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Hammertoe Deformity Workup

  • Author: Anthony Watson, MD; Chief Editor: Anthony E Johnson, MD  more...
 
Updated: Mar 28, 2016
 

Laboratory Studies

Serologic evaluation—including determinations of the rheumatoid factor, antinuclear antibody, human leukocyte antigen (HLA) B27, and Lyme titers if inflammatory arthropathy is suspected—should be considered.

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Imaging Studies

Radiographic evaluation of hammertoe is not necessary for clinical diagnosis; however, it can be helpful for ruling out alternative diagnoses and can aid in surgical planning. Imaging considerations in the evaluation of hammertoe deformity include the following:

  • Weightbearing anteroposterior and lateral radiographs of the involved foot are useful
  • Intra-articular or periarticular erosions suggest rheumatoid arthritis or psoriatic arthritis, respectively.
  • Enlargement of the metatarsal head and osteophytes suggests a previous Freiberg infraction.
  • Varus angulation and/or dorsal subluxation or widening of the joint space of the MTP joint suggests MTP instability.
  • The presence of other deformities should be noted
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Histologic Findings

Histologic evaluation is typically not available or necessary before hammertoe treatment. Skin ulceration and osteomyelitis may occur in neuropathic patients with hammertoe deformity. Histologic confirmation of osteomyelitis precludes most hammertoe reconstruction procedures.

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Contributor Information and Disclosures
Author

Anthony Watson, MD Orthopedic Surgeon, Private Practice

Anthony Watson, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Pennsylvania Orthopaedic Society, American Orthopaedic Foot and Ankle Society, Pennsylvania Medical Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Anthony E Johnson, MD Chairman, Department of Orthopaedic Surgery, San Antonio Military Medical Center; Research Director, US Army–Baylor University Doctor of Science Program (Orthopaedic Physician Assistant); Custodian, Military Orthopaedic Trauma Registry; Associate Professor, Department of Surgery, Baylor College of Medicine; Associate Professor, The Norman M Rich Department of Surgery, Uniformed Services University of the Health Sciences

Anthony E Johnson, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Healthcare Executives, American College of Sports Medicine, American Orthopaedic Association, Arthroscopy Association of North America, Association of Bone and Joint Surgeons, International Military Sports Council, San Antonio Community Action Committee, San Antonio Orthopedic Society, Society of Military Orthopaedic Surgeons, Special Operations Medical Association

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Society of Military Orthopaedic Surgeons; American Academy of Orthopaedic Surgeons<br/>Received research grant from: Congressionally Directed Medical Research Program<br/>Received income in an amount equal to or greater than $250 from: Nexus Medical Consulting.

Additional Contributors

Heidi M Stephens, MD, MBA Associate Professor, Department of Surgery, Division of Orthopedic Surgery, University of South Florida College of Medicine; Courtesy Joint Associate Professor, Department of Environmental and Occupational Health, University of South Florida College of Public Health

Heidi M Stephens, MD, MBA is a member of the following medical societies: Alpha Omega Alpha, American Academy of Orthopaedic Surgeons, American Medical Association, American Orthopaedic Foot and Ankle Society, Florida Medical Association

Disclosure: Nothing to disclose.

References
  1. Myerson MS, Shereff MJ. The pathological anatomy of claw and hammer toes. J Bone Joint Surg Am. 1989 Jan. 71(1):45-9. [Medline].

  2. Sarrafian SK, Topouzian LK. Anatomy and physiology of the extensor apparatus of the toes. J Bone Joint Surg Am. 1969 Jun. 51(4):669-79. [Medline].

  3. Badlissi F, Dunn JE, Link CL, Keysor JJ, McKinlay JB, Felson DT. Foot musculoskeletal disorders, pain, and foot-related functional limitation in older persons. J Am Geriatr Soc. 2005 Jun. 53(6):1029-33. [Medline].

  4. Barbari SG, Brevig K. Correction of clawtoes by the Girdlestone-Taylor flexor-extensor transfer procedure. Foot Ankle. 1984 Sep-Oct. 5(2):67-73. [Medline].

  5. O'Kane C, Kilmartin T. Review of proximal interphalangeal joint excisional arthroplasty for the correction of second hammer toe deformity in 100 cases. Foot Ankle Int. 2005 Apr. 26(4):320-5. [Medline].

  6. Konkel KF, Menger AG, Retzlaff SA. Hammer toe correction using an absorbable intramedullary pin. Foot Ankle Int. 2007 Aug. 28(8):916-20. [Medline].

  7. Jones S, Hussainy HA, Flowers MJ. Re: Arthrodesis of the toe joints with an intramedullary cannulated screw for correction of hammertoe deformity. Foot Ankle Int. 2005 Dec. 26(12):1101; author reply 1101. [Medline].

  8. Konkel KF, Sover ER, Menger AG, Halberg JM. Hammer toe correction using an absorbable pin. Foot Ankle Int. 2011 Oct. 32(10):973-8. [Medline].

  9. Nery C, Coughlin MJ, Baumfeld D, Mann TS. Lesser metatarsophalangeal joint instability: prospective evaluation and repair of plantar plate and capsular insufficiency. Foot Ankle Int. 2012 Apr. 33(4):301-11. [Medline].

  10. Ellington JK. Hammertoes and clawtoes: proximal interphalangeal joint correction. Foot Ankle Clin. 2011 Dec. 16(4):547-58. [Medline].

  11. Miller JM, Blacklidge DK, Ferdowsian V, Collman DR. Chevron arthrodesis of the interphalangeal joint for hammertoe correction. J Foot Ankle Surg. 2010 Mar-Apr. 49(2):194-6. [Medline].

  12. Bouché RT, Heit EJ. Combined plantar plate and hammertoe repair with flexor digitorum longus tendon transfer for chronic, severe sagittal plane instability of the lesser metatarsophalangeal joints: preliminary observations. J Foot Ankle Surg. 2008 Mar-Apr. 47(2):125-37. [Medline].

  13. Trnka HJ, Gebhard C, Muhlbauer M, et al. The Weil osteotomy for treatment of dislocated lesser metatarsophalangeal joints: good outcome in 21 patients with 42 osteotomies. Acta Orthop Scand. 2002 Apr. 73(2):190-4. [Medline].

  14. Smith SC, Bazzoli C, Chung I, Johnson A, Martin DR. Antimicrobial susceptibility of Escherichia coli in uncomplicated cystitis in the emergency department: is the hospital antibiogram an effective treatment guide?. Acad Emerg Med. 2015 Aug. 22 (8):998-1000. [Medline].

  15. Joshi S. Hospital antibiogram: a necessity. Indian J Med Microbiol. 2010 Oct-Dec. 28 (4):277-80. [Medline].

  16. Migues A, Slullitel G, Bilbao F, Carrasco M, Solari G. Floating-toe deformity as a complication of the Weil osteotomy. Foot Ankle Int. 2004 Sep. 25(9):609-13. [Medline].

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Diagram comparing clinical appearances of lesser-toe deformities.
Morton foot, wherein second ray (metatarsal and corresponding toe) is longer than first ray.
Pathomechanics of hammertoe deformity. Elongated plantar plate, caused by either metatarsophalangeal (MTP) synovitis and instability or chronic MTP hyperextension due to toe crowding, results in MTP subluxation or dislocation with compensatory proximal interphalangeal (PIP) flexion.
Painful dorsal callus over proximal interphalangeal (PIP) joint of second toe, caused by long-standing, fixed hammertoe deformity.
Physical examination maneuver to diagnose metatarsophalangeal (MTP) instability, wherein examiner attempts to translate proximal phalanx dorsally relative to metatarsal head. In most patients, subluxation is possible; therefore, this test is positive only when it causes pain.
Hammertoe shield for treatment of flexible hammertoe. Sling over proximal phalanx straightens toe, while shield under metatarsal head provides padding for painful callus that may be present, supports toe plantarly, and anchors sling.
 
 
 
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