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 Toe | Hammer Toe |
|---|---|
| All toes involved | Only 1-2 toes involved |
| Always extension at MTP joint | Extension at MTP (+/-) |
| Flexion at DIP | Not seen |
| Caused mainly by neuromuscular disease | No underlying intrinsic imbalance |
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
↓
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)
↓
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)
↓
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
