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Hammertoe Deformity

  • Author: Anthony Watson, MD; Chief Editor: Anthony E Johnson, MD  more...
 
Updated: Mar 28, 2016
 

Background

Hammertoe deformity is the most common deformity of the lesser toes. The fundamental problem is a chronic, sustained imbalance between flexion and extension force of the lesser toes from intrinsic forces, extrinsic forces, or both.

With progressive proximal interphalangeal (PIP) joint flexion deformity, compensatory hyperextension of the metatarsophalangeal (MTP) and distal interphalangeal (DIP) joints typically occurs. The hyperextension of the MTP joint and the flexion of the PIP joint make the PIP joint prominent dorsally. This prominence rubs against the patient's shoe, causing pain.

Early in its natural history, the deformity is flexible and passively correctable, but with time, it typically becomes fixed. Progressive deformity can lead to MTP joint dislocation. Once flexion contractions form, surgical treatment may be indicated. Surgical treatment of hammertoe deformity has historically been based on altering the relative lengths of the toe and its tendons in order to achieve balance between extensor and flexor forces. Options have included the following:

  • PIP joint resection arthroplasty
  • PIP joint fusion
  • Tendon transfers
  • Tendon lengthening
  • Metatarsal shortening

Metatarsal shortening has gained renewed interest, but PIP joint resection arthroplasty and tendon transfers are the main procedures for hammertoe correction.

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Anatomy

The lesser toe comprises three phalanges that articulate at the PIP and DIP joints. The proximal phalanx articulates with the metatarsal at the MTP joint. Medial and lateral collateral ligaments, a fibrocartilaginous plantar plate, and a thin dorsal capsule stabilize each of the three joints.

The extensor digitorum longus (EDL) tendon originates in the leg and crosses the ankle anteriorly. Although it extends all three joints of the lesser toe, it primarily acts at the MTP joint. The extensor digitorum brevis (EDB) originates in the sinus tarsi and blends with the EDL tendon over the proximal phalanx to form the extensor expansion. The EDL continues distally from the extensor expansion and trifurcates to form the central slip, which inserts onto the middle phalanx, and the lateral bands, which insert onto the distal phalanx. The central slip and lateral bands extend the PIP and DIP joints, respectively, when the MTP joint is in neutral position or in plantarflexion.

The flexor digitorum longus (FDL) tendon originates in the leg, crosses the ankle medially, and flexes all three joints of the lesser toes, though it acts primarily at the DIP joint. The flexor digitorum brevis (FDB) tendon originates from the plantar surface of the calcaneus and primarily flexes the PIP joint. The lumbricals originate from the medial and lateral surfaces of the metatarsals, pass plantarly to the MTP, and then extend dorsally to coalesce with the lateral bands. Thus, the lumbricals flex the MTP joint and extend the PIP and DIP joints.

The neurovascular bundles of each toe arise from a common interdigital artery and a common interdigital nerve. Each bifurcates at approximately the level of the MTP joint. Each branch then extends along the medial and lateral aspects of the toe deep to the subcutaneous tissue. Both the interdigital artery andthe interdigital nerve are plantar to the intermetatarsal ligament at the level of the MTP joint. Both can become contracted in a chronic hammertoe and are subject to traction injury with hammertoe correction.

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Pathophysiology

The fundamental problem is a chronic, sustained imbalance between flexion and extension force of the lesser toes from intrinsic forces, extrinsic forces, or both. Hammertoe deformity primarily comprises flexion deformity of the PIP joint of the toe, with hyperextension of the MTP and DIP joints (see the image below).

Diagram comparing clinical appearances of lesser-t Diagram comparing clinical appearances of lesser-toe deformities.

When a foot's second ray is longer than the first and shoe wear does not fit correctly, flexion of the PIP joint occurs to accommodate the shoe. This length difference also causes MTP synovitis to develop from overuse of the second MTP joint. Attenuation of the collateral ligaments and plantar plate results, and the MTP joint hyperextends and may even progress to dorsal subluxation or dislocation (see the image below). Rheumatoid arthritis causes hammertoe deformity by progressive MTP joint destruction, leading to MTP joint subluxation and dislocation.[1, 2, 3]

Pathomechanics of hammertoe deformity. Elongated p Pathomechanics of hammertoe deformity. Elongated plantar plate, caused by either metatarsophalangeal (MTP) synovitis and instability or chronic MTP hyperextension due to toe crowding, results in MTP subluxation or dislocation with compensatory proximal interphalangeal (PIP) flexion.

With all three of these etiologies, the EDL tendon gradually loses mechanical advantage at the PIP joint, as does the FDL tendon at the MTP joint. The intrinsic muscles sublux dorsally as the MTP hyperextends. They now extend the MTP joint and flex the PIP joint, as opposed to their usual functions of flexing the MTP joint and extending the PIP joint.

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Etiology

Etiologies of hammertoe deformity include the following:

  • A foot in which the second ray is longer than the first (see the image below)
  • MTP synovitis and instability
  • Inflammatory arthropathies
  • Neuromuscular conditions
  • Ill-fitting shoe wear
Morton foot, wherein second ray (metatarsal and co Morton foot, wherein second ray (metatarsal and corresponding toe) is longer than first ray.

MTP synovitis and instability are associated with a second ray that is longer than the first. Inflammatory arthropathies typically involve more than one of the lesser MTP joints. Ill-fitting shoe wear compounds the effects of any of the other causes.

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Epidemiology

The incidence of hammertoe deformity is undefined. However, the condition is strongly associated with the presence of a second ray that is longer than the first, and it is known to be more common in women and to increase in frequency with advancing age. Indeed, this length disparity is found in most patients presenting with foot complaints, though the actual prevalence of this foot shape also is undefined.

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Prognosis

Patients should be counseled that their expectations for a good result after hammertoe treatment should include the following:

  • Permanent relief of pain
  • Ability to wear reasonable shoes (those of appropriate length, width, and depth for their entire foot) without pain

Although nonoperative treatment of hammertoe deformity often successfully alleviates pain, the deformity typically progresses in magnitude and stiffness in most cases despite diligent nonoperative care. Surgical treatment of flexible hammertoe deformity reliably corrects the deformity and alleviates pain. Recurrence and progression are common, especially if the patient resumes wearing deforming shoes. Surgical treatment of fixed hammertoe deformity provides very reliable deformity correction and pain relief. Recurrence is rare after appropriate surgical management.

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Contributor Information and Disclosures
Author

Anthony Watson, MD Orthopedic Surgeon, Private Practice

Anthony Watson, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Pennsylvania Orthopaedic Society, American Orthopaedic Foot and Ankle Society, Pennsylvania Medical Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Anthony E Johnson, MD Chairman, Department of Orthopaedic Surgery, San Antonio Military Medical Center; Research Director, US Army–Baylor University Doctor of Science Program (Orthopaedic Physician Assistant); Custodian, Military Orthopaedic Trauma Registry; Associate Professor, Department of Surgery, Baylor College of Medicine; Associate Professor, The Norman M Rich Department of Surgery, Uniformed Services University of the Health Sciences

Anthony E Johnson, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Healthcare Executives, American College of Sports Medicine, American Orthopaedic Association, Arthroscopy Association of North America, Association of Bone and Joint Surgeons, International Military Sports Council, San Antonio Community Action Committee, San Antonio Orthopedic Society, Society of Military Orthopaedic Surgeons, Special Operations Medical Association

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Society of Military Orthopaedic Surgeons; American Academy of Orthopaedic Surgeons<br/>Received research grant from: Congressionally Directed Medical Research Program<br/>Received income in an amount equal to or greater than $250 from: Nexus Medical Consulting.

Additional Contributors

Heidi M Stephens, MD, MBA Associate Professor, Department of Surgery, Division of Orthopedic Surgery, University of South Florida College of Medicine; Courtesy Joint Associate Professor, Department of Environmental and Occupational Health, University of South Florida College of Public Health

Heidi M Stephens, MD, MBA is a member of the following medical societies: Alpha Omega Alpha, American Academy of Orthopaedic Surgeons, American Medical Association, American Orthopaedic Foot and Ankle Society, Florida Medical Association

Disclosure: Nothing to disclose.

References
  1. Myerson MS, Shereff MJ. The pathological anatomy of claw and hammer toes. J Bone Joint Surg Am. 1989 Jan. 71(1):45-9. [Medline].

  2. Sarrafian SK, Topouzian LK. Anatomy and physiology of the extensor apparatus of the toes. J Bone Joint Surg Am. 1969 Jun. 51(4):669-79. [Medline].

  3. Badlissi F, Dunn JE, Link CL, Keysor JJ, McKinlay JB, Felson DT. Foot musculoskeletal disorders, pain, and foot-related functional limitation in older persons. J Am Geriatr Soc. 2005 Jun. 53(6):1029-33. [Medline].

  4. Barbari SG, Brevig K. Correction of clawtoes by the Girdlestone-Taylor flexor-extensor transfer procedure. Foot Ankle. 1984 Sep-Oct. 5(2):67-73. [Medline].

  5. O'Kane C, Kilmartin T. Review of proximal interphalangeal joint excisional arthroplasty for the correction of second hammer toe deformity in 100 cases. Foot Ankle Int. 2005 Apr. 26(4):320-5. [Medline].

  6. Konkel KF, Menger AG, Retzlaff SA. Hammer toe correction using an absorbable intramedullary pin. Foot Ankle Int. 2007 Aug. 28(8):916-20. [Medline].

  7. Jones S, Hussainy HA, Flowers MJ. Re: Arthrodesis of the toe joints with an intramedullary cannulated screw for correction of hammertoe deformity. Foot Ankle Int. 2005 Dec. 26(12):1101; author reply 1101. [Medline].

  8. Konkel KF, Sover ER, Menger AG, Halberg JM. Hammer toe correction using an absorbable pin. Foot Ankle Int. 2011 Oct. 32(10):973-8. [Medline].

  9. Nery C, Coughlin MJ, Baumfeld D, Mann TS. Lesser metatarsophalangeal joint instability: prospective evaluation and repair of plantar plate and capsular insufficiency. Foot Ankle Int. 2012 Apr. 33(4):301-11. [Medline].

  10. Ellington JK. Hammertoes and clawtoes: proximal interphalangeal joint correction. Foot Ankle Clin. 2011 Dec. 16(4):547-58. [Medline].

  11. Miller JM, Blacklidge DK, Ferdowsian V, Collman DR. Chevron arthrodesis of the interphalangeal joint for hammertoe correction. J Foot Ankle Surg. 2010 Mar-Apr. 49(2):194-6. [Medline].

  12. Bouché RT, Heit EJ. Combined plantar plate and hammertoe repair with flexor digitorum longus tendon transfer for chronic, severe sagittal plane instability of the lesser metatarsophalangeal joints: preliminary observations. J Foot Ankle Surg. 2008 Mar-Apr. 47(2):125-37. [Medline].

  13. Trnka HJ, Gebhard C, Muhlbauer M, et al. The Weil osteotomy for treatment of dislocated lesser metatarsophalangeal joints: good outcome in 21 patients with 42 osteotomies. Acta Orthop Scand. 2002 Apr. 73(2):190-4. [Medline].

  14. Smith SC, Bazzoli C, Chung I, Johnson A, Martin DR. Antimicrobial susceptibility of Escherichia coli in uncomplicated cystitis in the emergency department: is the hospital antibiogram an effective treatment guide?. Acad Emerg Med. 2015 Aug. 22 (8):998-1000. [Medline].

  15. Joshi S. Hospital antibiogram: a necessity. Indian J Med Microbiol. 2010 Oct-Dec. 28 (4):277-80. [Medline].

  16. Migues A, Slullitel G, Bilbao F, Carrasco M, Solari G. Floating-toe deformity as a complication of the Weil osteotomy. Foot Ankle Int. 2004 Sep. 25(9):609-13. [Medline].

 
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Diagram comparing clinical appearances of lesser-toe deformities.
Morton foot, wherein second ray (metatarsal and corresponding toe) is longer than first ray.
Pathomechanics of hammertoe deformity. Elongated plantar plate, caused by either metatarsophalangeal (MTP) synovitis and instability or chronic MTP hyperextension due to toe crowding, results in MTP subluxation or dislocation with compensatory proximal interphalangeal (PIP) flexion.
Painful dorsal callus over proximal interphalangeal (PIP) joint of second toe, caused by long-standing, fixed hammertoe deformity.
Physical examination maneuver to diagnose metatarsophalangeal (MTP) instability, wherein examiner attempts to translate proximal phalanx dorsally relative to metatarsal head. In most patients, subluxation is possible; therefore, this test is positive only when it causes pain.
Hammertoe shield for treatment of flexible hammertoe. Sling over proximal phalanx straightens toe, while shield under metatarsal head provides padding for painful callus that may be present, supports toe plantarly, and anchors sling.
 
 
 
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