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Extensor Apparatus of The Lesser Toes: Anatomy With Clinical Implications - Topical Review
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Extensor Apparatus of the Lesser Toes: Anatomy With Clinical Implications−−Topical Review
Miquel Dalmau-Pastor, Betlem Fargues, Enric Alcolea, Nerea Martínez-Franco, Patricia Ruiz-Escobar, Jordi Vega and Pau
Golanó
Foot Ankle Int 2014 35: 957 originally published online 16 September 2014
DOI: 10.1177/1071100714546189
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What is This?
Topical Review
Foot & Ankle International®
Abstract
Lesser toe deformities are one of the most common conditions faced by orthopedic surgeons. Knowledge of the anatomy
of the lesser toes is important for ensuring correct diagnosis and treatment of deformities, which are caused by factors
such as muscle imbalance between the extensor apparatus and flexor tendons. However, this apparatus has not received
sufficient attention in the literature. In addition, the large number of inaccurate and erroneous descriptions means that
gaining an understanding of these structures is problematic. The objective of the present article is to clarify the anatomy
of the extensor apparatus by means of a pictorial essay, in which the structures involved will be grouped and discussed in
detail. The most relevant clinical implications will be addressed.
Level of Evidence: Level V, expert opinion.
Figure 1. Anatomical dissection of the dorsum of the foot showing the main components of the extensor apparatus. Neurovascular
structures were removed. (A) Dorsal view. (B) Lateral view. (1) Extensor digitorum longus tendons. (2) Middle or central slip. (3)
Lateral slips. (4) Terminal tendon. (5) Extensor digitorum brevis tendons. (6) Extensor sling. (7) Triangular lamina. (8) First dorsal
interosseous. (9) Extensor hallucis longus tendon. (10) Peroneus tertius tendon. (11) Abductor digiti minimi tendon.
images of the extensor apparatus of the foot led us to pres- In order to better understand the extensor apparatus, and
ent this article as a pictorial essay that will provide readers following the structure established by Sarrafian and
with an up-to-date visual portrayal of the anatomy of this Topouzian,38 we identified 3 basic components: the extrinsic
structure. contribution, which is formed by the extensor digitorum lon-
gus; the intrinsic contribution, which is formed by the exten-
sor digitorum brevis, lumbrical muscles, and interossei
Extensor Apparatus muscles; and a third component, which we term the stabiliz-
Current knowledge of the anatomy and function of the ing ligaments, comprising the extensor sling, extensor wing,
extensor apparatus of the lesser toes is limited. Most stud- and triangular lamina. As their names indicate, the main
ies focus on the extensor apparatus of the hand, with less function of these ligaments is to ensure that the extrinsic and
attention being paid to that of the foot. In their description intrinsic contributions remain in their appropriate anatomic
of the extensor apparatus of the lesser toes, most anatomy location (Figure 2 and 3).
textbooks refer us to the extensor apparatus of the
fingers.
A search of the literature on the extensor apparatus of the Extrinsic Contribution
lesser toes reveals only 2 articles that provide an overview
Extensor Digitorum Longus
of its anatomy.15,38 The 1969 work by Sarrafian and
Topouzian38 provides the most complete description of the The extensor digitorum longus is a muscle of the anterior
components of the extensor apparatus and will be used as a compartment of the leg. It provides 4 tendons for the sec-
reference in our description. Given the lack of a specific ond to fifth toes. These tendons reach their respective
nomenclature for this structure in the International metatarsophalangeal joints, where they meet the extensor
Anatomical Terminology of the Federative International apparatus and thus form their main axis. At the level of the
Committee on Anatomical Terminology16 and the indis- metatarsophalangeal joints, the extensor tendons are
criminate use of various terminologies, we will use the attached to the digital axis using a fibroaponeurotic struc-
nomenclature proposed by Sarrafian and Topouzian.38 ture known as the extensor sling, which is a stabilizing
Extension of the toes is the result of the combined action ligament. At this level, the extensor digitorum longus ten-
of the extensor digitorum longus, extensor digitorum bre- don divides into 3 tendinous components known as slips:
vis, interossei muscles, and lumbrical muscles, all of which a middle or central slip and 2 lateral slips, medial or lateral
converge to form a tendinofibroaponeurotic structure depending on their anatomic location (Figure 4).38 The
known as the extensor apparatus (Figure 1). middle slip inserts into the dorsal area of the base of the
Figure 2. Main drawing of the extensor apparatus and its components based on the drawings of Sarrafian and Topouzian.35 (A)
Dorsal view. (B) Lateral view. (C) Medial view. (1) Extensor digitorum longus tendons. (2) Middle or central slip. (3) Lateral slips. (4)
Terminal tendon. (5) Extensor digitorum brevis tendons. (6) Lumbrical muscle and tendon. (7) Interosseous muscles. (8) Extensor
sling. (9) Extensor wing. (10) Triangular lamina. (11) Deep transverse metatarsal ligament. (12) Flexor digitorum longus tendon. (13)
Flexor digitorum brevis.
Figure 3. Extension of the toes is the result of the combined action of the extensor digitorum longus, extensor digitorum brevis,
interossei muscles, and lumbrical muscles. All of which converge to form a tendinobroaponeurotic structure known as the extensor
apparatus.
thinner than those of the extensor digitorum longus, deeper this is more apparent the more lateral the toe under study is,
and more oblique in direction. These tendons reach the except for the fifth toe, which does not have extensor brevis
metatarsophalangeal joint and contribute to the extensor tendon (Figure 6). We consider this anatomic detail to be
apparatus from the first to the fourth toe. crucial for our understanding and treatment of lesser toe
Most descriptions of the incorporation of these 4 exten- deformities. We stress the importance of this structure, since
sor tendons into the extensor apparatus state that they are the extensor digitorum brevis muscle is omitted or poorly
incorporated on the lateral aspect of the extensor digito- addressed in the description of the extensor apparatus in
rum longus,6,29,34-36,38,39,41 thus countering the oblique chapters on lesser toe deformities in surgery textbooks7,8,44
direction of the tendons of the long extensor of the toes. and in common anatomy textbooks.31
Therefore, from a functional viewpoint, the action of both
muscles is considered a single action.29,41 This description
is corroborated by Sarrafian and Toupouzian,38 although the
Lumbrical Muscles
authors state that the extensor digitorum brevis sometimes The lumbrical muscles, which are numbered 1 to 4 medial
runs independently, without joining the extensor digitorum to lateral, are found at the bifurcation of the tendons of the
longus, and thus forms the lateral slip by itself. Our dissec- flexor digitorum longus muscle and arise from the neigh-
tions generally confirm this description. The lateral slip is boring tendons, except for the first lumbrical, which arises
formed exclusively by the extensor digitorum brevis, and from the flexor tendon of the second toe (Figure 7). From
Interossei Muscles
The 7 interossei muscles (3 plantar and 4 dorsal) arise on
the metatarsal aspects that delimit the corresponding inter-
metatarsal spaces. The plantar muscles are found in the
second, third, and fourth intermetatarsal spaces and arise
on the medial aspect of the delimiting metatarsal bones in
its inferior segment. The dorsal muscles, which are larger
than the plantar muscles, are found in all the intermetatar-
sal spaces (Figure 10).
The tendons from both the plantar and dorsal interossei
muscles course distally before running dorsal to the deep
transverse metatarsal ligament—in contrast with the lumbri-
cal muscles, which do so plantarly—to reach the metatarso-
phalangeal joint and insert in the plantar area of the proximal
Figure 8. (A) Medial view of the anatomical dissection of the
phalanx and plantar plate.8,15,27,31,33,36,38,39 At their insertion,
second toe showing the anatomical relationships of the first
they are covered by the extensor sling (Figure 11).37,38 lumbrical muscle. (B) Same anatomical image in which the extensor
According to the description of the extensor apparatus pro- wing (black arrows) and the extensor sling (white arrows) have
posed by Sarrafian and Topouzian,38 the tendons of the inter- been identified by software (Adobe PhotoShop). (C) Medial view
ossei muscles are closely associated with the capsule, into of the main drawing showing the anatomy of the lumbrical muscle.
which some fibers insert. The remaining fibers extend distally (1) First lumbrical muscle. (2) Lumbrical tendon. (3) Extensor
and insert into the base of the proximal phalanx. Some of wing. (4) Flexor digitorum longus tendon. (5) Medial slip. (6) Deep
transverse metatarsal ligament and plantar plate (cut). (7) Extensor
these fibers insert into the deep side of the extensor sling and
digitorum longus tendon (cut). (8) Extensor sling. (9) First dorsal
occasionally extend until they reach the extensor wing. interosseous muscle. (10) Second dorsal interosseus muscle.
The vast majority of authors report that the interossei (11) Vertical septum of plantar fascia. (12) Shaft of the second
muscles insert at the phalangeal tuberosity on the base of metatarsal bone. (13) Annular pulley of the fibrous sheath of the
the proximal phalanx.8,15,27,31,33,36,41 The area of greatest flexor tendons. (14) Toenail. (15) Nail matrix.
Figure 14. (A) Drawing of the extensor apparatus in proximal-superior view showing the anatomical relationship of the extensor
sling based on the drawings of Oukouchi et al.30 (B) Lateral view of the main drawing showing the highlighted extensor sling. Medial
view of the main drawing showing the highlighted extensor sling. (1) Extensor sling. (2) Extensor digitorum longus tendon. (3) Middle
slip. (4) Lateral slips. (5) Terminal tendon. (6) Entensor digitorum brevis tendon. (7) First lumbrical muscle. (8) Extensor wing. (9) First
dorsal interosseous muscle. (10) Second interosseous muscle. (11) Triangular lamina. (12) Deep transverse metatarsal ligament.
(13) Flexor tendons. (14) Metatarsal bone (cut).
Extensor Wing comparable to the extensor wing on the lateral side of the lesser
toes. Therefore, our illustration differs in this detail from the
The extensor wing, or extensor hood, is an aponeurosis situ- original drawing by Sarrafian and Topouzian (Figure 17).
ated distal to the extensor sling. It is composed of obliquely
oriented fibers and is triangular in shape.6,27,36,38,39 The
extensor wing unites the tendinous fibers of the intrinsic Triangular Lamina
muscles with the 3 slips of the extensor digitorum longus
(Figure 16).38 According to Sarrafian and Topouzian,38 the The triangular lamina occupies the space between the lateral
extensor wing is situated on both sides of each toe. The slip and the medial slip at the dorsum of the middle phalanx.37
superior border of each triangle inserts into each of the lat- This structure comprises a fine, almost transparent lamina of
eral slips corresponding to the trifurcation of the extensor tissue that is pearl in color and extends until it becomes the
digitorum longus muscle. Some fibers extend toward the terminal extensor tendon. The triangular lamina was a con-
dorsum of the proximal interphalangeal joint and join the stant finding in our dissections (Figure 18). Although we do
middle slip. The proximal border is continuous with the dis- not discuss its function, we think that the triangular lamina
tal margin of the extensor sling, and the inferior border runs helps to maintain the lateral and medial slips in their original
obliquely, distally, and dorsally. Observed in a medial view, anatomic position, thus avoiding their plantar displacement.
the tendon of the lumbrical muscle—after passing plantar to If this happens, the slips function as flexors rather than exten-
the deep transverse metatarsal ligament—runs dorsally to sors of the proximal interphalangeal joint.
form the oblique border of the extensor wing.6,29,33,36,38,39
Although most of the authors who discuss the extensor Clinical Implications of the Extensor
wing29,36 agree with the description proposed by Sarrafian and
Apparatus
Topouzian,37 our dissections confirm that on the medial side,
the extensor wing is evident, owing to the presence of the lum- The extensor apparatus of the lesser toes is a basic struc-
brical muscle. However, we did not observe a structure ture that must be addressed in order to correct lesser toe
deformities. Release of the extensor digitorum longus, apparatus is key to an appropriate performance of these
extensor digitorum brevis, metatarsophalangeal joint cap- procedures.
sule or lengthening of the extensor digitorum longus ten- Most authors agree that both the extensor digitorum lon-
don are common procedures aimed at eliminating the pull gus tendon and extensor digitorum brevis tendon should be
of the extensor apparatus, thus avoiding hyperextension of released.13,25,27 Joint capsule release, on the other hand,
the proximal phalanx.5,13,25,27,29 A tenotomy decreases the depends on how fixed the deformity is. Additional release
radiographic sagittal angulation of the toe.14 The correction of the lumbrical tendons has been suggested.24 Tendon
of these deformities is most effective if the deformity is release at the level of the metatarsophalangeal joint pre-
completely flexible and less effective if it is rigid.42 These vents proximal displacement of the tendon ends, owing to
procedures, although described for correction of lesser the attachment of the extensor sling. It is also possible to
toes deformities, have not been documented in the litera- perform dorsal release of the metatarsophalangeal joint
ture as effective as isolated procedures. They can, how- capsule through the same incision. Lengthening of the
ever, be useful as adjunctive procedures in lesser toes extensor digitorum longus tendon could be performed
deformities.39,40 A detailed knowledge of the extensor proximal to the extensor sling, since no proximal excursion
muscle and the intrinsic muscles, all of which converge to 11. Coughlin MJ, Dorris J, Polk E. Operative repair of the fixed
form the extensor apparatus. The imbalance between the hammertoe deformity. Foot Ankle Int. 2000;21(2):94-104.
extensor apparatus and the flexors of the toes leads to lesser 12. Cyphers SM, Feiwell E. Review of the Girdlestone-Taylor
toe deformities. These deformities can often be corrected by procedure for clawtoes in myelodysplasia. Foot Ankle Int.
1988;8(5):229-323.
soft tissue procedures. Knowledge of these structures can
13. De Prado M, Ripoll PL, Golanó P. Minimally Invasive Foot
have great importance when performing these surgical pro-
Surgery. Barcelona: About Your Health; 2009:221-238.
cedures and in avoiding recurrence. 14. Espinosa N, Myerson MS. Current concept review: metatar-
salgia. Foot Ankle Int. 2008;29(8):871-879.
Acknowledgments 15. Fahrer M, Chapius PH. Proceedings: the functional anatomy
We thank Roser Torres for her valuable help with the drawings of the extensor apparatus of the second, third and fourth toes.
presented in this paper. The authors are grateful to Thomas O’Boyle J Anat. 1973;116(3):478.
for editorial assistance. We thank Dr Cristina Manzanares for her 16. Federative Committee on Anatomical Terminology.
institutional support at the University of Barcelona. International Anatomical Terminology. Stuttgart: Thieme; 1998.
17. Femino JE, Mueller K. Complications of lesser toe surgery.
Clin Orthop Relat Res. 2001;391:72-88.
Editor’s Note 18. Ford LA, Collins KB, Christensen JC. Stabilization of the
This article is published in memory of Pau Golanó, MD, who died subluxed second metatarsophalangeal joint: flexor tendon
unexpectedly during the production phase of this outstanding sci- transfer versus primary repair of the plantar plate. Foot Ankle
entific contribution. Surg. 1998;37(3):217-222.
19. Fortin PT, Myerson MS. Second metatarsphalangeal joint
instability. Foot Ankle Int. 1995;16(5):306-313.
Declaration of Conflicting Interests
20. Gosling JA. Human Anatomy. Color Atlas and Textbook. 4th
The author(s) declared no potential conflicts of interest with ed. Philadelphia: Mosby; 2008.
respect to the research, authorship, and/or publication of this 21. Green DR, Brekke M. Anatomy, biomechanics, and pathome-
article. chanics of lesser digital deformities. Clin Podiatr Med Surg.
1996;13(2):179-200.
Funding 22. Holinka J, Schuh R, Hofstaetter JG, Wanivenhaus AH.
The author(s) received no financial support for the research, Temporary Kirschner wire transfixation versus strapping
authorship, and/or publication of this article. dressing after second MTP joint realignment surgery: a
comparative study with ten-year follow-up. Foot Ankle Int.
2013;34(7):984-989.
References 23. Jarrett BA, Manzi JA, Green DR. Interossei and lumbricales
1. Bade H, Tsikaras P, Koebke J. Pathomorphology of the ham- muscles of the foot: an anatomical and functional study. J Am
mer toe. Foot Ankle Surg. 1998;4:139-143. Podiatry Assoc. 1980;70(1):1-13.
2. Blitz NM, Ford LA, Christensen JC. Second metatarsopha- 24. Keenan MA, Gorai AP, Smith CW, Garland DE. Intrinsic toe
langeal joint arthrography: a cadaveric correlation study. Foot flexion deformity following correction of spastic equinovarus
Ankle Surg. 2004;43(4):231-240. deformity in adults. Foot Ankle. 1987;7(6):333-337.
3. Bojsen-Møoller F. Anatomy of the forefoot, normal and 25. Kitaoka HB, Richardson EG. Realignment of lesser toe
pathologic. Clin Orthop Relat Res. 1979;(142):10-18. deformities. In: Kitaoka HB, ed. The Foot and Ankle. 2nd ed.
4. Brand PW. The insensitive foot (including leprosy). In: Jahss Philadelphia: Lippincott Williams & Wilkins; 2002:147-168.
MH, ed. Disorders of the Foot. Philadelphia: W. B. Saunders 26. Knecht JG. Pathomechanical deformities of the lesser toes. J
Company; 1982:1266-1286. Am Podiatr Assoc. 1974;64(12):941-954.
5. Chadwick C, Saxby TS. Hammertoes/clawtoes: meta- 27. Mann RA, Coughlin MJ. Lesser-toe deformities. In: Jahss
tarsophalangeal joint correction. Foot Ankle Clin N Am. MH, ed. Disorders of the Foot and Ankle. Medical and
2011;16(4):559-571. Surgical Management. 2nd ed. Philadelphia: Saunders
6. Chan R. Anatomy of the digits. Clin Podiatr Med Surg. Company; 1991:1205-1228.
1986;3(1):3-9. 28. Matuszak SA, Baker EA, Fortin PT. The adult paralytic foot.
7. Cooper PS. Disorders and deformities of the lesser toes. In: J Am Acad Orthop Surg. 2013;21(5):276-285.
Myerson MS, ed. Foot and Ankle Disorders. Philadelphia: 29. McGlamry ED, Jimenez AL, Green DR. Lesser ray defor-
W.B. Saunders Company; 2000:308-358. mities. In: McGlamry ED, Banks AS, Downey MS, eds.
8. Coughlin MJ. Lesser toe deformities. In: Coughlin MJ, Mann Comprehensive Textbook of Foot Surgery. 2nd ed. Baltimore:
R, Saltzman CL, eds. Surgery of the Foot and Ankle. 8th ed. Williams & Wilkins; 1992:51-102.
Philadelphia: Mosby; 2007:363-464. 30. Milz S1, Putz R, Ralphs JR, Benjamin M. Fibrocartilage
9. Coughlin MJ. Lesser-toe abnormalities. J Bone Joint Surg in the extensor tendons of the human metacarpophalangeal
Am. 2002;84(8):1446-1469. joints. Anat Rec. 1999;256(2):139-145.
10. Coughlin MJ. Subluxation and dislocation of the sec-
31. Moore KL, Dalley AF. Clinically Oriented Anatomy.
ond metatarsophalangeal joint. Orthop Clin North Am. 6th ed. Philadelphia: Lippincott Williams&Wilkins;
1989;20(4):535-551. 2010:509-669.