pack through a thin towel to the inflamed joint. For 20 minutes with a break of 30 minutes, 3-4 times.

Diagnostics

Diagnostic measures begin with collecting the patient's medical history. The doctor asks him about the disturbing symptoms, asks what provokes their appearance (stress on the legs, walking, tight shoes), whether there are metabolic diseases, systemic diseases, injuries of the lower extremities, hereditary bone diseases in the medical history.

Next, an external examination is carried out, during which the person is asked to walk. The doctor observes the patient's gait while simultaneously determining the intensity of pain. The position of the big toe, its location relative to other toes, and the range of its flexion and extension are studied.

The presence of other external symptoms is checked (swelling, redness, thickening of the stratum corneum under the bones of the fingers). An X-ray of the foot is taken in three projections to identify the degree of foot deformity, joint subluxation and associated pathologies. To exclude circulatory disorders in the legs, an ultrasound scan of the blood vessels is performed.

What is rehabilitation like after surgery?

The rehabilitation process lasts one and a half to two months, and for one and a half months, the doctors at Odinmed recommend wearing special orthopedic shoes - Brooke Boot, which helps to firmly fix the leg and relieve discomfort when moving. In addition, to avoid swelling, you need to bandage your legs with an elastic bandage. For patients with venous insufficiency, experts recommend anticoagulants. Therapeutic exercises and physiotherapy may be prescribed, dressings are performed every other day, and sutures are removed after two weeks. After eight weeks it is recommended to take an x-ray.

“There is a misconception that a bump on the foot can grow back after surgery; this is not true; a technically correct operation and compliance with the recommendations completely eliminate such an unpleasant consequence.”

Treatment

Therapy for hallux valgus can be traditional or surgical. In the early stages, when you can still do without surgery, doctors advise choosing comfortable and proper shoes. It should not cause stress or friction on the foot. Comfortable shoes slow down the progression of the disease.

At the same time, the doctor will advise you to purchase special orthopedic devices:

• spacers for the joint capsule of the big toe (they eliminate the pressure of shoes);
• intertoe rollers, spacers, which contribute to the correct distribution of the load on the foot.

All orthopedic devices reduce pain, but it is impossible to completely get rid of discomfort with their help.

To eliminate pain and inflammation, non-steroidal anti-inflammatory drugs and corticosteroid injections are used. To relieve spasms and restore joint mobility, massage and special exercises to relax the feet are prescribed.

The effectiveness of physiotherapy

Physiotherapy plays an important role in the treatment of hallux valgus. To eliminate the disease, doctors prescribe electrophoresis with calcium, phonophoresis with hydrocortisone, paraffin and ozokerite applications.

One of the most effective methods for eliminating hallux valgus is shock wave therapy (SWT). This procedure involves short-term exposure of the painful area to acoustic low-frequency pulses. With the help of shock wave therapy, pain symptoms are eliminated and the factors contributing to their occurrence are affected.

The procedure is carried out using a special device that generates shock waves. They affect only pathological areas without affecting healthy tissue. With the help of ultrasound, metabolic processes are improved.

SWT is not performed in the presence of neurological, infectious, oncological, cardiac, somatic diseases, diabetes mellitus, or bleeding disorders. Shock wave therapy is not prescribed to pregnant, breastfeeding women and children under 18 years of age.

The effect of the procedure is observed after several procedures. Pain disappears, walking becomes easier. But it is impossible to completely remove the protruding bone using one UVT procedure. The doctor may prescribe at least 5-7 sessions. Depending on the stage of the disease, the order of procedures is prescribed. Some people are prescribed daily sessions, while for others one treatment per week is enough. The results of UVT treatment last for a long period.

Why do deformed toes occur?

Traumatic injuries

The following injuries are accompanied by deformities:

• Injury.
  The change in the appearance of the finger is due to swelling of the soft tissues. Pain, cyanosis, and sometimes hemorrhages are noted. All symptoms disappear within 1-2 weeks.
• Fracture.
  The deformation is especially noticeable when the fragments are displaced; the phalanx is bent at an angle, less often shortened. In non-displaced fractures, external changes are associated only with swelling, so such an injury can be confused with a bruise. A distinctive feature of a fracture is pain during axial load.
• Dislocation.
  The finger is sharply deformed in the projection of the joint. Movements are impossible; attempts to move the affected joint are accompanied by springy resistance.
• Frostbite.
  After warming up, the fingers swell sharply and become purple-bluish. Sometimes bubbles appear. The patient is bothered by increasing burning pain. Lack of pain and blackening are a sign of severe frostbite with tissue necrosis.

Arthritis

In patients with arthritis in the early stages, the deformity is caused by swelling, then by changes in the osteoarticular structures of the toes. The symptom is detected in the following types of arthritis:

• Rheumatoid.
  The lower extremities are affected less frequently than the upper extremities, and the fingers are affected symmetrically. The pain intensifies in the afternoon and at night, subsiding in the morning. Swelling of the joints is detected, and over time, hammer- or claw-shaped deformities are formed.
• Psoriatic.
  Distal arthritis is combined with skin changes. Due to axial inflammation, the fingers take on a sausage-like appearance. The defeat is asymmetrical. Flexion restrictions predominate.
• Gouty.
  1 metatarsophalangeal joint is affected. The disease proceeds in paroxysms. Unbearable pain, severe swelling, and increased local temperature suddenly occur. The affected area turns bright red.

With nonspecific infectious polyarthritis, short-term deformation against the background of edema is detected after acute infectious diseases. Post-traumatic arthritis develops after dislocations and fractures, is chronic, and affects one joint. A chronic course is also characteristic of arthritis caused by overload of the feet due to excess weight, but in such cases, not mono-, but polyarthritis is observed. A special type of deformation due to overload is “ballerina fingers”.

Toe deformity

Congenital anomalies

Deformities associated with changes in the number, shape and size of the toes, often combined with similar anomalies of the upper extremities, include the following malformations:

• Ectrodactyly.
  There is underdevelopment or absence of one or more toes. Possible underdevelopment of the metatarsal bones. Due to the often present median split, the foot may resemble a crayfish or crab claw.
• Syndactyly.
  One or more fingers grow together completely or partially. Simple syndactyly is characterized by fusion of unchanged fingers, complex syndactyly is characterized by a combination with other developmental defects: shortening, reversal, increase, decrease in the number of phalanges.
• Brachydactyly.
  Shortening of one or more phalanges. It can be supplemented by radial deviation of the phalanges, fusion of the phalanges, deformation of the nail plate, underdevelopment of the metatarsal bones.
• Polydactyly.
  Caused by the appearance of rudimentary, additional (bifurcating) or full fingers. Other abnormalities are often found.
• Clinodactyly.
  Curvature of the fingers or distortion of their position relative to the axis of the limb. As a rule, symmetrical. On the legs in most cases it is a minor aesthetic defect that does not require special correction. Clinodactyly of the thumbs is a sign of fibrodysplasia.

Hereditary diseases

The congenital anomalies of leg development listed above can form in isolation, be combined with other stigmata of embryogenesis, and be observed in the following hereditary diseases:

• Russell-Silver syndrome.
  Syndactyly of 1-2 toes is detected.
• Down syndrome.
  Brachydactyly and a wide distance between the 1st and 2nd toes are noted.
• Anderson's syndrome.
  Brachydactyly is characteristic. Possible curvature and fusion of fingers.
• Friedreich's ataxia.
  Deformities can be congenital, caused by flat feet, club feet, or neurological disorders.
• Pfeiffer syndrome.
  In mild cases, the expansion of the main phalanges is determined. Many patients exhibit syndactyly.

Unlike the pathologies listed above, with Ollier disease, deformities do not appear in utero, but in the first decade of life. Due to uneven growth and the formation of foci of cartilaginous tissue, the fingers are shortened or curved and become covered with spherical “swells.”

Foot deformities

Due to the redistribution of the load, the shape of the toes changes with all foot deformities, including clubfoot, cavus, cauda and calcaneal foot. The most common deformity is transverse flatfoot, therefore the most famous acquired disorders are associated with this pathology:

• Hallux valgus.
  Deviation of 1 finger is often bilateral in nature with some asymmetry. Progresses with age. Complicated by arthrosis, limited mobility of the 1st metatarsophalangeal joint.
• Hammer fingers.
  Often detected simultaneously with Hallux valgus. The deformity is provoked by the pressure of the curved 1 finger, an imbalance in the muscles. As a rule, the 2nd finger is affected, less often the 3rd finger. The main phalanx is extended, the distal one is bent. Initially, the finger is passively moved into the correct position, and subsequently the deformity becomes fixed.
• Claw-shaped fingers.
  As in the previous case, an imbalance occurs between the traction of the extensors and flexors. Several fingers are deformed. The pathology is aggravated by local circulatory disorders due to vascular, endocrine, and metabolic disorders.

Arthrosis

Osteoarthritis often develops in old age. May occur after injury. Accompanies other deformities. The appearance of the affected joints changes over several years due to bone growths, and during exacerbations it is aggravated by swelling due to inflammation of the soft tissues. Against the background of arthrosis of the first metatarsophalangeal joint, a rigid big toe sometimes forms. In this case, external changes are combined with a significant limitation of movements that prevents walking.

Neuroosteoarthropathy

Develops against the background of damage to peripheral nerves. The most common neuroosteoarthropathy is a type of diabetic foot called diabetic arthropathy. At the initial stage, deformities are provoked by edema. Subsequently, due to changes in the structure of bones and joints, the fingers become claw-shaped. Other pathologies in which neuroosteoarthropathy may occur include:

• toxic neuropathy in patients with alcoholism and other chronic intoxications;
• condition after spinal cord injury;
• polio;
• neurosyphilis;
• syringomyelia;
• leprosy.

Local infections

Panaritium affects the legs less often than the arms. In the acute period, deformation is observed in all forms of pathology and is caused by edema and accumulation of pus. In deep forms of panaritium (articular, bone, tendon), the cause of the change in the appearance of the leg is the melting of tendons and hard structures. As a result, extensive scars, contractures, and ankylosis often form, causing permanent severe deformities.