585965 research-articleXXXX
FASXXX10.1177/1938640015585965Foot & Ankle SpecialistFoot & Ankle Specialist
vol. XX / no. X
Foot & Ankle Specialist
〈 Case Report 〉 Claw Toe Deformity of the Foot due to Foreign Body Granuloma Abstract: We present a case of dynamic claw deformity of the right third toe due to a foreign body granuloma adhering to the flexor digitorum longus (FDL) tendon at the level of the body of the metacarpal bone. The deformity was completely corrected after removal of the granuloma and lengthening of the FDL tendon. A 25-year-old woman presented with pain and claw deformity of the right third toe, which corrected with ankle plantar flexion. Ultrasound and magnetic resonance imaging suggested the presence of foreign body granuloma of the right FDL tendon at the level of body of third metacarpal bone. On removal of the granuloma and Z plasty of the FDL tendon, there was complete correction of the claw. In the reported literature, claw deformity is seen with compartment syndrome or ankle fractures due to fixed length phenomenon or checkrein deformity of the flexor tendons usually at the level of medial part of the ankle. Here, we present a case of checkrein claw deformity of the FDL tendon due to a foreign body granuloma. Levels of Evidence: Therapeutic, Level IV, Case study
Kaushik Bhowmick, MS, Thomas Matthai, MS, Jerry Nesaraj, MS, and Thilak S. Jepegnanam, MS
Keywords: geriatric podiatry; agerelated problems; adolescent foot problems; age-related problems
C
of deformity with plantar flexion of the ankle (positive push up test). Correction of the deformity with plantar flexion indicates the dynamic nature of the deformity.4-6 Treatment varies from tendon lengthening in cases of dynamic deformity to footwear correction, soft tissue release, tendon release, flexor to extensor tendon transfer, resection
law toe is defined as a toe with hyperextension of the metacarpophalangeal joint and flexion of the proximal and distal “Claw toe is defined as a toe with interphalangeal joints. The causes usually are hyperextension of the restrictive effect of shoes, neuromuscular metacarpophalangeal joint and flexion of imbalances, inflammatory the proximal and distal interphalangeal arthropathies, or agejoints.” related degeneration of anatomical structures such as the joint capsule arthroplasty, to arthrodesis in cases of or plantar aponeurosis.1-3 In most cases, static contractural deformities.1-3,5-8 the cause is idiopathic. Because of the In many cases of acquired claw toes, nature of the deformity, there is loss of the causes are usually compartment intrinsic muscle function of the foot syndrome, established Volkmann resulting in major forces being borne by ischemic contracture, and tibial or ankle the metatarsal heads resulting in fractures. If clawing develops after metatarsalgia, plantar callosities, and injury without an overt compartment ulceration. The deformity can be classified as static syndrome, the implication is that either there has been a subclinical deep or dynamic depending on the correction
“
DOI: 10.1177/1938640015585965. From the Department of Orthopaedics, Christian Medical College, Vellore, Tamil Nadu, India. Address correspondence to: Kaushik Bhowmick, MS, Department of Orthopaedics–Unit 3, Christian Medical College, Paul Brand Building, Vellore 632004, Tamil Nadu, India; e-mail: kaushikbhowmick97@ yahoo.co.in. For reprints and permissions queries, please visit SAGE’s Web site at http://www.sagepub.com/journalsPermissions.nav. Copyright © 2015 The Author(s)
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1
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Mon XXXX
Foot & Ankle Specialist
Figure 1.
Figure 2.
Picture of claw deformity of the third toe.
(A, B) Claw deformity of right third digit.
compartment syndrome or that the muscle bellies of the tendons have been injured or trapped at the site of the fracture or scarred after a local hematoma. This produces a checkrein deformity of the long toe flexors, which is usually at the level of the medial part of the ankle.4,9 In this case report, we present a case of acquired dynamic claw deformity in which a foreign body produced a checkrein deformity of the long toe flexor at the level of the metacarpal, which almost completely corrects after removal of the foreign body and residual deformity is corrected by lengthening the tendon.
Figure 3. Ultrasound shows foreign body within the swelling.
Case Presentation A 25-year-old woman presented with a 9-year history of pain and clawing of the third toe of the right foot with difficulty in walking for which there were no antecedent causes. Examination of the right foot (Figure 1) indicated clawing of the right third toe with hyperextension of the metacarpophalangeal joint and flexion of the proximal and distal interphalangeal joint, with fullness of the medial arch.1,4 There was no warmth but tenderness was present on the plantar aspect of the third toe. On plantarflexion of the ankle, there was spontaneous correction of the claw deformity, which indicated the dynamic nature of the deformity and a
checkrein defect of the long flexor tendon.4 Radiographs (Figure 2A and B) showed clawing of the right third toe. Ultrasound examination (Figure 3) showed a linear intramuscular echogenic focus (likely foreign body) of size 8.6 mm in the medial plantar aspect of foot with a thick rim of collection around it. Magnetic resonance imaging (Figure 4A and B) showed a small cystic collection (4.6 × 4.4 × 9.0 mm) with a
linear hypointense focus in flexor digitorum brevis muscle of right foot in T2 image. Patient was positioned supine and thigh tourniquet was applied. A 6-cm longitudinal incision was applied on the plantar aspect in line with the third ray and plantar aponeurosis was divided. The foreign body granuloma was detected within the fibers of the flexor digitorum brevis muscle, which was incised along its fibers and the foreign body granuloma was excised (Figure 5A and B). The flexor digitorum longus (FDL) tendon of the third ray was found to be adhered to the granuloma resulting in the claw deformity. It was separated free at the level of the body of third metacarpal resulting in almost complete correction of the deformity. However, because of the long-standing nature of the problem resulting in fibrosis, complete correction of the remaining deformity was achieved by minimal Z lengthening of the FDL tendon. The FDL tendon was lengthened with Z plasty in ankle dorsiflexion and toes held in extension at the metatarsophalangeal level. The deformity (Figure 6A and B) was completely corrected after the surgery. A walking below-knee cast was applied for 4 weeks.
Downloaded from fas.sagepub.com at UNIV NEBRASKA LIBRARIES on October 9, 2015
vol. XX / no. X
Foot & Ankle Specialist
Figure 4. (A, B) Small cystic collection with a linear T2 hypointense focus within is noted in flexor digitorum brevis muscle of right foot.
Figure 5. (A, B) Foreign body in the muscle belly of the flexor digitiorum brevis and flexor digitorum longus tendon adhering to the granuloma.
There was no residual deformity on subsequent follow-up and normal rocker movement of the foot was restored after 1 year of follow-up.
Discussion There are many extrinsic and intrinsic causes of claw toes.1,2,7 The checkrein (dynamic) deformity of the long flexor tendons has been described to cause claw toes due to compartment syndrome or tibial or ankle fractures where the tendon is fixed at the level at the posteromedial part of the ankle joint. Conservative treatment has been attempted in the form of rocker heel.4,9 Checkrein deformity are dynamic causes of clawing of the toes. It is predominantly seen in the lesser toes but can also involve the hallux if there are interdigitating tendinous connections between the FDL and flexor hallucis longus tendons.10 Correction is usually attained by lengthening the FDL tendon.
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3
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Mon XXXX
Foot & Ankle Specialist
secondary to tethering of the FDL tendon at the midfoot-forefoot level.
Figure 6. (A, B) Postcorrection photographs of the deformity.
References 1. Coughlin MJ. Common causes of pain in the forefoot in adults. J. Bone Joint Surg Br. 2000;82:781-790. 2. Coughlin MJ. Lesser-toe abnormalities. J Bone Joint Surg Am. 2002;84:1446-1469. 3. Myerson MS, Shereff MJ. The pathological anatomy of claw and hammer toes. J Bone Joint Surg Am. 1989;71:45-49. 4. Feeney MS, Williams RL, Stephens MM. Selective lengthening of the proximal flexor tendon in the management of acquired claw toes. J Bone Joint Surg Br. 2001;83:335-338. 5. Kates A, Kessel L, Kay A. Arthroplasty of the forefoot. J Bone Joint Surg Br. 1967;49:552-557. 6. Taylor RG. The treatment of claw toes by multiple transfers of flexor into extensor tendons. J Bone Joint Surg Br. 1951;33: 539-542. 7. Fowler AW. A method of forefoot reconstruction. J. Bone Joint Surg Br. 1959;41:507-513.
If not fully corrected, the flexor hallucis longus tendon should also be lengthened. In the aforementioned patient, we have described a case of clawing of the right third toe due to formation of foreign body granuloma adhering to the FDL tendon at the level of body of the third metacarpal. There was complete correction of deformity and pain on the tip of the third toe after the surgery. The pain arose after the heel rise in the stance phase of the
gait cycle. This was because the tethered tendon did not allow normal dorsiflexion and rocker movement of the metatarsophalangeal joint. We have reviewed the literature on dynamic claw toe deformity in the English language, where the checkrein deformity develops at the mid leg or medial ankle joint area. Hence, we have presented the case of this patient who had an unusual presentation of dynamic claw deformity of the third toe
8. Tamir E, McLaren A-M, Gadgil A, Daniels TR. Outpatient percutaneous flexor tenotomies for management of diabetic claw toe deformities with ulcers: a preliminary report. Can J Surg. 2008;51:41-44. 9. Manoli A, Smith DG, Hansen ST Jr. Scarred muscle excision for the treatment of established ischemic contracture of the lower extremity. Clin Orthop Relat Res. 1993;(292):309-314. 10. Sarrafian SK, ed. Anatomy of the Foot and Ankle: Descriptive, Topographic, Functional. Philadelphia, PA: Lippincott Williams & Wilkins; 1993.
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FASXXX10.1177/1938640015585965Foot & Ankle SpecialistFoot & Ankle Specialist
vol. XX / no. X
Foot & Ankle Specialist
〈 Case Report 〉 Claw Toe Deformity of the Foot due to Foreign Body Granuloma Abstract: We present a case of dynamic claw deformity of the right third toe due to a foreign body granuloma adhering to the flexor digitorum longus (FDL) tendon at the level of the body of the metacarpal bone. The deformity was completely corrected after removal of the granuloma and lengthening of the FDL tendon. A 25-year-old woman presented with pain and claw deformity of the right third toe, which corrected with ankle plantar flexion. Ultrasound and magnetic resonance imaging suggested the presence of foreign body granuloma of the right FDL tendon at the level of body of third metacarpal bone. On removal of the granuloma and Z plasty of the FDL tendon, there was complete correction of the claw. In the reported literature, claw deformity is seen with compartment syndrome or ankle fractures due to fixed length phenomenon or checkrein deformity of the flexor tendons usually at the level of medial part of the ankle. Here, we present a case of checkrein claw deformity of the FDL tendon due to a foreign body granuloma. Levels of Evidence: Therapeutic, Level IV, Case study
Kaushik Bhowmick, MS, Thomas Matthai, MS, Jerry Nesaraj, MS, and Thilak S. Jepegnanam, MS
Keywords: geriatric podiatry; agerelated problems; adolescent foot problems; age-related problems
C
of deformity with plantar flexion of the ankle (positive push up test). Correction of the deformity with plantar flexion indicates the dynamic nature of the deformity.4-6 Treatment varies from tendon lengthening in cases of dynamic deformity to footwear correction, soft tissue release, tendon release, flexor to extensor tendon transfer, resection
law toe is defined as a toe with hyperextension of the metacarpophalangeal joint and flexion of the proximal and distal “Claw toe is defined as a toe with interphalangeal joints. The causes usually are hyperextension of the restrictive effect of shoes, neuromuscular metacarpophalangeal joint and flexion of imbalances, inflammatory the proximal and distal interphalangeal arthropathies, or agejoints.” related degeneration of anatomical structures such as the joint capsule arthroplasty, to arthrodesis in cases of or plantar aponeurosis.1-3 In most cases, static contractural deformities.1-3,5-8 the cause is idiopathic. Because of the In many cases of acquired claw toes, nature of the deformity, there is loss of the causes are usually compartment intrinsic muscle function of the foot syndrome, established Volkmann resulting in major forces being borne by ischemic contracture, and tibial or ankle the metatarsal heads resulting in fractures. If clawing develops after metatarsalgia, plantar callosities, and injury without an overt compartment ulceration. The deformity can be classified as static syndrome, the implication is that either there has been a subclinical deep or dynamic depending on the correction
“
DOI: 10.1177/1938640015585965. From the Department of Orthopaedics, Christian Medical College, Vellore, Tamil Nadu, India. Address correspondence to: Kaushik Bhowmick, MS, Department of Orthopaedics–Unit 3, Christian Medical College, Paul Brand Building, Vellore 632004, Tamil Nadu, India; e-mail: kaushikbhowmick97@ yahoo.co.in. For reprints and permissions queries, please visit SAGE’s Web site at http://www.sagepub.com/journalsPermissions.nav. Copyright © 2015 The Author(s)
Downloaded from fas.sagepub.com at UNIV NEBRASKA LIBRARIES on October 9, 2015
1
2
Mon XXXX
Foot & Ankle Specialist
Figure 1.
Figure 2.
Picture of claw deformity of the third toe.
(A, B) Claw deformity of right third digit.
compartment syndrome or that the muscle bellies of the tendons have been injured or trapped at the site of the fracture or scarred after a local hematoma. This produces a checkrein deformity of the long toe flexors, which is usually at the level of the medial part of the ankle.4,9 In this case report, we present a case of acquired dynamic claw deformity in which a foreign body produced a checkrein deformity of the long toe flexor at the level of the metacarpal, which almost completely corrects after removal of the foreign body and residual deformity is corrected by lengthening the tendon.
Figure 3. Ultrasound shows foreign body within the swelling.
Case Presentation A 25-year-old woman presented with a 9-year history of pain and clawing of the third toe of the right foot with difficulty in walking for which there were no antecedent causes. Examination of the right foot (Figure 1) indicated clawing of the right third toe with hyperextension of the metacarpophalangeal joint and flexion of the proximal and distal interphalangeal joint, with fullness of the medial arch.1,4 There was no warmth but tenderness was present on the plantar aspect of the third toe. On plantarflexion of the ankle, there was spontaneous correction of the claw deformity, which indicated the dynamic nature of the deformity and a
checkrein defect of the long flexor tendon.4 Radiographs (Figure 2A and B) showed clawing of the right third toe. Ultrasound examination (Figure 3) showed a linear intramuscular echogenic focus (likely foreign body) of size 8.6 mm in the medial plantar aspect of foot with a thick rim of collection around it. Magnetic resonance imaging (Figure 4A and B) showed a small cystic collection (4.6 × 4.4 × 9.0 mm) with a
linear hypointense focus in flexor digitorum brevis muscle of right foot in T2 image. Patient was positioned supine and thigh tourniquet was applied. A 6-cm longitudinal incision was applied on the plantar aspect in line with the third ray and plantar aponeurosis was divided. The foreign body granuloma was detected within the fibers of the flexor digitorum brevis muscle, which was incised along its fibers and the foreign body granuloma was excised (Figure 5A and B). The flexor digitorum longus (FDL) tendon of the third ray was found to be adhered to the granuloma resulting in the claw deformity. It was separated free at the level of the body of third metacarpal resulting in almost complete correction of the deformity. However, because of the long-standing nature of the problem resulting in fibrosis, complete correction of the remaining deformity was achieved by minimal Z lengthening of the FDL tendon. The FDL tendon was lengthened with Z plasty in ankle dorsiflexion and toes held in extension at the metatarsophalangeal level. The deformity (Figure 6A and B) was completely corrected after the surgery. A walking below-knee cast was applied for 4 weeks.
Downloaded from fas.sagepub.com at UNIV NEBRASKA LIBRARIES on October 9, 2015
vol. XX / no. X
Foot & Ankle Specialist
Figure 4. (A, B) Small cystic collection with a linear T2 hypointense focus within is noted in flexor digitorum brevis muscle of right foot.
Figure 5. (A, B) Foreign body in the muscle belly of the flexor digitiorum brevis and flexor digitorum longus tendon adhering to the granuloma.
There was no residual deformity on subsequent follow-up and normal rocker movement of the foot was restored after 1 year of follow-up.
Discussion There are many extrinsic and intrinsic causes of claw toes.1,2,7 The checkrein (dynamic) deformity of the long flexor tendons has been described to cause claw toes due to compartment syndrome or tibial or ankle fractures where the tendon is fixed at the level at the posteromedial part of the ankle joint. Conservative treatment has been attempted in the form of rocker heel.4,9 Checkrein deformity are dynamic causes of clawing of the toes. It is predominantly seen in the lesser toes but can also involve the hallux if there are interdigitating tendinous connections between the FDL and flexor hallucis longus tendons.10 Correction is usually attained by lengthening the FDL tendon.
Downloaded from fas.sagepub.com at UNIV NEBRASKA LIBRARIES on October 9, 2015
3
4
Mon XXXX
Foot & Ankle Specialist
secondary to tethering of the FDL tendon at the midfoot-forefoot level.
Figure 6. (A, B) Postcorrection photographs of the deformity.
References 1. Coughlin MJ. Common causes of pain in the forefoot in adults. J. Bone Joint Surg Br. 2000;82:781-790. 2. Coughlin MJ. Lesser-toe abnormalities. J Bone Joint Surg Am. 2002;84:1446-1469. 3. Myerson MS, Shereff MJ. The pathological anatomy of claw and hammer toes. J Bone Joint Surg Am. 1989;71:45-49. 4. Feeney MS, Williams RL, Stephens MM. Selective lengthening of the proximal flexor tendon in the management of acquired claw toes. J Bone Joint Surg Br. 2001;83:335-338. 5. Kates A, Kessel L, Kay A. Arthroplasty of the forefoot. J Bone Joint Surg Br. 1967;49:552-557. 6. Taylor RG. The treatment of claw toes by multiple transfers of flexor into extensor tendons. J Bone Joint Surg Br. 1951;33: 539-542. 7. Fowler AW. A method of forefoot reconstruction. J. Bone Joint Surg Br. 1959;41:507-513.
If not fully corrected, the flexor hallucis longus tendon should also be lengthened. In the aforementioned patient, we have described a case of clawing of the right third toe due to formation of foreign body granuloma adhering to the FDL tendon at the level of body of the third metacarpal. There was complete correction of deformity and pain on the tip of the third toe after the surgery. The pain arose after the heel rise in the stance phase of the
gait cycle. This was because the tethered tendon did not allow normal dorsiflexion and rocker movement of the metatarsophalangeal joint. We have reviewed the literature on dynamic claw toe deformity in the English language, where the checkrein deformity develops at the mid leg or medial ankle joint area. Hence, we have presented the case of this patient who had an unusual presentation of dynamic claw deformity of the third toe
8. Tamir E, McLaren A-M, Gadgil A, Daniels TR. Outpatient percutaneous flexor tenotomies for management of diabetic claw toe deformities with ulcers: a preliminary report. Can J Surg. 2008;51:41-44. 9. Manoli A, Smith DG, Hansen ST Jr. Scarred muscle excision for the treatment of established ischemic contracture of the lower extremity. Clin Orthop Relat Res. 1993;(292):309-314. 10. Sarrafian SK, ed. Anatomy of the Foot and Ankle: Descriptive, Topographic, Functional. Philadelphia, PA: Lippincott Williams & Wilkins; 1993.
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