Bilateral curley toe

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Hello there.

Just after some advice. Had a mother bring in her 3 month old the other day. Complained of both 4th toes being curled under and pushing up the 3rd toes.

Contracture of the 4th flexor tendons present, can be straightened out.

Any advice for conservative treatment? toe splints? strapping? The mother is concerned of when the patient begins to start walking.

Obviously there is the surgical option, but was after some conservative options.

Regards

 

I strap them up with 1cm strappal. Works well when they are strapped regularly, but about half relapse when strapping stops.
The ones that don't relapse are very rewarding.

 

Hi Dean

I have seen a fair number of these babies. The vast majority spontaneously resolve when the child begins walking, especially if flexible.

What do others think?

 

The tapping technique whereby you can externally rotate the digit and at the same time straighten the ip joints, then tape to the 3rd toe.

If you are looking at the 4th toe from the dorsum, a small (in a 3 month old very narrow) strip of tape applied to the dorsum of the digit, then down between the 4th and 3rd, under the forth, back up betwen the 4th and 5th to the dorsum and then across the 4th to the 3rd.

I've correct or seen a lot of digiti varus deformities with angulated IP joints on x-ray in older kids. These do not spontaneously repair themselves (if they are bilateral). Since you use the plural I assume it's both.

On occasion you may see an isolated deformity perhaps do to intrauterine positioning that my correct, but when they are bilateral I challenge anyone to show me a case that has corrected spontaneously (sorry ELLA!).

Steve

 

Oops - yes, sorry Steve, you are quite right. I shouldn't try to answer posts before my caffine fix - I completely ignored the word "bilateral" in the post title!! :wacko:

 

Hi Steve.

Thanks for your reply. It is a bilateral deformity. Do you think it will resolve with the strapping measures?

If not, is it common for this to be corrected surgically? And at what age is this usually the most effective?

Regards,
Dean

 

Hi Dean and al, this is also a thread that has been before so if you use the serach toos you will find further input.
One of the other things to check is who's feet does the 3 year od have?
Children I have seen who are older often come in with the parent stating that he has"mum/dad/outlaws feet"?? There is always some one to blame! At 3 months they may not have checked out the whole family yet. Given time they will though)
If they are there in the family they are not going away::--))
Cheers

 

Hi Dean:
Hard to say whether stretching/strapping/tapping will correct these. It's certainly worth a try.
Surgery can always be performed depending on symptoms.
There is absolutely no rush to surgically correct these, at three months, your patient has several years before a determination can be made as the whether surgery is indicated.

Good luck

Steve

 

Thankyou

 

I can't find a good site to check the evidence base for treating curly toes since seeing a 2-3 year old with this and concerned mum as uncle had problems with it,so thought I'd link my query with this. The sites I've checked indicate manipulation is effective under a year and that spontaneous resolution occurs. That doesn't tie in with the many adults seen with curly toes so am unclear how to proceed Kate

 

I've never done a study or even an audit into results of strapping, so this is PURELY anecdotal.

Very few parents keep up the strapping long term. I have rarely seen real improvement in congenitally deformed toes of this nature and suspect that in the few cases where there has been improvement it has spontaneously resolved.

Nowadays, I assure the parents that the toes MAY improve as the child becomes weightbearing. If not, it rarely causes real problems unless it is difficult to get footwear to accomodate the toes. Surgery is a possibility if the child finds as they get well into their teens that they cannot live with the "curly toes".
I take a "hands off" approach these days, leaving change to time, surgery and the child becoming old enough to make their own minds up about whether to have surgery or not.

 

Hello,

In bilateral cases I tend to use Otoform-K Silicone wedges or props. The children are generally very complaint with these. I also encourage the parents/relatives (even the patient in question if they are old enough) to carry out daily gentle passive stretching exercises of the digits affected.

I have found in my experience that treatment of Curly Toe Syndrome takes a very long time to show results. I have been doing a Podopaediatric clinic for 3.5 years now and only in the past year have my patients with curly toes shown improvement, after a couple years persisting with stretching and silicone wedges/props!

Hope this helps, even if just a wee bit!

Louise

 

Hi, In cases like this, (pending of the proximal articular set angle of the proximal and distal interphalangeal joints), a simple flexor digitorum longus tenotomy at the plantar aspect of the proximal interphalangeal joints acompained by an oblique lenticular incision, ( rotational plasty), dorsal to the proximal interphalangeal joints, offers good, prompt, perminant correction with little to no post-operatibe discomfort avoiding risk of epiphseal damage due to the deforming force of the the FDL, i.e. Wolfes Law of Contraction and Defoprmity) It can all be performed utilising Local, Naropin 1.% plain is prefered. Just a thought. Regards Stefan

 

I would tend to agree. As long as the problem does not become functional - infection/shoe fitting issues, it is best left to the child to decide when they are of an age that it is of importance to them.

What I do ask of parents is that they take digital photos of the feet in standing every few months. That way, deterioration of the angulation/rotation of the toe can be a little more objectively monitored

If the photographs show that it deteriorates rapidly over a short space of time then perhaps some kind of investigation into epiphyseal abnormalities needs to take place

That's my 2p worth

Robin

 

Yes, surgery is only indicated if the patient experiences pain, infection or irritation with footwear. I assumed the patient was experiencing this as is why they sort and received treatment. If the patient doesn't suffer from the toes is any way no treatment is indicated.I do like the idea of using the ID wedge / toe prop to achiece FDL lengthening, anything to avoid "the knife" should also be tried first, its just in my experience, patient complience issues have resulted in a poor long-term result with this type of approach.

If the toes are left to curl and are producing these issues, it is unlikely that time, i.e. observation, will improve the deformity as the deforming force, ( flexor stabilisation - excessive medial oblique pull / contraction, of the FDL that origionates from the medial proximal aspect of the foot) will still be there. Time will allow Wolfes Law of Contraction and Deformity to take it's toll and it will effect the epiphyseal growth plates. This is a physiological response, after all this is how dental braces work. If the toe is left? well, its not the end of the world if this happens, all of my adult patients with symptomatic varus contracture, ( curley toes), present with toes that have been neglected and the bone ,(PIPJ and sometimes DIPJ), has changed to accomodate the FDL excessive, pathological pull producing a non-reducable, fixed deformity with accociated painful HD or HM. In this type of case soft tissue work alone is not enough, bony/cartilagenous remodelling is required. Good results are expected in this type of case but post-operative discomfort if higher that soft tissue and recovery to enable walking is also increased. As long as the patient or the carer is informed of this I think that is all anyone should do. If you have questions about this advice or if you don't believe me, ( why should you), please refer to any current Podiatric Surgical research regarding Rotational Arthroplasty, flexor tenotomy, Wolfe's Law of Contraction and Deformity and Hammer Toe Syndrome and it proberblty explains it better that what I can. I have also found Podiatrists often find it more comfortable to refer their patients to an Orthopaedic Surgeon rather that listen to a Podiatric Surgeon, after all what do we know? : ) On a personnel note...If I left medical treatment choices up to my 6 and 8 year old boys, one would be deaf and the other would still have a broken arm... sometimes ( even if its not what the kids want to hear) I firmly believe parents know best. Thankfully, from a medico-legal stand point..they still do. Please also understand that doesn't mean that I think parents can do boob lifts on there 5 year olds, its just that if a toe or anythying is hurting a child, and it can be fixed, then any treatment should be up to the adult, not the child. I think placing the decision of choice on a child in pain is a cop out of the parents basic reponsiblities. Just my unusual opinion in a politically correct world.

 

:good:
Interesting stuff

You are very liberal, even considering letting a 6 or 8 year old make any kind of decision. i was thinking more along the lines of 16 or 17. Of course, I still beat my children daily because "it never did me any harm".......kidding. I only beat them weekly

Robin

 

Ask to see the mothers feet. Most of the time these things are hereditary (and then point out that her or her husband are OK). As a newish mother myself I find parents of newborns extremely worried about imperfections (mothers groups have a way of highlighting this) although don't say that to the mother! My recommendation is to assure the mother that it is more likely than not not going to interfere with her child's development and it is very early to predict a long term outcome as the baby has never weight beard, walked and for that mater hasn't been free of in-uterine constrictions for long . You can suggest taping to pacify the parents although it may be better just to reassure her that it is a very common complaint shared among new parents and its best and easiest left alone until the child is older.

 

Many thanks for all those interesting perspectives - will feel better placed to advise and handle now - Kate