Fourteen of the 26 bones in your feet are in your toes. The toes, particularly your big toe, help you move and keep your balance. Playing sports, running, stubbing your toe, and dropping something on your foot can damage your toes. Wearing shoes that are too loose or too tight can also cause toe problems. Certain diseases, such as severe arthritis, can cause toe problems and pain. Gout often causes pain in the big toe.

Common toe problems include

• Corns and bunions
• Ingrown toenails
• Sprains and dislocations
• Fractures

Treatments for toe injuries and disorders vary. They might include shoe inserts or special shoes, padding, taping, medicines, rest, and in severe cases, surgery.

Corns and calluses are caused by pressure or friction on your skin. They often appear on feet where the bony parts of your feet rub against your shoes. Corns usually appear on the tops or sides of toes while calluses form on the soles of feet. Calluses also can appear on hands or other areas that are rubbed or pressed.

Wearing shoes that fit better or using non-medicated pads may help. While bathing, gently rub the corn or callus with a washcloth or pumice stone to help reduce the size. To avoid infection, do not try to shave off the corn or callus. See your doctor, especially if you have diabetes or circulation problems.

Athlete's foot is a common infection caused by a fungus. It most often affects the space between the toes. Symptoms include itching, burning, and cracked, scaly skin between your toes.

You can get athlete's foot from damp surfaces, such as showers, swimming pools, and locker room floors. To prevent it

• Keep your feet clean, dry, and cool
• Wear clean socks
• Don't walk barefoot in public areas
• Wear flip-flops in locker room showers
• Keep your toenails clean and clipped short

Treatments include over-the-counter antifungal creams for most cases and prescription medicines for more serious infections. These usually clear up the infection, but it can come back.

Athlete’s foot (tinea pedis) is a skin infection caused by a type of fungus called a dermatophyte. Athletes foot is the most common dermatophyte infection seen and can affect anyone. People with compromised immune systems are especially vulnerable to infections caused by these organisms.

Athlete’s foot, or tinea pedis, is an infection of the skin and feet that can be caused by a variety of different fungi. Although tinea pedis can affect any portion of the foot, the infection most often affects the space between the toes. Athlete’s foot is typically characterized by skin fissures or scales that can be red and itchy.

Tinea pedis is spread through contact with infected skin scales or contact with fungi in damp areas (for example, showers, locker rooms, swimming pools). Tinea pedis can be a chronic infection that recurs frequently. Treatment may include topical creams (applied to the surface of the skin) or oral medications.

Each step you take involves a complex network of bones, muscles, tendons, and ligaments. This, combined with all of the weight they carry, explains why feet can have problems. To keep your feet healthy

• Examine your feet regularly
• Wear comfortable shoes that fit
• Wash your feet daily with soap and lukewarm water
• Trim your toenails straight across and not too short

Your foot health can be a clue to your overall health. For example, joint stiffness could mean arthritis. Tingling or numbness could be a sign of diabetes. Swelling might indicate kidney disease, heart disease, or high blood pressure.

Good foot care and regular foot checks are an important part of your health care. If you have foot problems, be sure to talk to your doctor.

Each of your feet has 26 bones, 33 joints, and more than 100 tendons, muscles, and ligaments. No wonder a lot of things can go wrong. Here are a few common problems:

• Bunions - hard, painful bumps on the big toe joint
• Corns and calluses - thickened skin from friction or pressure
• Plantar warts - warts on the soles of your feet
• Fallen arches - also called flat feet

Ill-fitting shoes often cause these problems. Aging and being overweight also increase your chances of having foot problems.

General or unspecified injuries involving the foot.

Your legs are made up of bones, blood vessels, muscles, and other connective tissue. They are important for motion and standing. Playing sports, running, falling, or having an accident can damage your legs. Common leg injuries include sprains and strains, joint dislocations, and fractures.

These injuries can affect the entire leg, or just the foot, ankle, knee, or hip. Certain diseases also lead to leg problems. For example, knee osteoarthritis, common in older people, can cause pain and limited motion. Problems in your veins in your legs can lead to varicose veins or deep vein thrombosis.

Heel problems are common and can be painful. Often, they result from too much stress on your heel bone and the tissues that surround it. That stress can come from

• Injuries
• Bruises that you get walking, running or jumping
• Wearing shoes that don't fit or aren't made well
• Being overweight

These can lead to tendinitis, bursitis, and fasciitis, which are all types of inflammation of the tissues that surround your heel. Over time the stress can cause bone spurs and deformities. Certain diseases, such as rheumatoid arthritis and gout, can also lead to heel problems. Treatments for heel problems might include rest, medicines, exercises, taping, and special shoes. Surgery is rarely needed.

Your ankle bone and the ends of your two lower leg bones make up the ankle joint. Your ligaments, which connect bones to one another, stabilize and support it. Your muscles and tendons move it.

The most common ankle problems are sprains and fractures. A sprain is an injury to the ligaments. It may take a few weeks to many months to heal completely. A fracture is a break in a bone. You can also injure other parts of the ankle such as tendons, which join muscles to bone, and cartilage, which cushions your joints. Ankle sprains and fractures are common sports injuries.

Foot drop syndrome describes the inability to raise the front part of the foot due to weakness or paralysis of the muscles that lift the foot. As a result, individuals with foot drop scuff their toes along the ground or bend their knees to lift their foot higher than usual to avoid the scuffing, which causes what is called a “steppage gait."

Foot drop can be unilateral (affecting one foot) or bilateral (affecting both feet). Foot drop is a symptom of an underlying problem and is either temporary or permanent, depending on the cause.

Causes include:

• Neurodegenerative disorders of the brain that cause muscular problems, such as multiple sclerosis, stroke, and cerebral palsy
• Motor neuron disorders such as polio, some forms of spinal muscular atrophy and amyotrophic lateral sclerosis (commonly known as Lou Gehrig's disease)
• Injury to the nerve roots, such as in spinal stenosis
• Peripheral nerve disorders such as Charcot-Marie-Tooth disease or acquired peripheral neuropathy
• Local compression or damage to the peroneal nerve as it passes across the fibular bone below the knee
• Muscle disorders, such as muscular dystrophy or myositis

Treatment depends on the specific cause of foot drop. The most common treatment is to support the foot with lightweight leg braces and shoe inserts, called ankle-foot orthotics. Exercise therapy to strengthen the muscles and maintain joint motion also helps to improve gait. Devices that electrically stimulate the peroneal nerve during footfall are appropriate for a small number of individuals with foot drop. In cases with permanent loss of movement, surgery that fuses the foot and ankle joint or that transfers tendons from stronger leg muscles is occasionally performed.

Foot drop caused by trauma or nerve damage usually has partial or even complete recovery. For progressive neurological disorders, foot drop will be a symptom that is likely to continue as a lifelong disability. People with foot drop are more likely to fall.

The distal extremity of the leg in vertebrates, consisting of the tarsus (ANKLE); METATARSUS; phalanges; and the soft tissues surrounding these bones.

What is diabetes?

Diabetes is a disease in which your blood glucose, or blood sugar, levels are too high. Glucose comes from foods you eat. The cells of your body need glucose for energy. A hormone called insulin helps the glucose get into your cells.

With type 1 diabetes, your body doesn't make insulin. With type 2 diabetes, your body doesn't make or use insulin well. Without enough insulin, glucose can't get into your cells as quickly as usual. The glucose builds up in your blood and causes high blood sugar levels.

How does diabetes cause foot problems?

Foot problems are common in people with diabetes. They can happen over time when high blood sugar damages the nerves and blood vessels in the feet. The nerve damage, called diabetic neuropathy, can cause numbness, tingling, pain, or a loss of feeling in your feet.

If you can't feel pain, you may not know when you have a cut, blister, or ulcer (open sore) on your foot. A wound like that could get infected. The infection may not heal well because the damaged blood vessels can cause poor blood flow in your feet.

Having an infection and poor blood flow can lead to gangrene. That means the muscle, skin, and other tissues start to die. If you have gangrene or a foot ulcer that does not get better with treatment, you may need an amputation. This is a surgery to cut off your damaged toe, foot, or part of your leg. It may prevent a bad infection from spreading and could save your life.

But there's a lot you can do to prevent a foot wound from becoming a major health problem.

How can I protect my feet if I have diabetes?

The best way to protect your feet is by controlling your blood sugar levels every day. This will help keep nerve and blood vessel damage from getting worse. The next step is to keep the skin of your feet healthy.

Good foot care for people with diabetes includes:

• Checking your feet every day. Look for cuts, redness, and other changes in the skin and toenails, including warts or other spots that your shoes could rub. Make sure to check the bottoms of your feet too.
• Washing your feet every day. Use warm water and soap. Don't soak your feet because that can dry out your skin. After you dry your feet, you can use talcum powder or cornstarch between your toes. They soak up moisture that can cause infection. If you use lotion, don't apply it between your toes.
• Asking your doctor how to remove corns and calluses safely. Thick skin on your feet can rub and lead to sores. But removing it the wrong way could damage your skin. So you don't want to cut the skin or use medicated pads or liquid removers.
• Trimming your toenails straight across with a clipper. If it's hard for you to trim your own toenails, or if they're thick or curve into the skin, have a podiatrist (foot doctor) do it for you.
• Always wearing well-fitting shoes and socks or slippers to protect your feet when walking. You don't want to walk barefoot, even indoors. And be sure your shoes are smooth inside. A seam or pebble could rub your skin raw.
• Protecting your feet from heat and cold. Use sunscreen on exposed skin and don't walk barefoot at the beach. In cold weather, wear warm socks instead of warming your feet near a heater or fireplace.
• Keeping the blood flowing in your feet. Put your feet up when you're sitting. Wiggle your toes and circle your feet throughout the day. Don't wear tight socks. And get plenty of activity that's not too hard on the feet, such as walking.
• Getting your feet checked at your health care visits. Even if you haven't noticed a problem, it's good to have your health care provider look at your feet.

When should I see my health care provider about diabetic foot problems?

Serious foot problems can develop quickly. See your health care provider right away if you notice:

• A cut, blister, or bruise on your feet that doesn't start to heal in a few days
• Red, warm, or painful skin on your feet
• A callus with dried blood inside
• A foot infection that becomes black and smells bad that could be gangrene

Remember, controlling your blood sugar and caring for your feet every day are the best steps you can take to prevent serious diabetic foot problems.

Introduction

The term “turf toe” was initially described by Bowers in 1976 as a sprain of the plantar capsule–ligament of the great toe metatarsophalangeal (MTP) joint. It occurs secondary to a forceful hyperextension of the first MTP joint. Injury to the plantar plate of the great toe leads to pain with push-off and reduced agility. It can be a devastating injury in the elite athlete but also a nuisance in the general population.

Etiology

Turf toe is most commonly sustained as a result of forceful hyperextension of the first MTP joint. Turf toe can occur during many sports such as basketball, soccer, and gymnastics, but it is most commonly described in football, and the prevalence is far greater in athletes who play on an artificial field since it is more rigid than a natural grass field. This injury was prevalent on the astroturf (short-pile) fields of the past because it was a much less compliant surface and placed more strain on the players' feet. Modern (high-pile) turf behaves in a way more similar to natural turf, and the prevalence of the injury has decreased.

Pathophysiology

The first MTP is a ginglymi arthrodial joint, which functions as a hinge and a sliding joint. The shallow articulation between the convex metatarsal head and the concave base of the proximal phalanx articular surface results in little bony stability. Therefore, it relies on the complex attachments of the capsule, ligaments, and musculotendinous structures surrounding the joint. The plantar plate is the strongest stabilizer of the first MTP joint and is composed of a thickening of the joint capsule. It attaches to the transverse head of the adductor hallucis, the flexor tendon sheath, and the deep, transverse intermetatarsal ligament. The classification system is composed of the degree of injury to the plantar plate:

• Grade I injury is a sprain of the plantar plate.

• Grade II is a partial tear of the plantar plate.

• Grade III is a complete tear of the plantar plate

History and Physical

The patient will commonly complain of pain and swelling of the first metatarsophalangeal joint. The patient may also complain of antalgic gait and pain, especially with foot flat to toe-off during the gait cycle. The patient may or may not describe an inciting event of an acute forceful hyperextension of the first MTP. There have also been reports of subacute to the chronic development of turf toe.

A physical exam should consist of inspection, palpation, ROM, muscle strength testing, and special testing.

• Inspection: There may be swelling and ecchymosis of the first MTP.  The examiner should evaluate the patient's gait pattern and note an antalgic gait, especially with the patient favoring toe-off. The patient will find it difficult to perform toe raises on the affected side.  The examiner should also note any obvious deformities of the joint, including dislocation, hallux valgus, or hallux varus deformities.

• Palpation: There should be point tenderness over the plantar aspect of the first MTP. There can also be tenderness over the medial and lateral or dorsal joint. Examiner should compare the location of the sesamoid bone to the unaffected side to assess proximal migration.  

• ROM: Examiners should evaluate passive and active ROM. The patient will complain of pain with extension of the first MTP with passive ROM. The patient will complain of pain with active flexion of the first MTP.

• Muscle strength: Examiners can have patient flex toes or extend toe against resistance. Abduction can also be performed.

• Special testing: Examiner can perform a valgus and varus stress test of the first MTP joint to assess medial and lateral stability. Vertical Lachman test will test the degree of vertical translation of the proximal phalanx compared to the metatarsal; it is important to compare this to the contralateral side. A positive test has more laxity than the contralateral side.

• To perform vertical Lachman, the examiner should neutralize the metatarsal head in one hand and the base of the proximal phalanx in the other; the maneuver is one of pure vertical translation at the joint. Normally a competent plantar plate will not allow for any vertical translation, but normal variations of soft tissue compliance make it important to compare the affected toe to the unaffected side.

Evaluation

Initial imaging studies should be limited to AP, lateral, and axial sesamoid weight-bearing radiographs to assess for fracture or dislocation. Bilateral radiographs should be obtained to assess the migration of sesamoid bone for migration or fracture. Radiographs should be normal, but there may be noted soft tissue swelling.

MRI without contrast should be performed to evaluate for soft tissue pathology. MRI can evaluate for a plantar plate or surrounding soft tissue injury. It can also assess the articular surface of the joint. If this becomes a chronic process, there may be a degenerative change of the joint, potentially leading to hallux rigidus or a traumatic bunion. T2 MRI sequences will best identify acute inflammatory changes.

Treatment / Management

Anderson Classification

Turf toe is diagnosed depending on physical exam and imaging findings. It is graded on a scale of 1 to 3 according to the Anderson classification system.

• Grade 1: Acute sprain without bony pathology or joint instability.  The patient will have normal ROM and should be able to weight bear.

• Grade 2: Partial tear of the plantar plate or joint capsule. The patient will have painful ROM, ecchymosis, swelling, and pain with weight-bearing.

• Grade 3: Complete tear with the loss of continuity of the plantar plate or capsule. Examiners may notice the migration of sesamoid bone on physical exam. There will be marked tenderness to palpation, decreased ROM, swelling, ecchymosis, and difficulty weight-bearing.

Treatment

Regardless of the grade, initial treatment for most injuries should consist of basic RICE principles (rest, ice, compression, and elevation). A stiff sole shoe or rocker bottom sole can also help limit motion. For more severe injuries, a controlled ankle motion (CAM) boot or walking cast can help minimize motion at the joint to allow the plantar plate to heal. Once the injury is stable, it is important to begin progressive motion.

Grade 1 injuries typically take a week or 2 to heal before a patient returns to play as tolerated. 

Grade 2 injuries typical recovery time is 4 to 6 weeks. The patient may require taping when they return to play as tolerated. Taping for these injuries, once the swelling has abated in the acute phase, should focus on resisting hyperextension of the MTP joint. Corticosteroid and/or anesthetic injections are not advised for this injury.

Grade 3 injuries are more severe but usually respond to conservative treatment, albeit of longer duration. Immobilization in a CAM boot or short-leg walking cast for 4 to 6 weeks may be enough time for the healing process to begin. Progressive, gentle range of motion should follow initial immobilization with continued protected ambulation with modified shoe wear or inserts like a carbon-fiber, foot-plate extension, commonly used for hallux rigidus. Progression of activity should be as tolerated. It is expected that this injury will take 6 to 12 months to heal.

If the patient fails conservative management, surgical repair is an option. Characteristics of injuries that could benefit from surgical intervention are large capsular avulsion with unstable joint, diastasis or retraction of sesamoids, vertical instability, traumatic hallux valgus deformity, chondral injury, intra-articular loose body, sesamoid fracture, and failed conservative treatment.

Surgical Technique

Medial plantar incision: Identify the plantar medial digital nerve and protect; identify and assess soft tissue injury.

• Assess FHL for longitudinal split tears

• Plantar plate tears are all distal ruptures. If there is enough distal stump, the surgeon may attempt a direct repair. If soft tissue is inadequate, use suture anchors or drill holes in the proximal phalanx to pass suture.

• If there is a sleeve avulsion from a sesamoid, the surgeon may drill in a hole in the distal sesamoid to pass the suture.

• With diastasis or fracture of the sesamoids, the surgeon may need to excise one or both poles and repair soft tissue defects. The surgeon may attempt repair of sesamoid fracture with a headless screw or suture repair.

Joint synovitis or osteochondral defects often require debridement or cheilectomy. If the plantar plate or flexor tendons cannot be restored, abductor hallucis transfer may be required.

Postoperative Management

Begin gentle passive motion at 7 to 10 days with a physical therapist, then be non-weight bearing in removable splint or boot with hallux protected for 4 weeks. At 4 weeks, increase active motion and allow ambulation in the boot. The patient should wear a modified shoe at 2 months and return to contact activity with protection from excessive dorsiflexion at 3 to 4 months. Expect 6 to 12 months for a full recovery.

Differential Diagnosis

• Hallux limitus

• Hallux rigidus

• Hallux valgus

• Reverse turf toe

• Soccer toe

Prognosis

The outlook for turf-toe recovery is commensurate with the grade of the injury. More severe injuries require additional recovery time. Some cases will result in incomplete recovery resulting in joint stiffness or an arthritic toe. Prevention of re-injury is paramount to avoiding long-term sequelae.

Complications

Complications of turf toe can include the following:

• Loss of push-off strength

• Hallux rigidus

• Cock-up deformity

• Traumatic bunion deformity,

• Loose bodies in the joint space

• Joint fibrosis

Acute complications can include infections, scar formation secondary to hypertrophy, and plantar nerve neuroma development.

Deterrence and Patient Education

Patients need to understand the factors that can increase the risk of a turf toe injury, including competing on artificial turf and shoes with excessively flexible soles. The athlete must understand that their athletic footwear must be supportive and appropriate to the surface on which they compete. They should receive instruction on flexibility and strengthening exercises for the ankle and foot to increase their ability to withstand the stresses that accompany their athletic activities.

Pearls and Other Issues

A relatively common injury pattern is suspected in athletes playing contact sports on more rigid surfaces with shoe wear that allows first MTP hyperextension. Early diagnosis and immobilization is key to quick healing and recovery. Avoid steroid injection into the plantar plate.

Enhancing Healthcare Team Outcomes

Diagnosis and management of tor turf are made by an interprofessional team that includes a sports physician, orthopedic surgeon, podiatrist, nurse practitioner, radiologist, and an emergency department physician. The initial treatment is conservative, but most severe injuries require some type of surgery. The symptoms often take months to subside. The majority of patients have a good outcome, but future protection of the toe is highly recommended to prevent a recurrence.

A bunion, known technically as hallux valgus, is a bony bump on the side of the foot at the base of the big toe. Bunions develop slowly as pressure on the joint at the base of the big toe causes the toe to move out of place, leaning inward toward the second toe. Because this joint carries a lot of weight during activities like standing and walking, bunions can cause foot pain, stiffness, redness, and swelling. Calluses may form where the big toe and second toe rub together or on the ball of the foot. Unless they are treated, bunions get worse over time, and it may become difficult to wear regular shoes or walk without pain. Bunions can occur in one or both feet.

In most cases, bunions develop in adulthood. Rarely, children may be born with bunions (known as congenital hallux valgus) or develop them later in childhood (juvenile or adolescent hallux valgus).

Polydactyly is a condition in which a person has more than the normal number of fingers or toes. It can occur in association with other physical anomalies or intellectual impairment, or it may occur as an isolated birth defect. Polydactyly can either be inherited or it can arise sporadically in an individual.

Polydactyly. In my human genetics class in college, I mentioned to my lab partner that I had never met anyone with polydactyly, and he replied, “Yes, you have.” It turns out that he was born with an extra finger on each hand that had been surgically removed, which helps to explain why I wouldn't have noticed. His hands actually looked nothing like the different photographs of hands with polydactyly that we had studied in class which had illustrated a lot of different ways that it can manifest with the extra fingers in different locations.

Introduction

Polydactyly consists of poly that means many and dactylos, which means digits. Polydactyly, also known as hyperdactyly, is the most common congenital anomaly of hand and foot. It is characterized by an extra finger or toe that may results from defective development during anterior-posterior patterning of developing limb. It may appear in isolation (non-syndromic polydactyly) or associated with other birth defects as a part of a syndrome (syndromic polydactyly).

Because it can be part of a syndrome, the clinician should be prepared to evaluate the newborn baby with polydactyly and consider the other syndromic presentations that may be associated with this anomaly. There is an increased tendency of polydactyly to involve the right hand rather than the left hand, the upper limb rather than the lower limb, and the left foot rather than the right.

Etiology

Polydactyly may present as an isolated trait or may occur in conjunction with other syndromes. Some patients may have a family history. Polydactyly may be associated with other diseases or syndromes such as Diamond-Blackfan anemia, Fanconi anemia, Ellis-van Creveld syndrome, VACTERL (vertebral defects, anal atresia, cardiac defects, tracheoesophageal fistula, renal anomalies, and limb abnormalities), trisomy 13, and trisomy 21.

Advanced molecular techniques have identified multiple gene loci that are responsible for the development of polydactyly which includes GLI3 which is associated with Greig cephalopolysyndactyly syndrome, the sonic hedgehog gene (SHH), fibroblast growth factor (FGF), homeobox protein aristaless-like 4 (ALX4), homeobox D (5’-HoxD), ZNF141, MIPOL1, IQCE, and PITX1.

Epidemiology

According to the study by Finley et al. in the USA, polydactyly is 10 times more common in Black versus White males and 22 times more common in Black females than White females. The incidence of polydactyly is 2.3 per 1000 in White males, 13.5 per 1000 in Black males, and 0.6 per 1000 in White females and 11.1 per 1000 in Black females.

The nature of polydactyly in the world seems to be influenced by genetic and ethnic factors. The incidence of preaxial polydactyly is 0.08 to 1.4 in 1,000 live births. It is more common in Whites and also relatively frequent in Native American and Asian patients.

In contrast, postaxial polydactyly is 10 times more frequent in the Black population compared to Whites. Postaxial polydactyly is more common than preaxial polydactyly and is frequently associated with other congenital defects. Its prevalence is 1-2/1000 live births.

Pathophysiology

Two theories are responsible for the development of polydactyly. One is a disorder in the programmed cell death during fetal limb development, and another is the genetic mutations of some gene loci. Limb development and growth are controlled by at least two signals, including the zone of polarizing activity (ZPA), where the sonic hedgehog molecule is found to mediate ZPA activity. Another signal is the apical ectodermal ridge (AER) that expresses fibroblast growth factors.

Preaxial polydactyly is due to the disturbance of the ectodermal and preaxial mesodermal apoptosis during the early embryologic period, approximately before the eighth week. Abnormal expression of genes such as the sonic hedgehog gene, Hox genes, bone morphogenic proteins, and GLI3 in the zone of polarizing activity is responsible for the development of preaxial polydactyly.

History and Physical

Patients with polydactyly may present in infancy or later and may appear in isolation or with other birth defects. Polydactyly of hand and foot can be classified into 3 main categories: preaxial, central, and postaxial. In 1995, the congenital hand committee of the International Federation of Societies for Surgery of the Hand decided to change the terms preaxial and postaxial polydactyly to radial and ulnar polydactyly. Radial polydactyly involves the thumbs, and ulnar polydactyly involves little fingers. Central polydactyly includes the ring, middle, and index fingers, and is often associated with syndactyly and cleft hand.

The most common form of polydactyly of hand is radial polydactyly, and the prevalence rate is higher in Whites compared to other ethnic populations. Most cases are sporadic and unilateral without any associated systemic problems. In these cases, the extra digits are seen anterior to the thumb. Radial polydactyly was further classified by Wassel in 1969 into seven subtypes, serially from type I to type VII, and it is used by hand surgeons very effectively during the management of the patients. Ulnar polydactyly was classified by Temtamy and Mckusick into two categories, type A and type B. The terms radial, central, and ulnar are used to describe the polydactyly of the upper limb.

In contrast, the terms tibial, central, and fibular are used to describe polydactyly of the lower limb. Polydactyly of the lower limb was classified by Swanson based on the presentation of the extra digit on the foot. If extra digit affects the great toe, it is called tibial polydactyly, and when it affects the little toe, it is called fibular polydactyly. When the central three digits are affected, then it is called central polydactyly.

Evaluation

At 9 weeks of intrauterine life, fetal finger buds can be seen through transvaginal sonography. Once polydactyly is detected, the clinician should be alert to evaluate for further anomaly screening. A thorough ultrasound evaluation should be done to image the heart, kidneys, nervous system, and limbs for identification of syndromes such as trisomy 13, Meckel-Gruber syndrome, Diamond-Blackfan anemia, Fanconi anemia, etc. For the diagnosis of isolated polydactyly, a follow-up ultrasound between 17 and 34 weeks should be done with a biometric profile.

After birth, radiographic investigations should be carried out once the infant is confirmed to have polydactyly to evaluate for bony elements in the extra digit. Before surgery, radiologic findings are needed to see the accurate anatomy of the extra digits and what type of surgery is required. Anteroposterior (AP) and lateral radiographs should provide adequate information for treatment purposes.

Treatment / Management

Treatment of Polydactyly of the Hand

The treatment of polydactyly depends on the complexity and location of the deformity. If it is a simple surgery, an outpatient surgical procedure may be enough. If it is more complex, then the surgery can involve the bones, ligaments, and tendons. Minor cases can be treated by tying off the base of extra digits, which interrupts blood flow and causes the digit to fall off.

In the early postnatal period, type A ulnar or postaxial polydactyly can be corrected by suture ligation or excision in the office under local anesthesia. After the suture ligation, there is an increased risk of painful neuroma formation. Sharp excision is another alternative for ulnar polydactyly to avoid neuroma formation. Type B ulnar polydactyly is also corrected by suture ligation that induces necrosis of the distal segment, which causes the autoamputation of extra digits approximately 10-20 days later.

If preaxial or radial polydactyly involves the radial hand and thumb, the functional and stable thumb should be ensured by using reconstructive techniques. Due to the functional importance, consultation with a surgeon who is expert in hand surgery is typically needed.

Treatment of Polydactyly of the Foot

Surgical therapy is indicated to enhance cosmesis and to improve quality of life. In order to minimize the effect on development and walking, surgery should be done at the age of approximately 1 year. Management of polydactyly of the foot seems to be simple at first glance, but careful consideration is needed before and during the surgical correction due to the multiformity of its configuration. But as a whole, treatment should be individualized.

Most medial and lateral digits of tibial and fibular polydactyly are usually resected. Care must be taken to minimize hallux varus in the case of tibial polydactyly. Because of its rare presentation, the treatment of central polydactyly of the foot is not well described. But in most of the cases, a racquet-shaped incision can be used to excise supernumerary central digits.

Differential Diagnosis

Polydactyly may be present in isolation or may be associated with the components of some syndromes including the following:

• Trisomy 13

• Meckel syndrome

• Down syndrome

• Acrocallosal syndrome

• Basal cell nevus syndrome

• Diamond-Blackfan anemia

• Bardet-Biedl syndrome

• Biemond syndrome

• Fanconi anemia

• Ellis van Creveld syndrome

• McKusick-Kaufman syndrome

• Mirror hand deformity (ulnar dimelia)

• Mohr syndrome

• Oral-facial-digital syndrome

• Pallister-Hall syndrome

• Rubinstein-Taybi syndrome

• Short rib polydactyly

• VACTERL (vertebral defects, anal atresia, cardiac defects, trachea esophageal fistula, renal anomalies, and limb abnormalities) association

Prognosis

For children with isolated polydactyly, the prognosis is excellent. Most children can use their fingers and toes after surgery with a full range of motion. If polydactyly presents as a part of the syndrome, the prognosis may be poor due to the presence of other birth defects rather than the effect of polydactyly.

Complications

In polydactyly of the hand, bleeding and anesthetic complications may occur during the perioperative period. Functionality can be decreased later due to the contracture or ligamentous laxity. A painful neuroma is another complication, especially when using suture ligation, and it occurs at the treatment site. Beneath the suture ligation site, a painful neuroma forms because the digital nerves of the extra digit are cut off at the skin level, so it cannot retract in the soft tissues. As a result, the children are prone to injury to the skin tag resulting in skin breakdown.

In polydactyly of the foot, hallux varus is the most common complication of tibial polydactyly that may lead to subsequent surgical correction. Fibular polydactyly may have a residual angular deformity.

Postoperative and Rehabilitation Care

Patients should be monitored during the postoperative period and evaluated for residual or future deformities.

Deterrence and Patient Education

Polydactyly may transmit throughout generations by an autosomal dominant pattern of inheritance. If the parent carries the trait, both male and female children carry the risk of inheriting the condition. Parents should be educated about prenatal ultrasonography to detect polydactyly of the fetus and screening for other fetal anomalies.

Enhancing Healthcare Team Outcomes

The diagnosis and management of polydactyly often requires an interprofessional team approach with healthcare providers such as geneticists, neonatologists, primary clinicians, and surgeons. It is necessary for clinicians to discuss with parents family history and counsel them properly about all the possible outcomes of the newly diagnosed baby. Neonatal health care workers also have a duty to advise those families with familial recurrence of polydactyly for taking genetic counseling regarding their risk assessment.