Hammer toe

Hammer Toe in Children

What is a hammer toe?

A hammer toe is a deformity of one of the smaller toes (most commonly the second, third, or fourth) in which the toe bends abnormally at the proximal interphalangeal (PIP) joint or the distal interphalangeal joint (DIP) — causing it to point downwards and assume a claw-like position. The end of the toe may press into the ground (mallet toe) or the knuckle of the toe may rub against the shoe (true hammer toe), causing pain, calluses, and difficulty with footwear.

In children, hammer toe may be congenital (present from birth), acquired due to muscle imbalance, or associated with an underlying neurological or connective tissue condition.

What causes hammer toe in children?

• Congenital — present from birth as an isolated finding

• Footwear — ill-fitting shoes that cramp the toes (contributory but rarely the sole cause in children)

• Neurological conditions — such as Charcot-Marie-Tooth disease, cerebral palsy, or spina bifida, causing muscle imbalance

• Connective tissue conditions — such as Marfan syndrome or Ehlers-Danlos syndrome

• Post-traumatic — following injury to the toe

• Idiopathic — no identifiable cause

How does it differ from curly toe?

Is it flexible or fixed?

This is the most important assessment:

• Flexible hammer toe — the joint can be passively straightened by hand. More amenable to conservative treatment and soft tissue surgery.

• Fixed (rigid) hammer toe — the joint cannot be straightened passively. Usually requires bony surgery to correct.

Treatment options

Conservative management (for flexible deformity and younger children)

• Wide-fitting footwear with a deep toe box to reduce pressure

• Toe splinting or buddy taping — taping the hammer toe to the adjacent normal toe to encourage a straighter position

• Silicone toe sleeves or gel shields — to protect the knuckle from shoe rubbing and reduce callus

• Physiotherapy and stretching exercises — particularly if associated with neurological muscle imbalance

• Observation — in young children, some flexible hammer toes improve with growth

Surgical treatment — flexible hammer toe

For flexible deformity that has failed conservative measures:

• Flexor tenotomy — division of the tight flexor tendon (similar to curly toe treatment), allowing the toe to straighten

• Flexor-to-extensor transfer (Girdlestone-Taylor procedure) — the flexor tendon is rerouted to the top of the toe to actively help straighten it. More powerful correction than tenotomy alone.

Surgical treatment — fixed hammer toe

For rigid deformity, soft tissue releases alone are insufficient and a bony procedure is required:

• PIP or DIP joint arthrodesis (fusion) — the joint is fused in a straightened position using a pin or small screw. This provides permanent, reliable correction but the joint will no longer bend

K-wire fixation

After corrective bony surgery, a K-wire (Kirschner wire) is often inserted along the length of the toe to hold it straight while healing occurs. The K-wire exits the tip of the toe (a few millimetres) and is removed in the outpatient clinic at 4-6 weeks — no general anaesthetic is required for removal.

Anaesthetic and hospital stay

• General anaesthetic for all surgical procedures

• Most hammer toe procedures are day case — home the same day

• Occasionally an overnight stay is required for more complex cases

Benefits of surgery

• Straightens the toe and relieves pain

• Reduces callus and rubbing on footwear

• Improves toe appearance and function

• Enables normal shoe fitting

Risks and possible complications

• Wound infection

• K-wire pin site infection — the small pin protruding from the toe tip requires daily cleaning

• Recurrence of deformity — commoner in children with neurological conditions

• Incomplete correction or slight residual angulation

• Stiffness — particularly after joint fusion

• Injury to digital nerves — rare

• Transfer lesion — relieving one toe can occasionally cause overloading of an adjacent toe

• Anaesthetic risks

Recovery

What to expect

Day 0-2

Dressed foot. Elevate. Rest.

48 hours

Wool and crepe removed at home.

2 weeks

Opsite dressing removed. Wound check at   4-6 weeks in clinic.

K-wire removed at clinic appointment.

Return to school

Usually 1-2 weeks in wide comfortable footwear.

Return to PE / sport - 6-8 weeks once healed.

Note: The small K-wire tip protruding from the end of the toe must be kept clean. Keep the dressing dry — use a waterproof cover for bathing. Do not attempt to remove the K-wire yourself. Report any redness, discharge, or increasing pain around the pin site to the department promptly.

Note: When to seek urgent help 

The K-wire appears to have moved, bent, or partially come out — contact the department Significant redness or discharge around the K-wire site The toe becomes very painful, pale, or cold Temperature above 38°C

This information is for general guidance only and is not a substitute for a consultation with Mr Wadia. If you are worried about your child, please seek medical advice.