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Hammer toe is a condition caused by an inherited muscle imbalance or abnormal bone length. It mostly occurs in children who outgrow their shoes rapidly; one or more small toes buckle when the middle joint contracts, which causes the tendons to shorten.

A foot with bunions will often also feature a hammer toe. Over time, the bunion slants the big toe toward and then under the second toe, which forces the second toe to rise into a claw-like position.
A hammer toe can lead to severe pain and pressure, because it creates extra stress in the ball of the foot, often leading to the development of corns and calluses. However, there are several treatment options available for correction of the deformity. If left untreated, the toe may become permanently fixed and rigid.

Toe deformities

The hammer toe problem is one of the most common deformities of the toe. The human foot is a highly complex mechanical apparatus, made of many bones and other coordinated structures.

Most common deformities of the toes are:

    * Claw toe
    * Hammer toe
    * Mallet toe

Although somewhat similar in appearance, each deformity has specific characteristics. Variations in the three conditions are caused by difference in the direction in which the joints of the affected toes bend, as well as degrees of deformity. These deformities often cause pain and a loss of function in the foot. Although these deformities are often considered not too serious, failure to treat these conditions may contribute to the development of serious and disabling changes in habitual ways of walking and carrying the body. Proper evaluation is the first step in treatment of toe deformities.

Possible causes of hammer toe

The main cause of hammer toe is wearing tight shoes that crowd the toes, or high heels. Of course, this isn't the only possible case; the deformity may also be brought on by an injury. Also, the cause of the condition is often a tightening of the ligaments and tendons of the toe, which causes a buckling of the joint of the toe. As a result, the toe is cocked upward, whereas in a normal foot the toes lie flat.

A hammer toe may also develop because of:

    * failing to replace children’s shoes when their feet outgrow them
    * wearing high heels and other restrictive shoes for too long
    * a congenital deformity causing tight tendons in the affected toe
    * a congenital misalignment of bones in the arch of the affected foot
    * joint inflammation, such as that caused by arthritis
    * damage to the muscles and nerves of the foot from a long-term disease, such as diabetes
    * an injury to the foot or toe

Symptoms of hammer toe

Besides pain and its claw-like physical appearance, symptoms of hammer toe include:

    * infections
    * ulcers in patients with a decreased sensitivity
    * changes in gait and balance
    * redness and swelling on and around the affected toe
    * corns or calluses where the toe bends and rubs

Surgical treatment of hammer toe

Surgery for the correction of hammer toe deformity is the most common method, approached via a sequential protocol, which means that if one procedure does not work, another is tried until the deformity is reduced.

Pre-operative Preparations

Before surgery, the patient usually receives appropriate anesthesia, and the foot is cleansed and draped. As anesthetic, an injection of 5% marcaine is applied locally at the base of the toe.

Surgical Incision

The first step in the surgical correction of a hammer toe should be the initial incision, of which several are possible. The most frequently cited method involves a dorsal longitudinal incision extending from the MTPJ distally to the mid-point of the intermediate phalanx. The second most commonly cited incision approach is also known as ‘two semi-elliptical’. The length of the incision must be approximately three times the width, so as to ensure adequate closure of the wound post-surgery..

Extensor Tendon Lengthening

This is usually the first correction made to the tendon of extensor digitorum longus muscle, which is lengthened in an open Z-plasty, and retracted with the tip of a curved hemostat. Next the collateral ligaments are severed, with the scalpel aligned parallel to the long axis of the proximal phalanx, which should relieve all the problems with contracture.

Another method involves the distal aspect of the proximal phalanx excised at or just proximal to the neck of the phalanx. The medial and lateral margins are then smoothed using a rongeur and a fine rasp, and the articular surface of the intermediate phalanx is removed. Only in case that the test show that the MTPJ does not realign, correction has not been fully achieved so either more bone is resected from the proximal phalanx or an extensor hood release is performed.

Extensor Hood Resection

If the extensor tendon has been lengthened without the release of the extensor hood, looseness will be experienced distal to the MTPJ. However, when the extensor hood is released, the tendon lengthening will create slack throughout the length of the tendon and across the MTPJ. Extensor hood resection is performed by first placing the tendon on stretch distally and excising the hood fibers medially and laterally at their attachments to the joint capsule and extensor sling.

Metatarsophalangeal Joint Capsulotomy

Before this procedure, the extensor digitorum longus muscle and the soft tissue medial and lateral to the MTPJ are retracted. This part is extremely important because it identifies the site for capsulotomy.  

Proximal Interphalangeal Joint Arthrodesis

After all these procedures, there is one made in order to prevent a recurrence of the deformity and ensure the success of the procedures, called arthrodesis. It is based on aligning with the rest of the toe in a corrected position and maintained in place. Initially, the wire is placed from the PIPJ through the tip of the toe. It is then driven in a retrograde fashion into the proximal phalanx. The exposed wire exiting the toe is bent to an angle greater than 90 degrees. Following the irrigation of the surgical site, the extensor tendon is re-approximated in a lengthened position under physiological tension with an absorbable suture, which means that these sutures are not being removed after all. Although this really sounds complicated, it is really rather simple, and most importantly effective.

Living with Hammer Toe

Any change to the foot significantly affects habitual ways of walking and standing. Of course, if this condition is being left untreated, foot ailments such as claw toe, hammer toe, or mallet toe may produce problems in other weight-bearing joints. That’s why any forefoot problems causing pain or discomfort should be given prompt attention. Anyone who experiences problems with feet should seek advice from an experienced physician or podiatrist.

Possible complications

1. Swelling of the toes for 1 to 6 months post surgery.
2. Recurrence of deformity.
3. Distraction of the K-wire pin from the digit.
4. Infection
5. Pain and discomfort after the operation
6. Injury to the neurovascular bundle