Some Pathologies of the Fifth Ray
French ladies are concerned by this fifth ray pathology because they like narrow shoes, and we observe that a narrow shoe is mainly obtai- ned by narrowing the last and the sole on their lateral part.
Hammer or Claw Toe
When the fifth toe is too long, it has no place in ladies shoes, so that the hammertoe has to be corrected and the fifth toe reduced. But the rela- tionships with the fourth toe has to be taken into account, notably the long flexor tendon shortness.
Fig. 37a. Some pathologies of the fifth ray – (1) Hammer or claw toe.
1. The assessment of correct lateral shape (thus of the corresponding toe shortening) of the forefoot is made by this test.
2, 3. When the fifth toe is too long, it has no place in ladies shoes. This results in hammer or claw toe we have to correct while reducing the toe length.
4. In such hammertoe, we often observe that there are only two phalanges on the fifth toe.
5. We perform a distal resection of the first phalanx combined or not with a long flexor distal section and if necessary with extensor tendon lengthening. Sometimes we also have to correct the combined fourth toe deformity.
6. Our aim: The possibility for our patients to fit this type of shoe.
Fig. 37b. Some pathologies of the fifth ray – (2) Intractable intercommissural keratosis.
1. This painful lesion may be explained in the dorso-plantar X-ray view (2). The lateral aspect of the fourth metatarsal head (sometimes too protuberant) has a too close contact with the medial aspect of the first phalanx of the fifth toe.
2, 3. The solution is a small shortening of the fourth metatarsal by scarf or Weil osteotomy (in this case, Weil).
Intercommissural Keratosis
In this painful lesion, which is almost only loca- ted on the fourth interdigital proximal edge, we
observe that the main cause is an incorrect rela- tionship between the last two metatarsal and phalanx, leading to a specific surgery.
Fig. 37c. Some pathologies of the fifth ray – (3) Overlapping fifth toe.
Lapidus procedure: Pictures provided by courtesy of P. Diebold (Nancy, France).
1. Aspect of the deformity.
2. Skin flap to be performed.
3. Extensor tendon is cut proximally; it remains distally attached.
4. The tendon is passed through the phalanx basis, from dorsal to plantar face, then it is laterally and plantarly pulled and attached to the lateral capsule.
5, 6. Result.
Overlapping Fifth Toe
The Lapidus procedure is a good solution for correcting this deformity, as indicated by P. Die-
bold (Nancy) [49] who provided the picture of this plate.
Fig. 37da. Some pathologies of the fifth ray. Taylor’s bunion. Generalities.
The taylor’s position (in the past) increased or provided the taylor’s bunion deformity.
1. The lateral part of the fifth metatarsal head is prominent, either by itself, or mainly as the top of the metatarso-phalangeal angulation.
2. In some cases, the prominence is also plantar.
3, 4. Two kinds of metatarsal shapes have to be distinguished:
3. Straight metatarsal. 4. Curved metatarsal “lame de sabre”.
5. Diverging first and fifth metatarsals.
Taylor’s Bunion
This interesting deformity presents some anato- mical specificities we have studied. This led to a specific surgery.
Fig. 37db1. Taylor’s bunion correction – (1) Scarf osteotomy. First steps.
1. The long scarf osteotomy of the fifth metatarsal allows a large medial shift while keeping stability.
2. Section of the MTP collateral ligaments is necessary to avoid postoperative excessive dorsal flexion of the first phalanx.
3, 4. As for the first ray, the PPE (Proximal Plantar Exposure) allows to perform the longitudinal cut close to the plantar surface, so preserving the medial surface which works as a strong longitudinal beam, useful in large displacements. The large “ciseau de cauchoix” also allows to protect the soft tissue and to control the sawing for the proximal transverse cut.
5. Transverse cuts, chevron shaped, to increase the osteotomy stability. Nevertheless, screw fixation is useful.
We think that, like for the first ray, we have to keep the metatarsal head cartilage in a frontal plane, so that we do not use osteotomies crea- ting rotation of this head. Elevation or shorte- ning are sometimes required in combination with the medial shift of the head. We use the scarf or Weil osteotomy with different indica- tions, which are reported. The technique and the results for each procedure are detailed. In each of these techniques, section of the collate-
ral ligaments is critical in making the approach to preserve a correct ground contact of the fifth toe. For isolated deformity, the scarf osteotomy is indicated. We reserve the Weil osteotomy when the fifth metatarsal osteotomy is combi- ned with the other lesser metatarsal osteoto- mies.
The fifth metatarsal scarf osteotomy: An accurate technique allows to avoid drawbacks and provides reliable results.
Fig. 37db2. Taylor’s bunion correction – Scarf osteotomy. Lateral shift: Fixation.
1. Medial displacement by lateral shift it is not a medial rotation, not to result in medial obliquity of the MTP joint. The plantar fragment can be pushed as far as two third of the surface.
2. The twist-off screw (DePuy) ensures strong fixation; its distal obliquity increases both the dorso-plantar and the longitudinal congruence of the fragments.
3, 4. Clinical and radiographic results.
Fig. 37db3. Taylor’s bunion correction – Scarf osteotomy. Shortening, elevation.
1. Both lateral and plantar prominence.
2. Shortening with the Maestro cut.
3. A distal closing wedge is performed from the dorsal fragment; in order not to fragilize this fragment, the longitudinal cut has to reach the head in its central aspect (not too much dorsally).
4. Radiographic aspect of the fifth metatarsal elevation (here combined with shortening).
Fig. 37db4. Taylor’s bunion correction – Scarf osteotomy. Drawbacks to avoid.
1, 2, 3. Postoperative remaining hammertoe or claw toe is avoided by the collateral ligament section performed during the surgery.
4, 5, 6. Fracture of the dorsal fragment is observed at the level of the transverse proximal cut. The PPE allows to avoid this drawback by performing under sight control a longitudinal cut very close to the plantar fragment and the transverse cut which is not too generous (not on the dorsal fragment).
7, 8, 9. Overcorrection results from excessive medial shift of the plantar fragment. It can easily be avoided by the distal screwing.
The Weil fifth metatarsal osteotomy: We distinguish the single metatarsal and the osteo-
tomy performed in combination with the other lesser metatarsal osteotomies.
Fig. 37dc1. Taylor’s bunion correction – Weil osteotomy. 1. Single metatarsal osteotomy.
1. Medial head displacement by Weil osteotomy corrects the deformity.
2, 3. Operative view.
4, 5. Clinical and radiological results.
6. Care has to be taken not to shorten excessively the fifth metatarsal which must not be 12 mm shorter than the fourth metatarsal.
Fig. 36dc2. Taylor’s bunion correction – Weil osteotomy. 2. Included in a whole lesser metatarsal shortening.
When Weil osteotomy is indicated on the four lesser metatarsals, it is easy to include a medial displacement of the fifth metatarsal head, to correct the combined taylor’s bunion, respecting the relative length of the metatarsals.
4, 5. Clinical and radiological results.
Fig. 37dc3. Taylor’s bunion correction. Lady’s footwear.
1. Diverging first and fifth metatarsal can be corrected by scarf osteotomies on these two metatarsals: X-ray aspect.
2. Clinical aspects. In France women like narrow shoes (as well as in other countries!).
The aim of the tailor’s bunion surgery is not only to relieve the pain but also to narrow this
lateral part of the foot that is critical for wea- ring elegant and narrow shoes.
