Curly toes are the most common deformity of the lesser toes.The fourth and fifth toes are most commonly affected. Curlytoes are characterized by flexion at the proximal interphalangeal joint with lateral rotation of the toe. It is caused bycontractures of the flexor digitorum brevis and longus tendons. Some curly toes will spontaneously resolve by 3 to 4years of age. Persistent deformity may be treated by surgical tenotomy.
Polydactyly (extra toes) is usually found on the initial newborn physical examination. When the extra toe is adjacent to the fifth toe and attached by only a stalk of soft tissue or skin, simple ligation or amputation is effective. When the deformity involves the great toe or middle toes, or when the extra digit has cartilage or bone, delayed surgical intervention is indicated. Syndactyly (fusion of toes) is more common than polydactyly. It is usually a benign cosmetic problem. Both syndactyly and polydactyly may be associated with malformation syndromes (Table 201-2).
Disorders Associated with Syndactyly and Polydactyly
A simplified classification of the common spinal abnormalities, scoliosis and kyphosis, is presented in Table 202-1.
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Most patients will present for evaluation of an asymmetrical spine, which is usually pain free. A complete physical examination is necessary for any patient with a spinal deformity, because the deformity can indicate an underlying disease. The back is examined from behind (Fig. 202-1). First, the levelness of the pelvis is assessed. Leg-length discrepancy produces pelvic obliquity, which often results in compensatory scoliosis. When the pelvis is level, the spine is examined for symmetry and spinal curvature with the patient upright. Cutaneous lesions (hemangioma, skin dimple, or hair tuft) should be noted. The spine should be palpated for areas of tenderness.
The patient is then asked to bend forward with the hands directed between the feet (Adams forward bend test). The examiner should inspect for asymmetry in the spine. The presence of the hump in this position is the hallmark for scoliosis. The area opposite the hump is usually depressed because of spinal rotation. Scoliosis is a rotational malalignment of one vertebra on another, resulting in rib elevation in the thoracic spine and paravertebral muscle elevation in the lumbar spine. With the patient still in the forward flexed position, inspection from the side can reveal the degree of roundback. A sharp forward angulation in the thoracolumbar region indicates a kyphotic deformity. It is important to examine the skin for café au lait spots (neurofibromatosis), hairy patches, and nevi (spinal dysraphism). Abnormal extremities may indicate
Failure of formation Wedge vertebrae Hemivertebrae
Failure of segmentation Unilateral bar Bilateral bar
Adapted from the Terminology Committee of the Scoliosis Research Society, 1975.
skeletal dysplasia, whereas heart murmurs can be associated with Marfan syndrome. It is essential to do a full neurologic examination to determine whether the scoliosis is idiopathic or secondary to an underlying neuromuscular disease, and to assess whether the scoliosis is producing any neurologic sequelae.
Estimating of rib hump and evaluation of curve unwinding as patient turns from side to side
Measuring of rib hump with straight edge
Measuring of leg length for
Medial malleolus A B iliac spine A determination of pelvic obliquity AB = actual length A B = apparent leg length Figure 202-1 Clinical evaluation of a patient with scoliosis.