Digital contraction deformities include hammertoes, clawtoes, and mallet toes.
There are three main causes of digital contracture deformity:
Flexor Stabilization- occurs about >70%. The muscles in the back of the foot and leg fire earlier and longer to stabilize the hypermobile fore foot. This results in overpowering the little muscles in the foot causing the hammertoe. It is possible to see rotation of the 4th and 5th digits with this type of deformity.
Extensor Substitution – is associated with a high arch foot, foot drop, and a weakness of the muscles in the front of the leg.
Flexor Substitution – is the least common cause of digital contracture, and occurs due to weakness of the muscles in the back of the leg.
A mallet toe involves bending of the far toe joint downward and may be associated with a long digit.
Hammertoes involve upward bending of the the first bone in the digit and downward bending of the middle bone in the digit.
The clawtoe involves downward bending of both the middle bone and the far bone of the digit.
Symptoms associated with advanced digital contracture deformity include painful motion, painful hyperkeratotic lesion (Thickened Skin), inability to wear regular shoes, contracted painful toe which is short.
Treatment for claw toes and hammertoes depends on the severity of the deformity.
Goals are to keep the foot comfortable:
If biomechanics is the reason for the hammertoe deformity tan the patient can be fitted for custom-molded orthotics.
Changing to a wider pair of shoes, with more depth in the toe box.
Hammertoe pads or Hammertoe cushions can also be used on hammertoes.
Padding placed under the toes, with a strap that is placed over the toes which helps to straighten the toes.
Pads and cushions can help to alleviate pain and irritation of the toes, these pads however will not change the deformity.
It is possible that the soft tissue structures can begin to tighten. A rigid deformity can develop in such a case.
When conservative care fails and there is considerable pain at the hammertoes, surgery is then considered.
Hammertoe surgery involves straightening the toe through either an arthroplasty by removing a small piece of bone of the digit, or arthrodesis (fusing the joint) using a wire or implant.
Arthroplasty is a minor surgical procedure that may be used to treat hammertoes. In this procedure, the head of the first bone in the digit is removed, allowing the toe to straighten. If the affected toe does not straighten sufficiently after arthroplasty, a number of progressive stepwise soft tissue procedures can be used to attempt to straighten the toe.
In some cases an arthrodesis is necessary. Arthrodesis involves fusing two bones together, typically the first and second bones of the digit. The articular cartilage is removed from each bone. They are then held together with either a pin or an implant.
Following surgery, the patient is placed in a surgical shoe or boot and the patients has limited activity for several weeks.
