I met with a charming young family several weeks ago. They came in with a very articulate, rambunctious 3-year-old boy who had a simple complaint. “My toes are stuck together!” he said.
When questioned a little further, he admitted that, “Sometimes it rubs on my shoes and my toes stay over each other.” I was amazed how just a few words given by this young lad pretty much gave me all the information I needed to start discussing what was going on with the parents of this very bright child.
Interestingly, the most common type of syndactyly is in the foot and of the second and third toes, which is what this little boy had.1 It occurs in approximately one in 2,000 births and can have significant psychological impact on the people it affects.2 There are two types of syndactyly: type 1, which presents as mostly cosmetic issues, and type 2, which presents functional issues and usually demands surgical intervention.3
After more discussion with the child’s parents, it was clear that this was beginning to present a functional issue with their child as he was having a hard time with shoes and blistering. His second toe distally overlapped the distal aspect of his third toe as the syndactyly ended between the proximal and distal interphalangeal joints. They had also already tried buddy splinting the toe, which the child didn’t tolerate and also failed to relieve the deformity.
I first had them get radiographs (in that particular office, we send out for films) to make sure the young lad had normal bone structures. He did. In the past, I have seen one proximal phalanx to the two distal aspects of the toes so I wanted to make sure this was not the case this time.
I explained to the parents that the goals of our treatment would be to relieve their son’s pain and achieve proper alignment of the toes so he can wear his shoes comfortably.4 Happily, I’ve had a good bit of experience correcting these cases so I explained to the parents what the potential surgical repair would entail.
There are two common types of procedures to correct this mostly dermatological issue. One involves creating a triangular flap out of the skin in the interspace area, using a skin graft (mostly from the sinus tarsi) to reconstruct any tissue that the triangular flap does not take into account.2 I do not prefer this method as I find that creating a rectangular flap both dorsally and plantarly creates a better template for full defect coverage without any ancillary skin requirement. One aspect of this I hadn’t really ever considered was that there may be a skin color difference between the plantar and dorsal skin, and this could cause the toes to be different colors.5 I had never encountered this complaint but I can see how this can be a concern for the parents as the child grows.
Some have discussed using absorbable sutures for skin closure. While this can cause less psychological trauma for the child, I do not personally favor this method.6 I find it causes both excessive swelling and irritation as the sutures resorb. This in turn can cause the child to pick at the area and disrupt the very fragile flaps created. I will use non-absorbable sutures and have the child take a mild sedative (antihistamine or anti-nausea medicine) prior to the suture removal visit.
I should mention that flap necrosis is a very real possibility with this procedure, even with the young, healthy tissue we are dealing with, so this is something to discuss with the family as a potential complication. This may even require some form of skin grafting down the road but there are so many skin equivalents available, a second trip to the OR is rarely indicated.
This is a very challenging situation in many respects. One should have the utmost confidence in discussing the potential outcomes and complications for such a delicate procedure as you may be dealing with apprehensive parents and potentially, a very scared little boy or girl. Postoperative care of the wounds is also an important aspect to discuss with parents. Finally, the procedure is technically challenging. The skin is very fragile and it is important to avoid the very tiny neurovascular bundles in the area. Performing this procedure successfully can be stomach churning.
The most unfortunate aspect of this deformity is how rarely we see it. It is even more rare to see it in the operating room. I would like to hear your thoughts on this topic. Please send me your thoughts or questions.
1. Castilla EE, Paz JE, Orioli-Parreiras IM. Syndactyly: frequency of specific types. Am J Med Genet. 1980; 5(4):357-64.
2. Marsh DJ, Floyd D. Toe syndactyly revisited. J Plast Reconstr Aesth Surg. 2011; 64(4):535-40.
3. Mondolfi PE. Syndactyly of the toes. Plast Reconstr Surg. 1983; 71(2):212-18.
4. Lee HS, Lee WC. Congenital lesser toe abnormalities. Foot Ankle Clin. 2011; 16(4):659-78.
5. Kajikawa A, Ueda K, Katsuragi Y, Momiyama M, Horikiri M. Aesthetic repair for syndactyly of the toes using a plantar rectangular flap. Plast Reconstr Surg. 2010; 126(1):156-62.
6. Cisco RW, Pitts TE, Cicchinelli LD, Caldarella DJ. Bilateral syndactyly: a unique case with surgical correction. J Am Podiatr Med Assoc. 1993; 83(11):645-50.