Hallux Valgus in Adolescents

HALLUX VALGUS is a common deformity in adults, particularly women, and in children and adolescents its frequency is greater than many surgeons realize. When an adult seeks medical advice about a hallux valgus it is usually on account of pain which may occur in the joint itself, over the bunion or under the metatarsal heads. When a child is referred on account of a hallux valgus the reason may be one of manythe appearance of the deformity, an increasing deformity, fear of increasing deformity, particularly when this has occurred to other members of the family, the spoiling of shoes or pain particularly over the bunion. Very often the child makes no complaint of pain. Various operative procedures have been devised for the correction of hallux valgus in adults, such as Keller's or Mayo's arthroplasty and arthrodesis of the metatarsophalangeal joint of the great toe. Selection of the most suitable operation in an individual case is most important and even then the result is not by any means always an unqualified success. However, in an adult the metatarsophalangeal joint is often arthritic and in consequence we are dealing with poor articular material. In a child or adolescent the problem is much more difficult as the metatarsophalangeal articular surfaces are usually normal and whatever treatment is carried out the joint should not be interfered with if possible. Various conservative measures have been described for the correction or control of hallux valgus. These are almost all useless. They include hallux valgus splints which, of necessity, can only be worn in bed and have to be removed when wearing shoes; toe pegs between the first and second toes which tend to push the second toe into valgus rather than correct the deformity of the first; exercises which mobilize the feet and toes but have little if any real effect on the deformity of the great toe. If correction of the great toe deformity is necessary in any particular case in childhood or adolescence, operation is the only way to achieve this. Whatever operation is carried out the function of the foot must not be interfered with nor must the surfaces of the metatarsophalangeal joint be encroached upon or damaged. Before embarking on any surgical procedure it is desirable to discover the underlying cause of the condition and to correct this first if possible. In hallux valgus, at least in childhood, the basic deformity is a metatarsus primus varus and correction of this is of prime importance. This has not always been considered to be the case, as witness the opinion expressed by Peabody (1931): "While it may safely be assumed that in some instances hallux valgus develops secondarily and inevitably from a congenital primus metatarsus varus, we believe that in the majority of cases the deformity at the great toejoint is the important one." However, more recently the metatarsus primus varus has been considered the basic deformity. This opinion was expressed by Hawkins et al. (1945) in their paper on the correction of hallux valgus by metatarsal osteotomy. It has been argued that the varus of the first metatarsal is secondary to the hallux valgus. If this is so, then we must produce some adequate reasons for the lateral deviation of the great toe and this must incriminate the shoes. This, however, will not explain the cases of unilateral hallux valgus sometimes seen in children, but one cannot deny that some of the modern "casual" shoes worn by children have an undesirable influence on the progress of the deformity of the great toe and in town dwellers, at least, there has been an increase in the incidence of hallux valgus in adolescent girls.