Toe Pathology

Radiographic toe pathology includes:

  • contracture (hammer toe, claw toe, mallet toe, and adductovarus toe)
  • fracture
  • congenital deformity (polydactyly, macrodactyly, syndactyly)

Here are some examples of toe pathology followed by interpretations (*):

  • Case 1
  • *Case 1
  • Case 2a
  • Case 2b
  • *Case 2a
  • *Case 2b
  • Case 3
  • *Case 3
  • Case 4
  • *Case 4
  • Case 5
  • *Case 5
  • Case 6
  • *Case 6
  • Case 7
  • *Case 7
  • Case 8
  • *Case 8
  • Case 9
  • *Case 9
  • Case 10
  • *Case 10
  • Case 11
  • *Case 11
  • Case 12
  • *Case 12
  • Case 13
  • *Case 13
hammertoe dphammertoe lateral
hammertoe dp markedhammertoe lateral marked

Dorsoplantar and lateral views. The 2nd MPJ is dorsiflexed, the PIPJ is plantarflexed, and the DIPJ is dorsiflexed (lateral view). As a result, the ends of the proximal phalangeal head (white arrows) and middle phalangeal base (black arrows) are superimposed upon one another in the dorsoplantar view. Diagnosis: hammer toe.

claw toe dp
claw toe lateral
claw toe dp marked

Dorsoplantar view. The 2nd toe PIPJ and DIPJ are not clearly visualized due to the plantarflexion contractures at these joints (see *Case 2b). Diagnosis: claw toe. (This patient recently had bunion surgery: the medial eminence of the first metatarsal head is absent, a wedge of bone has been removed from the hallux proximal phalanx proximal diaphysis and fixated with circlage wire such that the distal half angulates medially, and increased soft tissue density and volume surrounds the operative site.)

claw toe lateral marked

Lateral view. The 2nd MPJ is slightly dorsiflexed, the PIPJ is plantarflexed, and the DIPJ is plantarflexed (lateral view). Diagnosis: claw toe. (The hallux and wire fixation are superimposed on the 2nd toe proximal phalanx.)

claw toe lateral view
claw toe lateral view marked

Lateral view. The 2nd MPJ is dorsiflexed, the PIPJ is plantarflexed, and the DIPJ is plantarflexed. Diagnosis: claw toe.

mallet toe lateral
mallet toe lateral marked

Lateral view. The 2nd MPJ is minimally dorsiflexed and the PIPJ is minimally plantarflexed, but the DIPJ is plantarflexed. Diagnosis: mallet toe.

adductovarus toe
adductovarus toe marked

Dorsoplantar view. The 5th toe is angled and rotated medially in the transverse and coronal planes, respectively. Diagnosis: adductovarus deformity.

transverse fracture
transverse fracture marked

Medial oblique view. A transversely-oriented linear decreased density runs across the 5th toe proximal phalanx at the junction of the base and diaphysis separating the bone into two segments. There is minimal angulation or displacement. Diagnosis: transverse fracture. (Incidental finding: the 5th toe DIPJ is absent and the middle and distal phalanges are united as one bone. Diagnosis: synostosis.)

comminuted fracture
comminuted fracture marked

DP view. The 4th toe proximal phalanx is separated into three segments. The diaphyseal segment is angulated medially relative to the basal segment (there may also be rotation); the head segment is displaced and angulated laterally relative to the diaphyseal segment and is in a "bayonet" position. The phalanx is shortened as a result. Diagnosis: comminuted fracture.

phalangeal ridge
phalangeal ridge marked

Dorsoplantar view. The arrows point to the phalangeal ridge, which is present along the diaphyseal margins of the 2nd through 4th toe proximal phalanges. It serves as the insertion site for the extensor hood. It varies in size and may not be as prominent as they are here. The phalangeal ridge is a normal /variant finding and is featured here because it is sometimes misinterpreted as a periosteal reaction.

syndactyly
syndactyly marked

Dorsoplantar view. The phalanges of the 2nd and 3rd toes are joined together within the soft tissue confines of one digit. Diagnosis: syndactyly.

extra toes PIPJ
extra toes PIPJ

DP view. The second digit proximal phalanx gives rise to two separate middle and distal phalanges. Diagnosis: polydactyly.

extra toe mpj
extra toe mpj marked

Dorsoplantar view. The first metatarsal head articulates with two separate halluces. Diagnosis: polydactyly.

extra toes mets
extra toes mets marked

Medial oblique view. This child has seven toes and metatarsals. Diagnosis: polydactyly.

absent middle phalanges
absent middle phalanges marked

DP view. The middle phalanges of the 2nd and 3rd toes are absent. Diagnosis: congenital anomaly. (Incidental finding: the 5th toe DIPJ is absent and the middle and distal phalanges are united as one bone. Diagnosis: synostosis.)

Should a radiographic study be ordered for evaluation of toe pathology?

Yes, if symptomatic.

What are the best views to order?

Order dorsoplantar, medial oblique, and lateral oblique views.

  • the lateral oblique view provides a sagittal plane perspective of the 4th & 5th toes;
  • the lateral view could be added when the focus is one the first and/or second toes.
When should additional imaging studies be ordered?

Special studies are generally not indicated; however, ultrasound and MRI could be useful for assessing soft tissue pathology.

Related Information

Synostosis of the lesser toe DIPJ is very common with the 5th toe. When there is synostosis of the 4th toe (less common), there is almost always synostosis of the 5th also. This holds true with the 3rd toe DIPJ synostosis (uncommon) where there will also be synostosis of the 4th and 5th toes.

References:

  1. Christman, RA: Foot and Ankle Radiology, Churchill Livingstone, 2003.