| Introduction |
 Hammer deformity characterized by
- flexion of the PIP joint
- extension deformity at DIP
- deformity can be rigid or flexible
- Epidemiology
- most common deformity of lesser toes
- more common in older women
- second toes usually affected
- Pathoanatomy
- overpull of EDL
- imbalance of intrinsics
- Associated conditions
- painful corns at dorsal PIP joint
|
| Classification |
| |
Claw Toe
|
Hammer Toe
|
Mallet Toe
|
| |
 |
 |
 |
| DIP |
flexion
|
extension
|
flexion
|
| PIP |
flexion
|
flexion
|
normal
|
| MTP |
hyperextension
|
normal (slight extension)
|
normal
|
|
| Presentation |
- Symptoms
- pain on dorsal surface with shoe wear
- deformity
- Physical exam
- flexion deformity of the PIP joint of the lesser toes with extension of DIP
- Push up test
- flexible deformity is reducible with dorsal directed pressure on the plantar aspect of the involved metatarsal
- effect of over active extrinics is removed
|
| Imaging |
- Imaging not required in diagnosis and treatment
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| Treatment |
- Nonoperative
- shoes with high toe boxes, foam or silicone gel sleeves
- indications
- pain and or corns on dorsal PIP
- Operative
- flexor tendon (FDL) to extensor tendon transfer
- indications
- flexible deformity that has failed nonoperative management
- resection arthroplasty +/- tenotomy and tendon transfers
- indications
- rigid deformity that has failed nonoperative mangement
- girdlestone procedure with flexor to extensor transfer
- indications
- MTP involvement
- similar to claw toe treatment
- arthrodesis
- indications
- an option in rigid deformity
- outcomes
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| Surgical Techniques |
- Resection arthroplasty +/- tenotomy and tendon transfers
- resection of head and neck of proximal phalanx to create a fibrous joint
- hold in place with K-wire for 2-3 weeks
- postoperative
- protect for additional 3 weeks with taping of PIP in extension
- girdlestone procedure (flexor to extensor transfer)
- extensor tendon lengthening with Z plasty
- peform MTP capsule release
- +/- metatarsal shortening with oblique osteotomy
- FDL to EDL transfer
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|
Please Rate Educational Value!
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3.0
t-7014
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Average 3.0 of 11 Ratings
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Qbank (2 Questions)
TAG
(OBQ10.184)
A 57-year-old woman complains of pain and deformity of the second toe that is limiting ambulation. Shoe accomodations and NSAIDs have failed to provide relief. She has a fixed flexion deformity of 40 degrees at the PIP joint, but the MTP joint is not involved. The hallux is normal, but painless PIP flexion contractures are present in the other lesser toes. Which of the following is an indication for PIP resection arthroplasty as opposed to soft-tissue balancing and realignment?
Review Topic
DISCUSSION:
Hammertoe is defined as a flexion deformity of the proximal interphalangeal joint. A diagram of the deformity is provided in illustration A. There are many causes including neurogenic, degenerative, and metabolic processes. Hammertoe can also be secondary to another deformity in the foot such as hallux valgus or curly toe. Consequently, there are numerous surgical procedures available for treatment including soft tissue releases, tendon transfers, resection arthroplasty, and arthrodesis. The presence of fixed deformity precludes success with soft tissue procedures alone. O'Kane et al review 100 cases of excisional arthroplasty for second digit hammertoe. High rates of clinical satisfaction were acheived with only 2 revision surgeries. Floating toe was the most frequent complication (7). However, floating toe did not adversely affect shoe wear in any patient experiencing this complication. Coughlin et al review 63 cases of excisional arthroplasty for fixed hammertoe. The resection arthroplasty was stabilized with K-wire fixation that led to bony fusion in 81% and fibrous union in the remaining 19%. Only minor complications occurred and 84% of patients reported high clinical satisfaction.
Illustrations:
A
REFERENCES:
1.
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.
PMID:15829216 (Link to Abstract)
2.
Coughlin MJ, Dorris J, Polk E. Operative repair of the fixed hammertoe deformity. Foot Ankle Int. 2000 Feb;21(2):94-104.
PMID:10694020 (Link to Abstract)
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Please Rate Educational Value!
|
4.0
q-3277
|
Average 4.0 of 12 Ratings
|
-
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.
PMID:15829216 (Link to Abstract)
Level of Evidence 5 and Other Journal Articles (includes Case Reports, Expert Opinions,
Personal Observations, and Biomechanic Studies)
-
Coughlin MJ, Dorris J, Polk E. Operative repair of the fixed hammertoe deformity. Foot Ankle Int. 2000 Feb;21(2):94-104.
PMID:10694020 (Link to Abstract)
Textbooks
- Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
- AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
- Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
- Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
- Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
- Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
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