A 68-year-old female patient with diabetes diagnosed at the age of 50 years and treated with insulin, was referred to the outpatient diabetic foot clinic because of foot deformities and recurrent superficial toe ulcers.
The patient had findings of peripheral neuropathy. Peripheral pulses were palpable. No other diabetic complications were present.
Onychomycosis was noticed and confirmed by direct microscopic examination of nail specimens. The skin on her feet was dry; hallux valgus and hammer toe deformity of her second left toe were observed. Tiny superficial ulcers on the dorsum of her second and third toes due to shear pressure were present, as well as a small ulcer on the inner aspect of her great toe, and
Figure 3.20 Hallux valgus, overriding toe, claw toes and edema
Mild hallux valgus and hammer toe deformity on the right second and third toes was apparent, with a superficial ulcer on the dorsum of the second toe (Figure 3.24). Hammer toe is a complex deformity consisting of contraction (hyperflexion) of the proximal interphalangeal joint, while the metatarsophalangeal joint is either dorsi-flexed or in the neutral position. The distal interphalangeal joint may be in the neutral position, hyperextended or in plantar flexion (Figure 3.25). Hammer toe may be flexible or rigid.
Overriding toe deformity often occurs in the second and the fifth toes. The cause of the overriding fifth toe is mainly congenital, while a second overriding toe is acquired and multifactorial. Elongation and laxity of the plantar synovium bursa of the metatarsal joint result in dorsal subluxation of the affected joint. The second toe lacks plantar interossei muscles, therefore lum-brical muscles predominate, causing dor-siflexion of the toe. Subluxation of the metatarsophalangeal joint results in shrinkage of the dorsal synovium bursa and the dorsal interossei muscles. Further atrophy of the intrinsic muscles contributes to the development of the deformity which may be fixed or flexible.
Figure 3.21 Hallux valgus, overriding toe, claw toes and edema. Plantar aspect of the foot illustrated in Figure 3.20
Keywords: Onychomycosis; hallux valgus; hammer toe deformity
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