Introduction Hammer deformity characterized by PIP flexion DIP extension MTP neutral (or extended) deformity can be rigid or flexible Epidemiology most common deformity of lesser toes more common in older women 2nd 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 ankle plantar flexion flexible deformity corrects fixed deformity does not correct with ankle plantar flexion push up test flexible deformity is reducible with dorsal directed pressure on the plantar aspect of the involved metatarsal effect of over active extrinsics is removed Imaging Imaging not required in diagnosis and treatment 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 EDL tendon transfer indications flexible deformity that has failed nonoperative management PIP resection arthroplasty +/- tenotomy and tendon transfers indications rigid deformity that has failed nonoperative management Girdlestone procedure with FDL to EDL transfer indications MTP involvement similar to claw toe treatment EDL Z-lengthening or tenotomy indications mild MTP hyperextension EDL Z-lengthening and dorsal capsular release ndications moderate to severe MTP hyperextension PIPJ arthrodesis indications an option in rigid deformity outcomes high nonunion rate treat concurrent forefoot deformities correct hallux valgus (for 2nd hammer toe) arthrodesis for severe hallux valgus amputation for severe hallux valgus touching 3rd toe indications elderly poor health does not want hallux reconstruction Surgical Techniques Resection arthroplasty +/- tenotomy and tendon transfers resection of head and neck of proximal phalanx to create a fibrous joint +/- FDL to EDL transfer 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 perform MTP capsule release +/- metatarsal shortening with oblique osteotomy FDL to EDL transfer
QUESTIONS 1 of 2 1 2 Previous Next (SBQ12FA.36) A 43-year-old female presents with a painful right 2nd toe. On examination, she has a rigid flexion contracture of the second proximal interphalangeal (PIP) joint, with neutral position of the metatarsophalangeal (MTP) joint. The deformity does not correct with foot plantarflexion. What is the most appropriate sequence of treatment options? Review Topic QID: 3843 1 Dorsal PIP joint padding, shoe modification, PIP resection arthroplasty 46% (888/1915) 2 Plantar PIP joint padding, PIP resection arthroplasty, MTP capsular release 4% (77/1915) 3 Dorsal PIP joint padding, shoe modification, extensor tenotomy, metatarsal head excision 23% (435/1915) 4 Plantar PIP joint padding, shoe modification, PIP resection arthroplasty 8% (156/1915) 5 Dorsal PIP joint padding, extensor tenotomy, PIP resection arthroplasty 18% (345/1915) ML 5 Select Answer to see Preferred Response PREFERRED RESPONSE 1 (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 QID: 3277 1 Fixed deformity 85% (1913/2246) 2 Pain with shoe wear 1% (24/2246) 3 Presence of hammertoe deformity in all lesser toes 6% (125/2246) 4 Absence of metatarsophalangeal joint deformity 5% (119/2246) 5 Absence of a concomitant hallux valgus deformity 3% (57/2246) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 1
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