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(SBQ12FA.36) A 43-year-old female presents with a painful right 2nd toe. On examination,
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she has a rigid flexion contracture of the second proximal interphalangeal (PIP) joint, with
Active Test neutral position of the metatarsophalangeal (MTP) joint. The deformity does not correct
Tagged Questions 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

45% (756/1692)

2 Plantar PIP joint padding, PIP resection arthroplasty, MTP capsular release
4% (73/1692)

3 Dorsal PIP joint padding, shoe modification, extensor tenotomy, metatarsal head
excision
24% (411/1692)

4 Plantar PIP joint padding, shoe modification, PIP resection arthroplasty

8% (133/1692)

5 Dorsal PIP joint padding, extensor tenotomy, PIP resection arthroplasty

18% (306/1692)

PREFERRED RESPONSE 1 (

The patient presents with a rigid 2nd hammertoe. The most appropriate progression of
treatment is padding the dorsum of the PIP joint, modification of shoe wear, followed by
PIP resection arthroplasty if conservative treatment fails. Extensor tenotomy/lengthening
may be performed concomitantly to address MTP dorsiflexion contracture.

Rigid hammertoe deformity is characterized by fixed PIP flexion which does not correct
with foot plantarflexion. It is associated with neutral to slight MTP extension, and variable
position of the DIP. Persistent deformities are symptomatic from dorsal pressure to the PIP
joint, which is why padding and shoe modification are first line of treatment.

The resection arthroplasty procedure involves resection of the distal condyle of the
proximal phalanx, resection of the articular surface of the middle phalanx, and compression
of these two surfaces into proper alignment. The phalanges are then pinned in position
using a Kirschner wire. The procedure produces either an arthrodesis or a fibrous union at
this interface, and a true arthrodesis is not necessary for a successful result.

Coughlin et. al. evaluated resection arthroplasty for rigid hammertoe deformities in 118
toes. After surgery, most patients reported return to normal shoe wear, and rated their toes
as satisfactory. Additionally, surgery reduced callus severity, and patient-reported post-
operative alignment was rated as excellent or good in 85% of cases.

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Incorrect Answers:
! $ Answer 2: Pain occurs at the dorsum of the PIP joint due to pressure, thus plantar padding
would not be helpful. MTP capsular release would not help the deformity of the PIP joint.
Answer 3: Metatarsal head excision would not be helpful for the deformity of the PIP joint.
Extensor tenotomy is indicated in conjunction with PIP resection arthroplasty in severe
Qbank Menu cases of hammertoe.
Answer 4: Pain occurs at the dorsum of the PIP joint due to pressure, thus plantar padding
My TestMaster would not be helpful.
Answer 5: Extensor tenotomy should not precede PIP resection arthroplasty, but should be
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performed in conjunction with it in severe cases to address MTP dorsiflexion contracture
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) REFERENCES (1) (
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Tagged Questions Operative repair of the fixed hammertoe

deformity.
Coughlin MJ, Dorris J, Polk E
Foot Ankle Int. 2000 Feb;21(2):94-104. PMID: 10694020
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(Link to Abstract) 16 responses

Coughlin, FAI 2000

Authors: Edward DelSole MD, Thomas Hearty MD, Brian Weatherford MD, Franz Kopp MD

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+ QUESTION COMMENTS (5) QUESTION EMAIL NOTIFICATION: , (

Recent Comment

Johnny T. Nelson 6:44AM on 06/10/18

Explanation states that answer 5 is incorrect because "Extensor tenotomy

should not precede PIP resection arthroplasty, but should be performed in
conjunction with it..." I agree that shoe modification is important, but how
does answer 5 imply anything but that the extensor tenotomy and the PIP
resection arthroplasty are done in conjunction?

Comments (4)
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