WORLD JOURNAL OF PHARMACY AND PHARMACEUTICAL SCIENCES
Arun Kumar et al.
World Journal of Pharmacy and Pharmaceutical Sciences
Volume 3, Issue 1, 772-777.
Research Article
ISSN 2278 – 4357
AN UNUSUAL MALPOSITION OF 4th TOE OVERLAPPING ON 5th
TOE.
Dr Arun Kumar.S.Bilodi1, Dr.M.R.Gangadhar2
1
Professor and Head, Department of Anatomy, Velammal Medical College Hospital &
Research Institute(VMCH & RI), Velammal Village,Anuppanadi, Madurai -625009, TAMIL
NADU.
2
Professor of Anthropology, Department of Anthropology, Manasagangothri., University of
Mysore, MYSORE-570006, KARNATAKA.
Article Received on
23 October 2013,
Revised on 20 November
2013,
Accepted on 30 December
2013
ABSTRACT
Aim :-The objective of present study is report a unusual case of
malposition and overlapping of fourth toe on the fifth toe. Both the
toes were shorter than other medial three toes. Place and period :This case was studied in the month of March 2009 at Bangalore. Case
*Correspondence for
Report :-A female 19 years old ,came to outpatient of hospital with
Author:
pain in right foot. On examination, she had malpositioning as well as
Dr Arun Kumar.S.Bilodi
over lapping of 4th toe over the 5th toe. So she had difficulty in
Professor and Head.
Department of Anatomy
walking, tendency to fall sideways and even to run to catch the bus.
Velammal Medical College
There was alteration in her gait too. Overall, she had great difficulty in
Hospital & Research , Institute
carrying out her normal activities and she had gone in for depression as
(VMCH & RI), Velammal
she was more conscious about her deformed and anomalous right foot.
Village,Anuppanadi Post:
She was thoroughly examined for her deformity .Later she underwent
MADURAI -625009, TAMIL
NADU.
[email protected]
surgery and she
was corrected. Her post operative period was
uneventful. DISCUSSION:- This is deformity of toe where there is
overlapping of 4th toe over the 5th toe .This may be due to lack of
space or deformed position in the uterine cavity during intra uterine period. This present
case has been reviewed, compared and correlated with the available literatures.
CONCLUSION:- This knowledge of deformity of fourth toe will be useful to orthopaedic
surgeons and orthopaedic surgeon can study the deformity to correct it by surgical line of
treatment Hence it has been studied and reported.
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World Journal of Pharmacy and Pharmaceutical Sciences
Key words: Bi phalangeal fifth toe,- Hammer toe -Claw toe- Over Riding of Fifth Toe –over
riding of 4th toe –malposition of 4th toe Congenital Digitus Minimus Varus-- Congenital
Digitus Quinti Varus.-Triplane Deformity-overlapping of toes.
INTRODUCTION
It is one common anomaly that is seen in the family showing the adduction position of the
little toe dorsally resulting in the disability.Here there is there is lateral rotation phalanges of
fifth toe associated with contraction of contraction of
capsule of the contraction
metatarsophalangeal joint.This deformity can be corrected by the Butler’s operation goes
after the name R. Weeden Butler of Cambridge.About 70 operations have been performed to
correct the dorsally adducted 5th toe 1.These anomalies of the toes have been studied various
surgeons .They are Mc Farland (1950)2, Scrase (1954)3, Lapidus (1942)4, Colonna(1950)5,
Butlers (1964)6.
This deformity has been studied and operated by many surgeons,namely., Mc Farland
(1950)1, Scrase (1954)2, Lapidus (1942)3, Colonna(1950)4, Butlers (1964)5. (Ref 67, 68, 69,
70,71) This is also known as congenital digitus minimus varus or congenital digitus quinti
varus. There is overlapping of 5th toe which has primary 3 components . They are adduction
in a transverse plane, dorsiflexion in sagital plane and varus rotation in the form of external
rotation in a frontal plane.Movements occur at fifth metatarsophalangeal joint.There may be
associated contracture of within the fifth toe .Correction of this deformity is by consolidated
surgical approach which has given a very good result6.
CASE REPORT
A 19 years old female patient came with history of pain in right lower limb to the
outpatient of hospital On examination she had mal positioned of 4th toe dorsally adducted
and overlapping of 4th toe on the 5th toe which has given rise to difficulty in walking, and
tendency to fall forward and sometimes stamping gait in her right
foot. Overall, she had
great difficulty in carrying out her normal activities and she had gone in for depression as she
was more conscious about her anomalous right foot.
FAMILY HISTORY
She was the second daughter born to her non consanguineous parents .But there was family
history of limb anomaly. Her elder sister’s daughter aged one year has supernumerary of
digits(6 digits ) in her left foot.
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Arun Kumar et al.
World Journal of Pharmacy and Pharmaceutical Sciences
ON PHYSICAL EXAMINATION
She is normally built and nourished .There is no cyanosis, jaundice ,clubbing, and
lymphadenopathy. Her spine was normal, All the fingers with nails were normal .All the
toes were normal except her toe i.e.,4th and 5th toes of right foot There was over lapping
over the 4th toe over the fifth toe. Both the toes 4th and fifth toes were significantly shorter
when compared to medial three toes on the right limb.There was malposition of .4th toe. No
other deformity was present and no other anomalies were present in her.She was thoroughly
investigated with all laboratory investigations. All results were within the normal limits. ,
Later her deformity was corrected and her post operative period was uneventful.
LOCAL EXAMINATION
Showed wide spacing 1st inter digital cleft in the right lower limb. All the 5 toes were present
in the both lower limbs. But on the right side, there was malposition of 4th toe . Both 4th and
5th toes were
very much shorter than the other medial three toes. The 4th toes was
overlapping on 5th toe, but not on 3th toe. All the toes were long but not the 4th toe. Skin and
nails were normal. There are only two inter digital spaces, namely 1st and 2nd while no 3rd
inter digital space which is obscured by the overlapping of 4th toe on the 5th toe. Big toe ,
second & third toes were much longer than the fourth and fifth toes . 1st inter digital space
was much wider and deeper and there was second interdigital space ,but interdigital space of
3rd and 4th were obscured by the overlapping and adduction of 4th toe over the 5th toe.
DISCUSSION
This anomaly of overlapping of 5th toe is also known as congenital digitus minimus varus or
congenital digitus quinti varus which has 3 primary
components known as triplane
deformity. They are adduction in a transverse plane, dorsiflexion in sagital plane and varus
rotation in the form of external rotation in a frontal plane. All these movements occur at fifth
metatarsophalangeal joint. Sometimes associated with contracture with in fifth toe.This
deformity can be corrected surgically by Consolidated surgical approach which has given
good result but statistical analysis is awaited for the clinical observations.7This deformity was
due to malposition of fifth toe for long time in the uterine cavity during intra uterine life
8
.The biphalangeal fifth toe is one of the common variation in European population. The
incidence is higher in Japanese population and it considered to be anatomical variation of
triphalangeal fifth toe. The incidence of biphalangeal toe associated with hammer or claw
toes is 65%, bunionettes-47% and overriding of fifth toe- 37%. It is the group of hammer toe
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Arun Kumar et al.
World Journal of Pharmacy and Pharmaceutical Sciences
or claw toe which is considered to be significantly high when compared that of control group
(37%). It is concluded that the rigidity and stiffness caused by biphalangeal fifth toe is the
predisposing for the formation of hammer or claw toe 9(ref 74). The single line of treatment
for the correction of fifth adducted toe is Butler arthroplasty A study was done in North
America in the year 1968-1982 where thirty six operations have been conducted.Out of
them, thirty operation were unilateral, six operation were bilateral.The study showed, thirty
four out of thirty six has given excellent results.10This deformity has to be corrected in the
early part of life in order to prevent disability in later part of life11.
Legend-1, Photograph showing An unusual malposition of 4th toe ovewrelapping
overlapping on 5th toe.
WIDENING OF SPACE BETWEEN BIF TOE AND SECOND TOE ALSO SEEN
Legend-2 Photograph showing An unusual malposition of 4th toe ovewrelapping
overlapping on 5th toe.
WIDENING OF SPACE BETWEEN BIF TOE AND SECOND TOE ALSO SEEN
PRESENT STUDY
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World Journal of Pharmacy and Pharmaceutical Sciences
Has shown mal position and
lower placement of 4th toe overriding on 5th toe unlike as
found in the literatures where there is overriding of 5th toe on the 4th toe.Length of all the
medial toes of the right foot were normal ,but the length of 4th and 5th toes were very much
shorter than the other toes in the same foot. First and second interdigital cleft were present
but interdigital cleft between 3rd and 4th also 4th and 5th was obscured due to overriding of 4th
on the fifth toe.This may be due to compression of toes in the uterine cavity during
intrauterine life(as suggested by Lantzounis.) (ref 73)
or
may be developmental error
causing malpositioning of 4th toe.There was no adducted position of the fifth toe which has
caused disability. Fifth toe is not laterally rotated and there is no contraction of capsule of
that metatarsophalangeal joint on its dorsal aspect.
CONCLUSION
The deformity of limbs has important embryological importance .Some times there may be
associated anomalies.These deformities will be challenging for the orthopaedic surgeons to
give the patients better life because very few deformities can be corrected surgically while
others have high rate morbidity.Hence it has been studied and reported.
TAKE HOME MESSAGE
These anomalies of toes are causing difficulty in walking and in females ,they are more
conscious about their deformity .Hence ,if operable they should be corrected in order to
minimise their mental trauma as well for better gait
REFERENCES
1 ) J. Cockin, Oxford, Butler’s Operation for an overriding of fifth toe : The Journal of Bone
and Joint Surgery, Vol-. 50 B, NO.- 1, February 1968, pp 78-81.
2)McCarland. B. (1950): Congenital Deformities of the Spine and Limbs. In Modern Trends
in Orthopaedics, p. 107. Edited by Sir Harry Platt. London: Butterworth & Co.
(Publishers) Ltd.
3) Scrase, W. H. (1954): The Treatment of Dorsal Adduction Deformities of the Fifth Toe.
Journal of Bone and Joint Surgery, 36-B, 146.
4) Lapidus P. W. (1942): Transplantation of the Extensor Tendon for Correction of the
Overlapping Fifth Toe. Journal of Bone and Joint Surgery, 1942 24, 555-9.
5) Colonna , P. C. (1950): Regional Orthopedic Surgery. Philadelphia and London: W. B.
Saunders Company. , p. 492.
6) BUTLER, R. W. (1964): Personal communication.
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7) Micbael S. Dounelt, DPM, FACFAS, Congenital Overlapping of fifth toe, Deformity: A
Consolidated Surgical Approach
8) Lantzounis
LA.:. Congenital subluxation of the
fifth toe and
its correction by a
periosteocapsuloplasty and tendon transplantation. J Bone Joint Surg 1940; 22: 147-50
9)Dereymaeker G, van der Broek C. Biphalangeal fifth toe. Foot Ankle Int. 2006
Nov;27(11):948-51.
10) Black GB, Grogan DP, Bobechko WP. Butler arthroplasty for correction of the adducted
fifth toe: a retrospective study of 36 operations between 1968 and 1982. J Pediatr
Orthop. 1985 Jul-Aug;5(4):439-41.
11)DeGnoreI.T,:The Congenital overlapping of 5th toe :Foot ankle Clin ;1978:3:313-19.
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