Forefoot and Toe Deformities in Cerebral Palsy

Abstract

Forefoot problems in children with cerebral palsy (CP) are almost always cosmetic but may cause symptoms such as irritation with shoe wear. There are multiple different deformities including bunions, hallux valgus, dorsal bunions, claw toes, hammertoes, and prominent metatarsal head weight-bearing. The vast majority of these deformities are coexistent with hindfoot and midfoot planovalgus deformities. As such these deformities almost always are managed concurrent with correction of the hindfoot deformity. Forefoot supination and the associated dorsal bunion often include a fixed flexion deformity of the hallux. The treatment of this requires correction of the forefoot supination. The common hallux valgus deformity with a bunion is usually caused by lateral weight-bearing on the hallux due to planovalgus deformity and external foot progression angle. Hammertoes and claw toes may be isolated to one or two toes. It is uncommon in CP to have all the lesser toes in a claw or hammertoe position. Ingrown toenails are very common in children with CP due to the high forces that tend to be applied to malposition of the hallux. Treatment of toe deformities usually requires concomitant correction of the hindfoot planovalgus position. Correction of the hallux valgus and bunion may be performed with realignment procedures and in severe cases or recurrent deformities with fusion of the first metatarsal phalangeal joint. Correction of hammertoes and claw toes is relatively simple with tenotomy of the flexor tendon. Treatment of ingrown toenails usually requires radical lateral border resection for permanent resolution.