Updated: 9/13/2017

Hammer Toe

Topic
Review Topic
0
0
Questions
2
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0
Evidence
3
0
0
Videos
2
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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 
 

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Questions (2)

(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%

(887/1913)

2

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

4%

(77/1913)

3

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

23%

(435/1913)

4

Plantar PIP joint padding, shoe modification, PIP resection arthroplasty

8%

(155/1913)

5

Dorsal PIP joint padding, extensor tenotomy, PIP resection arthroplasty

18%

(345/1913)

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%

(1912/2245)

2

Pain with shoe wear

1%

(24/2245)

3

Presence of hammertoe deformity in all lesser toes

6%

(125/2245)

4

Absence of metatarsophalangeal joint deformity

5%

(119/2245)

5

Absence of a concomitant hallux valgus deformity

3%

(57/2245)

ML 1

Select Answer to see Preferred Response

PREFERRED RESPONSE 1
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Topic COMMENTS (6)
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