What are the treatment options for pediatric hammertoes?

Treatment of Pediatric Hammertoes

The primary treatment for pediatric hammertoes should focus on conservative measures first, with surgical intervention reserved for cases that fail to respond to non-surgical management. 1

Assessment and Risk Stratification

When evaluating a child with hammertoes, consider:

• Flexibility of the deformity (rigid vs. flexible)
• Presence of pain or discomfort
• Impact on daily activities and footwear
• Associated foot deformities
• Age of the patient

Conservative Treatment Options

First-Line Approaches:

1. Properly Fitting Footwear

   • Shoes with adequate toe box width and depth
   • Athletic or walking shoes that accommodate the shape of the feet 1
   • Avoid narrow-toed shoes that compress the toes

2. Orthotic Devices

   • Toe silicone or semi-rigid orthotic devices to reduce excess callus 1
   • Custom-made insoles for associated foot deformities
   • Toe spacers to maintain proper alignment

3. Physical Therapy

   • Foot-ankle exercise programs (8-12 weeks) under supervision of a trained healthcare professional 1
   • Stretching exercises for flexible deformities 2

4. Kinesiology Taping

   • May provide symptomatic relief for flexible deformities 3
   • Can help with proper toe alignment

For Moderate Deformities:

• Custom-made footwear or extra-depth shoes for significant deformities 1
• Regular monitoring every 3-6 months by a foot care specialist 1

Surgical Interventions

When conservative measures fail, surgical options include:

1. Digital Flexor Tenotomy

   • Recommended as first-line surgical treatment for flexible hammertoes with nail changes, excess callus, or pre-ulcerative lesions 1
   • High success rate (92-100% in children) 4
   • Can be performed as an outpatient procedure
   • Particularly effective for distal toe ulcers in cases with neuropathy 1

2. Proximal Interphalangeal Joint Arthrodesis

   • For rigid deformities that don't respond to conservative treatment 2
   • Fusion rates of 83-98% 2
   • High patient satisfaction (83-100%) 2
   • May require internal fixation with Kirschner wires or intramedullary devices

3. Arthroplasty

   • Alternative to arthrodesis that preserves some joint motion 2
   • May be suitable for less severe deformities

4. Intramedullary Devices

   • One-piece intramedullary implants can be used as an alternative to Kirschner wires 5
   • Advantages include elimination of wire migration and decreased need for hardware removal

Special Considerations

• In children, open flexor tenotomy has shown excellent long-term results with success rates of 95% 4
• Surgical complications to watch for include:
  • Transfer lesions
  • Recurrence of deformity
  • Stiffness
  • Vascular compromise
  • Excessive bone resection leading to cosmetically undesirable short toe 2

Follow-up Care

• Regular monitoring based on severity:
  • Moderate risk: every 3-6 months
  • High risk: every 1-3 months 1
• Patient and family education about proper foot care and footwear
• Monitoring for recurrence of deformity

Algorithm for Decision-Making

1. Assess flexibility: If flexible → conservative treatment
2. Try conservative measures for 3-6 months
3. If conservative treatment fails:
   • For flexible deformities → consider flexor tenotomy
   • For rigid deformities → consider arthrodesis or arthroplasty
4. Post-surgical rehabilitation with appropriate footwear and exercises

The evidence strongly supports starting with conservative approaches for pediatric hammertoes, with surgical intervention reserved for cases that fail to respond to non-surgical management. Digital flexor tenotomy has emerged as a particularly effective surgical option for children with persistent deformities.