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Updated: Mar 7 2023

Hammer Toe

Images image_moved.jpg fx_moved.jpg
  • 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
      • plantar plate injury
      • 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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