Here are some examples of toe pathology followed by interpretations (*):
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.
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.)
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.)
Lateral view. The 2nd MPJ is dorsiflexed, the PIPJ is plantarflexed, and the DIPJ is plantarflexed. Diagnosis: claw toe.
Lateral view. The 2nd MPJ is minimally dorsiflexed and the PIPJ is minimally plantarflexed, but the DIPJ is plantarflexed. Diagnosis: mallet toe.
Dorsoplantar view. The 5th toe is angled and rotated medially in the transverse and coronal planes, respectively. Diagnosis: adductovarus deformity.
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.)
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.
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.
Dorsoplantar view. The phalanges of the 2nd and 3rd toes are joined together within the soft tissue confines of one digit. Diagnosis: syndactyly.
DP view. The second digit proximal phalanx gives rise to two separate middle and distal phalanges. Diagnosis: polydactyly.
Dorsoplantar view. The first metatarsal head articulates with two separate halluces. Diagnosis: polydactyly.
Medial oblique view. This child has seven toes and metatarsals. Diagnosis: polydactyly.
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.)
Yes, if symptomatic.
Order dorsoplantar, medial oblique, and lateral oblique views.
Special studies are generally not indicated; however, ultrasound and MRI could be useful for assessing soft tissue pathology.
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.