Pediatric Care Online
Chapter 183: Foot and Leg Problems
TOE DEFORMITIES IN CHILDREN
Hallux valgus is a common problem. In a child with hallux valgus (Figure 183-2), the great toe is deviated laterally to overlap the second toe, and the first metatarsal bone is deviated medially,
causing a prominence to form on the medial aspect of the metatarsophalangeal (MTP) joint. A bursa forms over the area as a result of the constant irritation and inflammation, forming a painful
bunion. Some degree of foot pronation (flat feet) associated with the condition may be found.
Many factors come into play to cause the problem, including foot structure, which may or may not be hereditary, and use of narrow stylized shoes that crimp the toes. Most cases of hallux valgus are
mild and asymptomatic and do not need treatment. Patients should be counseled in wearing shoes with plenty of toe room and no heels. If flatfoot is present, then a shoe insert to correct the foot
pronation may help prevent progression of the disease. In the more severe cases, surgical correction may be needed.
Common toe anomalies.Hammertoe
Hammertoe occurs at the proximal interphalangeal joint (PIP) (see Figure 183-2). In an infant, hammertoe is usually hereditary; in the older child, it usually results from faulty shoe wear. Most
cases of hammertoe are mild, cause no pain, and can be left alone. Parents should make sure that the child has roomy shoes that allow the toes to stretch. In the more severe cases, at an older age,
surgical correction may be needed.
Mallet toe occurs at the distal interphalangeal joint (DIP) (see Figure 183-2). Most cases of mallet toe are mild and need no treatment. When a corn develops over the deformity, shaving and padding
will help. In the more severe cases, surgical correction can be performed.
Claw toe involves all joints of the toe--hyperextension of the MTP joints and flexion at both the PIP and DIP joints (see Figure 183-2). Claw toe is a rare condition but usually occurs in conjunction
with a cavus foot, present in neuromuscular diseases such as Charcot-Marie-Tooth disease or myelomeningocele.
In a child with a curly toe 4th or 5th toe is usually flexed downward and twisted underneath the adjacent toe (see Figure 183-2). Curly toe is quite common in infancy and childhood. If curly toe does
not cause symptoms, then no treatment is needed; if the condition is severe and causes irritation with shoe wear, then surgical transfer of the toe flexor may correct the problem.
Polydactyly, the presence of an extra digit, usually the great toe or 5th toe (see Figure 183-2), may exist as an isolated finding or as part of a more extensive syndrome of congenital anomalies (5%
of cases). The family history of the same anomaly is often found. If the extra toe is not causing problems with walking and shoe wear, then no treatment is needed. Vestigial digits can be ablated by
suture ligation. If the duplication occurs in the little or big toe and sticks out prominently, then difficulty with shoe wear is common. In these cases, surgical excision will remove the problem.
Surgery is typically performed after 9 to 12 months of age.
Syndactyly, the presence of webbed digits (toes) (see Figure 183-2), may also exist as an isolated finding or as part of a more extensive syndrome of congenital anomalies (5% of cases). A family
history of the same anomaly is often found. Syndactyly is quite common and rarely causes problems. The interconnection between two or more toes can vary from thin skin to a bony attachment
(synostosis) between parts of the phalanges. Unlike in the fingers, in which surgical separation is needed to obtain finer hand functions, syndactyly in the toes does not need treatment. The growth
differential between the involved toes tends not to be significant.
Bunionette (Tailor Bunion)
Whereas a bunion forms on the great toe, the less common bunionette occurs at the fifth MTP joint. When a bunionette develops, the bursa over the lateral aspect of the fifth MTP joint gets prominent
and inflamed and painful. If padding does not help relieve the discomfort of a bunionette, then surgical correction is needed.
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