Dr. Kevin Yip

Dr Kevin Yip
Orthopaedic Surgeon
MBBS(UK), FRCS(EDIN), FAM(SING), FHKCOS(ORTHO)

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Hammer Toes

Basics
Description
  • The term hammer toe describes a flexion deformity of the PIP joint of the lesser toes.
  • It may be a flexible or rigid deformity.
General Prevention
Because the most common cause of hammer toes is poor shoe wear with a tight, narrow toe box, the best prevention is to wear shoes with a wide, high toe box that does not constrain the forefoot area.
 
Incidence
More common in females than in males
 
Etiology
  • Most commonly from poorly fitting shoes
  • Neuromuscular disease
  • Diabetes mellitus
  • Inflammatory arthropathy
  • Compartment syndrome
Associated Conditions
  • Hallux valgus
  • MTP dorsiflexion deformity (claw toe)
Diagnosis
Signs and Symptoms
  • Dorsal prominence over the lesser-toe PIP joints
  • Toe may be erythematous from shoe irritation.
  • Overlying callus may be present from pressure of the shoe on the toe.
History
  • Patients complain of pain over the dorsal prominence of the hammer toe with shoe wear.
  • Patients also may have pain under the metatarsal heads (metatarsalgia).
Physical Exam
  • Determine if the flexion deformity of the toe is flexible or rigid.
  • Determine if an associated dorsal subluxation of the MTP joint is present.
  • Look for an associated hallux valgus deformity (bunion).
Imaging
Plain radiographs of the foot show the flexion deformity of the PIP joint of the lesser toes consistent with the examination.
 
Differential Diagnosis
  • Claw toes have a concomitant dorsiflexion deformity of the MTP joint.
  • Mallet toes have a flexion deformity at the DIP joint.
Treatment
General Measures
  • If the deformity is flexible, a Budin splint may help straighten the dorsal prominence of the toe and diminish symptoms.
  • If the deformity is rigid, then padding, including doughnut pads, and silicone gel toe sleeves help decrease pressure over the dorsal prominence.
Geriatric Considerations
  • Hammer toes are a common diagnosis in elderly females.
  • In patients with coexisting morbidities, such as diabetes or peripheral vascular disease, nonoperative management should be exhausted before considering surgery.
Surgery
  • For flexible hammer toes, a flexor-to-extensor tendon transfer may be used to correct the deformity.
  • Resection arthroplasty of the distal end of the proximal phalanx with pinning can straighten a rigid hammer toe.
  • PIP fusion:
    • Is an alternative option for treating painful hammer toes
    • Can be used for primary surgery or for revision surgery on recurrent deformities
Follow-up
Disposition
Issues for Referral
  • Patients for whom nonoperative interventions, such as padding or splinting, fail may require surgical consultation.
  • Diabetic patients need early consultation to prevent the development of neuropathic ulceration.
Prognosis
Hammer toes usually worsen over time, with increasing deformity and pain.
 
Complications
  • Complications of surgical treatment include:
    • Stiffness
    • Wound infection
    • Persistent pain
    • Failure to correct deformity adequately
    • Recurrence
Miscellaneous
Codes
ICD9-CM
735.4 Hammer toe
 
FAQ
Q: What are simple nonsurgical measures to relieve symptoms of painful hammer toes?
A: Shoes with low heels and a wide toe box are recommended to relieve pressure. Taping or strapping devices may improve alignment, whereas foam or gel pads can relieve focal pressure or calluses caused by the shoe.
 
Q: What is the key physical finding of hammer toes?
A: Determining the flexibility or rigidity of hammer toes is crucial to determining nonoperative treatment options and surgical strategies.

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