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Hammer Toe

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Topic updated on 08/15/16 10:51pm
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 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 extensor tendon transfer
      • indications
        • flexible deformity that has failed nonoperative management
    • resection arthroplasty +/- tenotomy and tendon transfers
      • indications
        • rigid deformity that has failed nonoperative management 
    • girdlestone procedure with flexor to extensor transfer
      • indications
        • MTP involvement
        • similar to claw toe treatment
    • arthrodesis
      • indications
        • an option in rigid deformity
      • outcomes
        • high nonunion rate
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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Qbank (1 Questions)

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(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? Topic Review Topic

1. Fixed deformity
2. Pain with shoe wear
3. Presence of hammertoe deformity in all lesser toes
4. Absence of metatarsophalangeal joint deformity
5. Absence of a concomitant hallux valgus deformity

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