What is a Hammer Toe?
Hammering of the toe describes a deformity of the lesser toes. The toes have two joints in them. If the joint furthest from the toe nail becomes bent, then it can rub on the shoe above it. This can form a hard area of skin over time, or even ulcerate. Both of these are painful. If the toe remains bent for a long period, it can become stuck in the bent position. This is what is known as fixed deformity, and no amount of pulling or insoles will cause it to return to a normal position.
Hammering may occur because of unusual toe lengths. If the second or third toe is longer than the big toe, then when shoes are worn, the joints have to bend to allow the toes to be accomodated within the shoe. If the big toe is affected by a bunion, the big toe may ride under the second toe, again causing a deformity. Hammering may also occur as a result of diseases of the nerves or muscles.
The toe is sore when shoes are worn, and there may have been an ulcer in the past. The toe may not straighten out, even with force. There may be hard skin over the joint, and sometimes under the ball of the foot.
If you have a hammer toe, it is best to see an orthopaedic surgeon who specialises in foot and ankle surgery. You should have x-rays taken in a standing position – this will show if there is any bony damage that has caused the deformity, and also gives an idea of what the best method of treatment may be.
How is the Surgery Performed?
Hammer toes are often stuck in a bent position that cannot be straightened without surgery. The operation to straighten them involves taking out the joint that is stuck in one position. The bones are held in a straight position with a wire that sticks out of the end of the toe. This is removed after six weeks.
A metal device can be inserted which grips the bone from the inside, but if there is an infection around this, it must be removed and the toe may become flail. An xray of this device is shown to the left. They can have complications of their own and are used in special circumstances.
The vast majority of these operations pass without any difficulty and a good result is achieved, but there are small risks of complications.
If the toe has been stuck in a bent position for a long time, then straightening it may stretch the blood vessels underneath the bone. If this occurs, the toe bone may need to be shortened to take the tension from the blood vessels. If this problem becomes apparent after surgery has finished, the wire will need to be removed from the toe to allow blood to get into the end of the toe and this toe will remain a little flail. If the problem is not recognised, the end of the toe may die from not having any blood and turn black. This is a risk of surgery.
Surgery is carried out under general anaesthetic, but can be carried out with local anaesthetic injections behind the knee or around the ankle. The injections are normally given while you are asleep for your comfort. They can give good pain relief for the first day after the operation. You can go home the same day in the evening.
What Happens after Surgery?
You will have had injections to numb your foot so that you are not in pain after the operation. This injection will wear off after 18-24 hours, so you must take regular painkillers so that you are not in severe pain when the injection wears off. Ibuprofen and Diclofenac should not be used for more than a few days after the operation as they can interfere with bone healing.
The pain will settle over a few weeks. You may see blood stains on the dressings. This is normal and not a cause for alarm. If blood is dripping from the dressings however, return to hospital.
The foot will be swollen as well as sore. You should keep the foot elevated as much as possible for the first two weeks. Keep walking down to a minimum – going to the toilet or for meals. Letting the leg hang down will cause the foot to become more swollen. Most of the swelling will settle within the first few months, but swelling can continue for up to one year.
If you are resting on your sofa, keep your foot elevated on the back rest or arm rest. If you are resting in bed, then place a few pillows under the foot to keep it elevated.
You have been given a special shoe that does not allow you to put weight on the front of the foot. This is because the bones are held by a wire and weight bearing can bend the wire. You should wear this continuously for the first two weeks, including in bed. After that, you should wear it whenever you are walking, even at home. Many patients use the shoe to stop the wire from catching on clothes and bed linen. Crutches are for balance only.
You should not perform any exercises with the involved toe. However, you can draw the alphabet in the air with the foot to keep other joints mobile.
RETURNING TO WORK
You will be wearing the special shoe for six weeks, and we will then take an xray. If this is satisfactory, then the wire will be removed in clinic. I advise that you do not return to work before this, especially if you are on your feet all day at work. However, if you have just had an isolated hammer toe operated upon, you may find that you can manage with a crutch adequately. Most people can drive after 8 weeks. Remember that not everyone is the same, and some people take a longer time to recover from their surgery. Please request a sick note before you leave hospital, if you need one.