​Kembara Xtra - Medicine - Hammer Toes

​Kembara Xtra - Medicine - Hammer Toes 
Toe contraction malformations
Hammer toes come in three different varieties of malformation.
The term "hammer toe" refers to a plantar flexion deformity of the proximal interphalangeal joint (PIP) with different degrees of distal interphalangeal joint (DIP) hyperextension, mostly in the sagittal plane.
- A plantar flexion deformity of the PIP and DIP joint, along with variable degrees of MTP hyperextension, is known as a claw toe.
Each one may be flexible, semirigid, or fixed; the mallet toe solely involves a plantar flexion deformity of the DIP joint.
- Adjustable passively to neutral position
Semirigid: able to be partially corrected to neutral position
- Fixed: not reversible to neutral state without assistance

Epidemiology 

The most typical malformation of the smaller digits, which typically only impacts one or two toes: 
The second toe is most frequently affected.
When the great toe (hallux) is implicated, the phrase "hallux malleus" is used.
Incidence
Not specified
Age-related increases in deformity duration (from flexible to rigid)
Prevalence
Female is more prevalent than male - Depending on the age category, there are 2.5:1 to 9:1 more women than men.
Black people are more likely to be impacted than White people, with a range of 1% to 20% of the population surveyed.


Pathophysiology and Etiology 
Can be acquired or congenital
There are three types of inherited hammer toes: - Flexor stabilization, which is most frequently caused by pronated feet or feet with pes planus. As a result of continued overuse of the toes to help with relative foot instability, the flexor digitorum longus (FDL) muscle is hyperactive.
- The most frequent extensor substitution is pes cavus.
occurs as the gait cycle swings. Extensor digitorum longus (EDL) muscle continues to be hyperactive and takes the place of the hip and ankle extensors that aren't working properly.
- Flexor replacement. least frequent cause and frequently observed with pes cavus. As compared to the primary foot flexors, the Achilles and flexor hallucis longus (FHL), the FDL muscle continues to be hyperactive and dysfunctional.
The EDL tendon at the PIP joint and the FDL tendon at the MTP joint become imbalanced due to biomechanical dysfunction; the imbalance at the MTP joint level changes the stabilizing force of the intrinsic muscles inserting into the extensor sling and wing apparatus of the MTP joint. The toe(s) sublux dorsally in a classic example of hammer toes as the MTP hyperextends. This causes the MTP joint to hyperextend and the PIP joint to plantar flex.

By etiology, several pathomechanics apply: The 4th and 5th toes frequently adopt an adductovarus attitude, which can cause the toes to appear to sit on their side. - Toe length discrepancy or narrow footwear toe box induces PIP joint flexion by forcing digit to accommodate shoe. - May also lead to MTP joint synovitis secondary to overuse, with elongation of plantar plate and MTP joint hyperextension. - Any condition that impairs intra-articular and periarticular tissues, such as second ray longer than first, inflammatory joint illness, neuromuscular disorders, improperly fitting shoes, and trauma - Instability of the PIP joint or MTP joint results from damage to the joint capsule, collateral ligaments, or synovia.

Genetics: Heritability rates of 49–90% that are statistically significant; no known genetic markers.

Risk factors include trauma, narrow-toed shoes and/or tight socks, pes cavus and pes planus, hallux valgus, metatarsus adductus, ankle equinus, abnormal metatarsal and/or digit length, inflammatory joint disease (such as RA), connective tissue disease, and diabetes mellitus.


Prevention 
Correct shoe sizing. Footwear that disperses pressure reduces pain.

Foot orthoses control muscle imbalance and biomechanical dysfunction, halting advancement.

 Restricting the wear of shoes on growing feet. When essential, wear shoes with no drop. Traditional footwear has a higher heel than the foot's ball (MTP joints). As a result, the toes are pushed to contract (referred to as the toe spring) at rest due to their location in dorsal subluxation at the MTP joints.
Controlling predisposed conditions, such as inflammatory joint disease, may also halt progression. Toe strengthening exercises can help prevent an imbalance between the intrinsic and extrinsic muscles of the foot.

Hallux valgus, pes cavus, pes planus, metatarsus adductus, and dorsal callus are all associated conditions.


Diagnosis 

Usually, a history and physical exam are enough to diagnose hammer toes. There are more tests available to rule out alternative conditions.

Presenting History: Type, location, and length of discomfort; Patients frequently describe feeling of a lump on the plantar facet of the MTP joint. Location, duration, severity, and rate of advancement of foot deformity.
Peripheral neurologic symptoms, the severity of functional impairment, aggravating or mitigating circumstances, the type of shoes and hosiery used, and any previous medical care received


clinical assessment 
Note the PIP joint flexion, DIP joint extension, and MTP joint hyperextension.
Keep an eye out for any deformities of the nearby toes, such as hallux valgus or flexion contractures.
Determine the deformity's degree of flexibility and reducibility in both weight-bearing and non-weight-bearing situations.

Note any skin breakdown or ulceration, erythema, adventitious bursa, clavi (dorsal PIP joint, metatarsal head), hyperkeratosis above the joint, or ulcers.

 Feel the dorsal aspect of the PIP joint or the MTP joint for pain.

 MTP joint drawer test
To rule out interdigital neuromas, palpate web gaps.
Neurovascular assessment (including pulses, feeling, and muscle mass)


Differential diagnosis includes: Hyperextension of the MTP and DIP joints and plantar flexion of the PIP joint in a hammer toe; dorsiflexion of the MTP joint and plantar flexion of the DIP joint in a claw toe; fixed or flexible deformity of the DIP joint in a mallet toe; overlapping of the fifth toe; interdigital neuroma; plantar plate rupture; nonspecific synovitis of the MTP joint


Initial test results from the laboratory and imaging
In order to rule out potential metabolic or inflammatory arthropathies, this is not necessary unless clinically indicated:
antinuclear antibodies (ANA), HLA-B27 serologies for inflammatory illness, and rheumatoid factor
Anteroposterior (AP), lateral, and oblique weight-bearing x-rays of the afflicted foot: - AP view superior for evaluating subluxation or dislocation of the transverse plane MTP - A lateral view is ideal for assessing hammer toes.


Tests in the Future & Special Considerations
MRI or bone scan if osteomyelitis is thought to be present

Diagnostic Techniques/Other Nerve conduction investigations or EMG if a neurologic issue is suspected Plethysmography or Doppler if there is poor blood flow and surgery is being considered Computerized weight-bearing pressure testing is only recommended in the presence of neuromuscular abnormalities.
Interpretation of Tests
Prior to treatment, a histologic examination is not necessary.


Management Surgical and nonsurgical therapies are possible. The aim of treatment is to relieve symptoms and assist patients in returning to their usual activity level.
Treatment may not be needed in situations that are mild and asymptomatic.

General Actions 

Shoe adjustments (wider and/or deeper toe box) to accommodate the deformity and lessen pressure over osseous prominences are examples of nonsurgical (conservative) therapies. Avoid wearing heels.

Metatarsal pads in reducible deformities and crest pads in nonreducible deformities, as well as dynamic toe splints for MTP joint subluxations or dislocations with (semi)reducible deformity, are recommended.
Taping or orthotics that straighten the toes to treat flexible deformities  Hyperkeratotic lesions might be excised to lessen symptoms. Topical keratolytics might be advantageous.

Physical therapy for stretching and strengthening of the toes, which includes intrinsic muscle strengthening (short foot exercises), helps preserve flexibility. Shoe orthotics minimize incorrect biomechanics.

Medications for treating pain
Initial Line
NSAIDs may be useful in treating joint and soft tissue inflammation as well as pain sensations.

Referral 
A patient may be sent to an orthopedic surgeon or podiatrist if nonsurgical (conservative) treatment is unsuccessful or impractical, or if the patient has combined deformity of the MTP joint, PIP joint, and/or DIP joint.

Surgical Techniques Depending on the severity and flexibility of the contracture(s) and associated abnormalities, different surgical techniques are used to repair hammer toes.
The most common surgical procedures for flexible hammer toes are PIP joint arthroplasty and arthrodesis.
- Extensor tendon lengthening/tenotomy/MTP joint capsulotomy - Flexor tendon transfer with digital arthrodesis - Flexor tenotomy for reducible or mallet toe deformities with distal ulceration
- Exostosectomy - Arthroplasty with implants
The following surgical procedures can be used to treat semirigid or rigid hammer toes: Girdlestone-Taylor flexor-to-extensor transfer; PIP joint excision; and metatarsal shortening (Weil osteotomy).
- Middle phalangectomy (more frequent in the fifth toe) - Exostosectomy
- Soft tissue releases and lengthening - Less frequently performed proximal phalanx diaphysectomy
- Resection of the phalangeal base during the Hoffman-Clayton operation for RA mutilans
Procedures can be carried out independently or in tandem with other procedures.
Active infection, insufficient vascular supply, and a preference for cosmesis alone are all contraindications to surgery.

Alternative Therapies 
Additionally useful in treating pain and inflammation symptoms are CBD lotions and oils.

Follow-up Immediately after surgery or at the first postoperative appointment, get radiographs; get additional x-rays if necessary Full weight-bearing in a postoperative (surgical) shoe or other device depending on the procedure(s) carried out and the specific patient
The MTP joint is frequently pinched, which necessitates 3 to 5 weeks of forefoot immobilization.
Elevating the foot will help to reduce swelling.
Return to wearing your normal shoes once the pain has been managed, the swelling has gone down, and the sores have healed.
● Uncertain role and effectiveness of postoperative physical therapy 
patient observation
The patient should be seen for the first time within the first week after the procedure(s), assuming there are no problems.
The number of additional visits will depend on the procedure(s) carried out and how the recovery went.
Patients should be advised that mild to moderate edema and plantar foot soreness may last for several months (1 to 6) following surgery and may restrict the kind of shoes they can wear until they go away.

The MTP joint and PIP joint may endure prolonged stiffness.
The "molding" of the operative toe, which involves taking the shapes of neighbouring toes, is quite common.
Encourage patients to wear shoes with a "roomy" (rounded or squared) toe box that are the proper size.

The deformity may worsen despite nonoperative (conservative) treatment for small abnormalities often relieving pain.
Flexible hammer toe deformities can be successfully treated surgically to rectify the deformity and relieve pain.
Recurrence and advancement are frequent, particularly if the patient keeps donning uncomfortable shoes.
Fixed hammer toe deformities can be successfully treated surgically to rectify the deformity and relieve pain.
Rarely do recurrences occur.

Common post-digital surgical problems include, but are not limited to: persistent edema, recurrence of deformity, residual discomfort, excessive stiffness, and metatarsalgia.
Less frequent side effects include numbness (example: digital nerve palsy).
Flail toe, symptomatic osseous regrowth, toe malposition, malunion or nonunion, infection, sausage toe, and vascular impairment (such as gangrene or toe ischemia).

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