Approach

• Expose both ankles and feet

	Hammer	Claw	Mallet
Aetiology	Imbalance between intrinsic (lumbricals and interossei) and extrinsic (long flexors and extensors) More common in Females Elderly Patients with rheumatoid arthritis	Imbalance between intrinsic (lumbricals and interossei) and extrinsic (long flexors and extensors) More common in Females Elderly Patients with rheumatoid arthritis May be secondary to neurological disorders such as peripheral neuropathy (diabetes, Charcot-Marie-Tooth) LMN disease, UMN disease
Appearance
Look	Affects lesser toes, commonly 2nd toe May be associated with hallux valgus Flexion deformity at PIPJ of involved toes DIPJ can be in any position, but extension most common Note any associted callosities	Affects lesser toes - frequently all 4 involved May be bilateral Flexion deformity at the PIPJ and DIPJ Involves MTPJ an Note any associated callosities - plantar to the metatarsal heads and dorsal to the PIPJ
Feel	Tenderness	Tenderness
Move	Deformity fixed or mobile	Deformity fixed or mobile

Completion

1. Gait assessment
2. Examine shoes
3. Ask how condition affects life

Management options

1. Non-surgical
   • Appropriate footwear - high, wide toe
2. Surgical
   • Mobile deformity - flexor to extensor tendon transfer (split flexor digitorum longus transfer to the extensor hood)
   • Fixed deformity - consider resection of phalangeal head and neck; arthrodesis