Sunday, November 16, 2014

Great Toe Polydactyly (extra toes)

It might seem odd that I am writing about extra toes.  Typically, hand surgeons don't take care of the foot but, in many situations, the hand surgeon is the perfect person to help take care of certain foot problems including extra toes, toe syndactyly (toes joined together), and even things like cleft foot. The reason I feel that the hand surgeon can help with certain foot problems is pretty clear- the foot issues are similar to the hand problems and the reconstruction techniques are very similar.  This not to say that there are plenty of great pediatric orthopedic surgeons who can care for toe and foot issues like these, because there certainly are.  

I have previously blogged about extra toes- find that here.   I hope to also post about toes on the outside of the foot- there are a bit easier to address and less critical for balance and walking.

It is key that the big toe be as sound as possible with reconstruction.  We want to create the right sized digit (i.e., one that won't cause problems wearing shoes) that has good motion and is stable.   To me, this is very similar to reconstructing the extra thumb as the goals are similar and the thumb and the great toe are critically important to hand and foot function.  The timing is debatable.  Some surgeons chose to operate before the child really starts walking as it makes the recovery easier while other wait longer as the toes get larger (and operate at 18-24 months).  I prefer to operate before walking but there are a number of factors to consider and discuss with each family.

Surgically, the reconstruction involves the following:
1) The skin.  We need to create a great toe that is not tensioned by the skin immediately or in the future (from scarring).
2) Removing the extra toes.  Ideally the smaller toe or the toe with greater challenges from a bony or ligament standpoint.  Sometimes, as in this case, the toes are relatively equal and this decision is not quite as straightforward but typically we remove the inner toe.
3) Stabilize the remaining toe to create good ligaments
4) Make sure the remaining toe is as straight as possible and is well set up for growth in the future.  There is always a chance that there will need to be a surgery later but hopefully it can be avoided if we get good balance with the first surgery.
5) Address the toenail.  This can be quite challenging with conjoined nails but the goal is a well balanced toe with good nail support.

I typically cast for about 5 weeks and often use a pin to stabilize the healing toe.  That pin is removed at the time of cast removal.  Here is a case example.  The x-rays are particularly interesting as there are delta phalanges on both sides- that is the bones are not the typical rectangular shape but are curved which can indicate an abnormal growth plate.  This may be corrected at the initial surgery.

Extra great toes with conjoined nails (synonychia is the technical term).  Note that there is some deviation of the toes.

Weight bearing with even more deviation noted in the extra great toes.

X- rays of the extra great toes.  Note that the feet are different.  
3 months after surgery.  The child is walking well and the family is very pleased.  
Great toes after reconstruction.  Excellent alignment has been achieved.  The nails are imperfect.
Great toe after reconstruction.  Right.

Great toe after reconstruction. Left.


  1. hello. I was wondering if you had to do follow up surgery on your patience with this condition. My daughter was operated on for the same condition 18 month old. Now that she is 7 years old she is not only complaining of great pain and her baby tell but it seems to be bending inward and creating a protuding bunion.

    futhermore, have these patients needed further surgery and/or treatment as they reach full maturity, say at the age of 18 and over? many thanks!

    1. Chitown Momma,

      Thanks for your question. Only rarely have we had to perform followup surgery in this situation but certainly that need can occur and, when required, can be helpful. The goal with any surgery is to align the toes (and growth plates) to allow future growth without the need for additional surgery down the road. But, you are correct, surgery can be required all the way to the time of skeletal maturity (maybe aged 14) but hopefully not after.

    2. Hello, and thank you for the information concerning "synonychia", of which I have on both feet. I haven't had any surgeries to correct them, though I have always thought about it. I'm almost 50 now, so I don't see need to do so now. Thanks again : )

  2. My daughter had corrective surgery at the age of 6 months. She is now almost 3, and her toes are kind of a mess. I wish I wouldn't have trusted the one and only orthopedist we consulted so quickly. We are now seeing a podiatrist and know she will need at least 2 follow-up surgeries. On top of a lot of extra tissue left, leaving very bulky toes, they are "tethering" b/c of the scars. There is also extra bone still left that will need to be cleaned out. She walks quite "flat-footed" and I have to think her toes play a role in that.
    I have googled polysyndactyly, Griegs Syndrome, etc. a million times and am just now finding this page. Wish I would have found it sooner! Wish you could have worked on my daughter...the results above are astonishing!!!

    1. Angi,
      Good luck with your daughter. Sometimes more time can help things but it is really important to find a surgeon with experience in this particular area (at the first surgery and now). The growing foot is not the same as the adult foot- usually pediatric orthopedic surgeons are the best ones to help in this area. And, as you know, every child is different so it is difficult to compare the pictures above with your daughter (but thank you very much).

  3. What age did you do this surgery? And l, what age would you recommend this surgery done? My daughter has one on her right toe and right ring finger. She's 8 months old now. Thanks.

    1. You daughter is 10 months now and is a candidate for surgery. The timing for the foot may be affected by weight bearing age and so sometimes we aim for surgery at the 9-10 months age although older kids can do just fine. And the hands presumably can be treated at a similar time.

  4. Hello Charles. My daughter is 2 years old and has the same problems that looks in these pictures. She dont have any problems to walk and run. But I think that the problems will be to wear shoes in the future. We have to buy shoes 1 or 2 size more large. Is necessary the surgery. Is urgent or we can spect to talk with her when she will be 6 or 7 years old about the surgery.

    1. Shoe wear and social issues are the challenges. I typically recommend that families go ahead and consider surgery at a younger age (or accept the limitations and shoe wear needs). Even at age 6 or 7, kids are not able to make an informed decision about surgery- if you really want her input, you probably need to wait until she is at least 12 or older.

    2. Dear Doctor: Thank you very much for your advice. My wife and I have decided to operate our daughter, taking into account your recommendations to surgery in early age.