Sometimes you have to think outside of the box. This is especially the case when it comes to possible surgical intervention in the pediatric population. Even the simplest procedure can test your skills and experience.
Recently, a very pleasant family brought in their two and a half year-old daughter so she could be evaluated for “walking problems.“ I eventually diagnosed these walking problems as a severe metatarsus adductus. I decided to attempt conservative management with a custom-molded orthotic with a medial flange. This initially helped the toddler.
Upon the initial examination, I also noted a pretty significant underlapping third toe. Since she was not ambulating much due to her in-toeing and pain, it was asymptomatic at the time.
Several months later, this young patient was happily running around with her friend in her new orthotics during the day. However, she was now complaining to her mother at night to the point of tears about that “crooked” third toe. I attempted conservative treatment with splinting but this unfortunately failed to relieve her symptoms.
At this point, the child’s mother asked about surgical options. The literature suggests a syndactyly procedure. Do we approach this as we would an adult hammertoe procedure? That is an option.
As we learn in school, we can follow the procedure of removing the proximal interphalangeal joint (PIPJ) by performing a derotational skin plasty. In a patient so young, this is risky as it can damage the epiphysis of the middle phalanx and lead to a shortened toe. Will a simple tenotomy do the trick? It can but this should not be the focus of the discussion as one needs to make the patient’s family aware of all the possibilities.
The patient’s mother wanted to try the hammertoe repair even though she was aware of the potential risks.
On the day of surgery, as I manipulated the toe and reviewed the X-rays, it became clear that the first thing I should attempt was a simple flexor tenotomy. I thought this would be necessary in any case. I had considered repairing the hammertoe first via the PIPJ arthroplasty and derotational skin plasty, and seeing if this was sufficient. Rather than do all of that, it seemed more reasonable to just perform the tenotomy. This would also prevent any damage to the epiphysis of the middle phalanx.
Even though this seems like a simple procedure on its surface, it did take some thought and previous experience to come to the conclusion that simpler is better. As my practice partner always tells me, no one will ever fault us for being too conservative surgically. This is especially the case when dealing with pediatric patients.
If you have an interest in how this case turned out, please e-mail me at firstname.lastname@example.org  and I will see if I can forward the pre-operative and post-operative films for this case.