July 18, 2024

Hammer toe and claw toe deformities are deformities of toes due to the imbalance in muscle and tendon maintaining normal cascade of the foot.

Claw ToeHammer Toe
All toes involvedOnly 1-2 toes involved
Always extension at MTP jointExtension at MTP (+/-)
Flexion at DIP Not seen
Caused mainly by neuromuscular diseaseNo underlying intrinsic imbalance
Differences between hammer toe and claw toe
 Hammer toe and Claw toe deformities
Hammer toe and Claw toe

Claw toe

Loss of intrinsic function of foot muscles

Loss of balance

Extensor digitorum longus: Extends MTP joint

Flexor digitorum longus: Flex PIP joint

Attenuate deformity

Hammer toe

Hammer toe is due to abnormal flexion of PIP joint of one of lesser 4 toes

  • Flexible: Passively correctable
  • Fixed: Not passively correctable

Causes

Poorly fitted shoes

Crowding of toes with excessive tight toe box

Anatomical factors:

  • Two bone toe
  • A long second ray (may result in buckling of toes)

Hallus Valgus: Pressure against 2nd toe

Connective tissue disorder

Treatment Options

Conservative with manipulation and taping ( If deformity is of not long duration + extension at MTP not present)

Some examples are :

  • Hammer toe cushion
  • Hammer toe straightener or aids
  • hammer toe splint or braces

Hammer toe exercises

Surgical Options

Procedure for Hammer toe deformity

Flexible Hammer toe

No fixed contracture at MTP or PIP Joint

Treatment:

Non-operative

Rarely Flexon-extensor transfer

Rigid hammer toe with MTP subluxation

FFD at PIP, MTP subluxed in extension

Treatment Options

  • Resection of condyle of proximal phallanx
  • Dermodesis
  • Lengthening of EDL
  • Tenotomy of EDB
  • MTP Capsulotomy
  • Collateral Ligament sectioning

Rigid Hammer toe with MTP subluxation with Claw toe

Treatment:

Same as above and MTP arthroplasty or Weil’s osteotomy

Crossover toe

FFD at PIP, MTP subluxed in varus/ valgus

Treatment:

Resection of condyle of proximal phalanx, dermodesis,collateral ligament capsule repair, EDB transfer

Mallet toe

FFD at DIP joint

Treatment:

Resection of condyle of middle phalanx, dermodesis, FDL tenotomy

Correction of severe deformity

  • FFD at PIP
  • Extensor contracture of MTP

Both required correction

Straight or angled incision at MTP joint centred over fibular aspect

Skin incision for hammer toe and claw toe

Retract and expose extensor tendons [ EDB is slightly lateral and deep to EDL]

Tenotomy of EDB and remove 2-3 mm segment perform Z-plasty lengthening of EDL with small blade

From proximal part of skin incision incise longitudinally to EDL till it reaches to extensor expansion and exit through opposite side (lengthened 8-10 mm)

Lengthening of EDL

Lift the tendon away from soft tissue attachments

If extensor contracture is 20-30 °, no dorsal subluxation of proximal phalanx on MT head

Firmly flex toe in 30° -40°

If toe rest in neutral position with ankle at 90°

Completed procedure for this joint

But if still there is 10-20° of extension at MTP joint

Perform Dorsal capsulotomy transversely while the flexed in 40° to 50 ° flexion (gives better exposure of capsule)

Again ankle at 90°

Flex toe acutely

Resting position of toe 0-10° of MTP extension , no need further intervention

Complete suturing of EDL tendon

If unacceptable position of toe extension

Excise collateral ligaments of both side of MT head down

(Collateral ligament sectioning)

Suture EDL after correcting,

Proximal IP joint correction

Make elliptical incision over proximal IP joint that measures 5-6 mm wide, 2-3 mm lateral extension

Remove smaller segment of extensor tendon and dorsal capsule of PIP joint leaving 2 mm attached to base of middle phalanx

Dorsal capsule + Both collateral ligaments + Extensor tendon sectioned transversely

Distal 25-30% (Head and neck )of proximal phalanx excised

(Resection of condyle of proximal phalanx)

Extend toe in neutral position

3-0, 4-0 non adsorbable suture enters proximal skin edge and passes through proximal end of tendon and enter distal end of its joint surface and exits through skin

(Dermodesis)

Dermodesis and dorsal capsulotomy
Dermodesis and dorsal capsulotomy

Skin closure is done

Postoperative care

Weight bearing 48-72 hr of elevation of foot

Wooden sole shoe worn for 4 weeks

Suture removal after 2 weeks

Other methods

Weils osteotomy

MTP joint arthoplasty

See also: Lisfranc Injury

See also: Achilles Tendon Injury

See also: Mallet finger