Updated: 6/7/2021

Hammer Toe

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  • summary
    • Hammer Toe is a lesser toe deformity characterized by PIP flexion, DIP extension and MTP slight extension.
    • Diagnosis is made clinically with the presence of a rigid or flexible lesser toe with PIP flexion, DIP extension and MTP slight extension.
    • Treatment is a trial of nonoperative management with shoe modification. Surgical management is indicated for progressive deformity, fixed contractures, and dorsal toe ulcerations.
  • Epidemiology
    • Incidence
      • most common deformity of lesser toes
    • Demographics
      • more common in older women
    • Anatomic location
      • 2nd toes usually affected
  • Etiology
    • Pathoanatomy
      • overpull of EDL
      • imbalance of intrinsics
    • Associated conditions
      • painful corns at dorsal PIP joint
  • Classification
    • Claw toe vs. Hammer toe vs. Mallet toe
      Claw toe 
      Hammer toe
      Mallet toe
      DIP 
      Flexion
      Extension
      Flexion
      PIP
      Flexion
      Flexion
      Normal 
      MTP
      Hyperextension
      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
  • 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

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Questions (3)
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(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?

QID: 3843
1

Dorsal PIP joint padding, shoe modification, PIP resection arthroplasty

52%

(1760/3383)

2

Plantar PIP joint padding, PIP resection arthroplasty, MTP capsular release

4%

(134/3383)

3

Dorsal PIP joint padding, shoe modification, extensor tenotomy, metatarsal head excision

18%

(608/3383)

4

Plantar PIP joint padding, shoe modification, PIP resection arthroplasty

9%

(319/3383)

5

Dorsal PIP joint padding, extensor tenotomy, PIP resection arthroplasty

16%

(536/3383)

L 5 B

Select Answer to see Preferred Response

(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?

QID: 3277
1

Fixed deformity

84%

(2483/2952)

2

Pain with shoe wear

1%

(42/2952)

3

Presence of hammertoe deformity in all lesser toes

6%

(179/2952)

4

Absence of metatarsophalangeal joint deformity

6%

(172/2952)

5

Absence of a concomitant hallux valgus deformity

2%

(66/2952)

L 1 B

Select Answer to see Preferred Response

Evidence (4)
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EXPERT COMMENTS (8)
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