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PubMed2002

The frequency and significance of 'striatal toe' in parkinsonism.

A striatal toe has been defined as an apparent extensor plantar response, without fanning of the toes, in the absence of any other signs suggesting dysfunction of the cortico-spinal tract. Little is known about the frequency and significance of this sign in parkinsonian syndromes. We prospectively examined 62 patients (Parkinson's disease: other akinetic-rigid syndromes=38:24) for the presence or absence of striatal toe and extensor plantar responses, as defined by Babinski. Details of the history, physical findings and investigations previously undertaken were rated and examined for their relevance to the response obtained from the hallux. Of the 62 patients, 17 patients showed an upgoing plantar response, of whom 13 (Parkinson's disease: other akinetic-rigid syndromes=7:6) had striatal toes, either unilateral (10) or bilateral (3). The remaining four patients showed a classical Babinski sign (Parkinson's disease: other akinetic-rigid syndromes=2:2). There was no lateralising relationship between lesions of the basal ganglia found on imaging and the side of the striatal toe, or the side of dyskinesias found at the time of examination. However, there appeared to be a greater frequency of dyskinesias and evidence of lesions involving the basal ganglia on imaging in patients with striatal toes compared with those who showed a plantar response other than upgoing. The possible relevance of these findings is discussed.

Aged↗
PubMed1998

Recovery of post-tetanic count and train-of-four responses at the great toe and thumb.

We have studied the recovery of post-tetanic count and train-of-four responses at the great toe and thumb accelerographically after the administration of vecuronium 0.2 mg.kg-1. Sixty adult patients scheduled for anaesthesia with nitrous oxide and isoflurane were studied. The times to the return of the first post-tetanic twitch were comparable at the great toe and thumb (mean (SD) times: 30.0 (6.5) min and 35.0 (8.5) min, respectively). Recovery of post-tetanic count followed similar time courses at the great toe and thumb. Also, time to the return of the first twitch of the train-of-four did not differ significantly at the great toe and the thumb (47.5 (9.6) min vs. 49.7 (10.5) min). Similarly, time to the return of the second, third and fourth twitches of the train-of-four did not significantly differ at the great toe and the thumb. However, the value of the first twitch of the train-of-four, expressed as a proportion of control twitch, was significantly higher than that at the thumb between 50 min and 110 min after the vecuronium injection, and the train-of-four ratio at the great toe was significantly higher than that at the thumb between 60 min and 100 min after the vecuronium injection.

Adult↗
PubMed2000

'Sausage toe': a reliable sign of underlying osteomyelitis.

AIMS: To follow-up patients with a 'sausage' deformity of the toe associated with local neuropathic ulceration to confirm the diagnosis of underlying osteomyelitis. This was based on our observation that some diabetic patients with suspected pedal osteomyelitis with a local neuropathic ulcer have a 'sausage' deformity of a toe. METHODS: Over a period of 2 years, 14 patients with foot ulcers, who were observed to have the 'sausage' deformity of a toe in the diabetic foot clinic were followed up and investigated. RESULTS: Underlying osteomyelitis was confirmed in six on the very first X-ray examination. A further seven had osteomyelitis diagnosed on bone scanning. Both the X-ray and the bone scan were equivocal in one patient, whose ulcer only healed after an 8-week course of antibiotics. Antibiotic therapy was successful in 11 patients and three patients required amputation of the affected toe. Following successful treatment, there was full resolution of the 'sausage toe' in the majority. CONCLUSIONS: The appearance of a 'sausage toe' should alert the physician of the possibility of underlying osteomyelitis in diabetic foot, so that prompt treatment can be commenced with antibiotics.

Adult↗
PubMed1998

A polydactylous human foot with 'double-dorsal' toes.

A human polydactylous left foot with 9 toes, amputated from an 11-mo-old child, was examined by x-ray and magnetic resonance imaging and by gross dissection to identify the digits. The normal sequence of toes from medial to lateral is 1, 2, 3, 4, 5. Examination of the morphology of tendons and muscles suggested the toe sequence was 1, 2, 3/4, ?5, 2, 3/4, 3/4, 5. The 2 toes in the sequence that are underlined were displaced dorsally and were found to have 2 extensor tendons, no flexor tendons and nails that were conical and situated at their tips. These toes resembled those described as 'double-dorsal' and which develop in paws of mice in which a gene normally expressed ventrally is functionally inactivated (Loomis et al. 1996). Specification of toe formation occurs in leg buds early in embryonic development and later there is rotation of the limb so that the anterior (rostral) part comes to lie medially, i.e. the hallux which was anterior (rostral) now is on the inner (medial) side of the foot. A disruption in the patterning of this foot in both anteroposterior (rostral-caudal) and dorsoventral axes during development could be responsible.

Female↗
PubMed1999

The toe pole test for evaluation of arterial insufficiency in diabetic patients.

OBJECTIVES: to evaluate if the pole test at the toe level can be used for assessment of arterial insufficiency in diabetic patients. METHODS: twenty-five legs in 23 diabetic patients suffering from leg ischaemia were examined prospectively. A laser Doppler probe was attached to the pulp of the first toe to monitor perfusion continuously before and after occluding the arterial inflow with a cuff and during elevation of the leg until perfusion disappeared (the pole test). At ankle level the examinations were made similarly but with an ankle cuff and a hand-held Doppler. RESULTS: in the 44% (11/25) of the legs where it was possible to compare cuff blood pressure at ankle level with the pole test, the cuff measurements were significantly higher (p <0.01). In 13 of the remaining 14, maximal elevation did not result in disappearance of the Doppler signal. At toe level where 76% (19/25) of the legs could be compared, there was no significant difference between the two methods. CONCLUSION: the pole test can be used at the toe level to evaluate arterial insufficiency in diabetes. When used in the toe, the pole test can assess pressures below 55-70 mmHg, while only pressures below 45 mmHg can be determined at the ankle level. Falsely elevated blood pressure in diabetics is probably of less importance in digital arteries than in ankle arteries, which makes cuff pressure at toe level a more acceptable approximation.

Aged↗
PubMedDate not supplied

Neglected irreducible dislocation of the interphalangeal joint of the great toe: a case report.

Irreducible dorsal dislocation of the interphalangeal joint of the great toe is rare. We report a case of a 58-year-old man with an irreducible interphalangeal joint of the great toe that had been untreated for 4 years. The mechanism of this injury was thought to be a combination of axial loading with a hyperextension force when the patient hit his great toe against a pipe. Invagination of the sesamoid became a barrier for manual reduction attempted after the initial injury. The patient did not seek treatment because of the minor deformity of the affected great toe and lack of severe symptoms. One year later, symptoms eventually developed on the plantar aspect of the great toe, particularly when the patient was walking upstairs. He decided to seek treatment as pain worsened and he became more active when he changed occupations 4 years later. Manual reduction was impossible. The patient was treated with operative exploration of the joint and arthrodesis of the great toe. The operative course was uneventful. At 4 years after surgery, the patient could walk, run, and walk up and down stairs without discomfort.

Humans↗
PubMed2000

An outcome study of thumb reconstruction using microvascular toe transfer.

The purpose of this study was to evaluate outcomes following microvascular toe to thumb transfer in a cohort study using the Michigan Hand Outcomes Questionnaire, the 36-item Short-Form Health Survey, the Lower Limb Function Questionnaire, and standardized hand function tests. Twenty-one patients who had unilateral, isolated thumb amputations at the metacarpophalangeal joints were studied: 16 patients had toe transfer and 5 patients did not have reconstruction. The mean follow-up period was 7.2 years (range, 3-13 years). Toe transfer patients showed statistically significantly better overall hand function (effect size = 1.4), ADL (effect size = 3.4), work performance (effect size = 2.1), aesthetics (effect size = 1.9), and satisfaction (effect size = 1.1). Functional testing showed that strength and dexterity of the toe transfer hands were comparable to the opposite normal hands. Foot donor site morbidity was minimal. No significant difference was found in the mean Lower Limb Function Questionnaire scores between the toe transfer patients (1.4) and the amputation patients who did not undergo reconstruction (1.6). The results of our study showed that patients with toe transfer have better hand function than patients with thumb amputations at the level of the metacarpophalangeal joints.

Adult↗
PubMed2001

Postoperative monitoring of pediatric toe-to-hand transfers with differential pulse oximetry.

Twenty-three toe-to-hand transfers performed in 21 children were monitored after surgery using differential pulse oximetry for 4 to 12 days. Pulse rate recorded by the pulse oximetry monitored the patency of the arterial anastomosis, whereas oxygen saturation (SaO(2)) corresponded to the patency of the venous anastomosis; these were both compared with the systemic pulse rate and oxygen saturation recorded by a second control pulse oximeter probe attached to a contralateral finger or toe. All 23 toe transfers were ultimately successful, but 2 required re-exploration for anastomotic problems detected by the pulse oximeter. Based on this experience, the following criteria have been developed for the nursing and junior medical staff: if the arterial pulse of the toe transfer is lost completely or if the pulse rate differs significantly from the systemic pulse rate, measured by the second control pulse oximeter, thrombosis of the arterial anastomosis should be suspected. If the oxygen saturation of the toe transfer decreases below the oxygen saturation measured by the control pulse oximeter and this differential is sustained over a period of time, thrombosis of the venous anastomosis should be suspected. Differential pulse oximetry appears to be superior to temperature monitoring and percutaneous and laser Doppler monitoring and provides the most simple and continuous technique of noninvasive postoperative monitoring of toe-to-hand transfers in children requiring reconstruction of traumatic or congenital deformities.

Adolescent↗
PubMed2002

Simultaneous toe-to-hand transfer and lower extremity amputations for severe upper and lower limb defects: the use of spare parts.

From 1995 to 2000, five microvascular toe-to-hand transfers were performed in three children who were simultaneously undergoing lower extremity amputations. Their ages at time of transfer ranged from 4 to 10 years and the types of lower extremity amputation included toe amputation, foot amputation and through-knee amputation. The resulting toe-to-hand transfers included three great toe-to-thumb transfers and one combined great and second toe-to-hand transfer. The toe-to-hand transfers were all successful and all the lower extremity amputations healed without complications. In all cases, improved hand function and lower extremity function was noted by the families. These unique cases represent the ultimate use of spare parts in congenital hand surgery.

Amputation, Surgical↗
PubMed2003

[Finger reconstruction by microvascular second toe-to-finger transplantation in patients with traumatic loss of all fingers].

PURPOSE: To assess the utility of second toe-to-finger transplantation with neurovascular reconstruction in patients with loss of all four digits. METHOD: Analysis of 24 toe-to-finger transplantations in 18 patients regarding over-all survival, complications and secondary procedures, sensibility, function, foot symptoms, and patient satisfaction. The original metacarpophalangeal joint was preserved in 50 % of the transplantations. In six patients, a second transplantation was performed. RESULTS: A mean follow-up of 5.8 years was available in 94 % of the patients. 92 % of the transplanted toes survived, in 38 % of the cases complications occurred followed by a secondary procedure. Two-point-sensibility was present in 62 % of the transplantations, the largest range of motion of ca. 50 degrees was obtained in the metacarpophalangeal joint. An increase in the range of motion could be achieved by preservation of the original finger joint. The mean extension lag was 37 degrees independent of the preservation of the metacarpophalangeal joint. Foot symptoms were mild in four patients, in two cases severe donor-site-problems were observed. Cold intolerance was present in 47 % of the transferred toes. Overall patient satisfaction was high with 83 % of the patients confirming their decision to undergo operative treatment. CONCLUSION: Second toe-to-finger transplantation is indicated in patients with traumatic loss of all digits. By this method, a great functional gain could be achieved as well as a high level of satisfaction. The rate of complications and possible foot symptoms should be considered. The preservation of the original metacarpophalangeal joint seems to be of importance for the function of the transplanted toe.

Adolescent↗
PubMed1988

Reconstruction of the thumb with a trimmed-toe transfer technique.

The trimmed-toe transfer is a new modification of the existing great-toe transfer technique for thumb reconstruction. This procedure was devised to circumvent patient concerns regarding overly large reconstructed digits following total great-toe-to-hand transfer. This technique involves reduction of both the bony and soft-tissue elements along the medial aspect of the transferred great toe in order to produce a more normal sized thumb. Follow-up of the initial 20 patients from 1983 to 1986 demonstrates good stability, grip strength, and pinch strength. Although compared with total great-toe transfer a modest reduction in joint motion of trimmed toes has been observed, the overall appearance and usefulness of the reconstructed thumbs have been excellent.

Adolescent↗
PubMed1997

Aesthetic fingertip reconstruction with a free vascularized nail graft: a review of 60 flaps involving partial toe transfers.

Microsurgical toe transfer is an established procedure for functional reconstruction of fingers. However, even if the functional loss is minimal, the fingertip defect is often a large problem for patients for not only functional reasons but also aesthetic reasons. In these patients, although the normal appearance of the fingertip is very important, total toe transfer is not acceptable because of resection of an entire toe. With this background, partial toe transfer techniques have greatly progressed. On the other hand, various types of innervated finger flaps also have been developed in hand surgery. Based on this progress, we developed the combined technique of innervated finger flaps in the hand and osteo-onychocutaneous flaps from the toe. This technique provides better aesthetic results in fingertip reconstruction, thus broadening the indications for vascularized nail grafts. We have now experienced 60 flaps in partial toe transfer. In this report, a review of 60 consecutive flaps is presented, and the indications, technique, and postoperative treatment are discussed.

Adult↗
PubMed2006

Immediate partial great toe transfer for the reconstruction of composite defects of the distal thumb.

BACKGROUND: Thumb defects distal to the interphalangeal joint do not cause any disability; therefore, any consideration to reconstruct the thumb is governed by the lifestyle and cultural background of the patient. This study presents the excellent results achieved by immediate partial great toe-to-hand transfer to reconstruct acute composite defects of the distal thumb. METHODS: Fifty-three patients with amputation or crush injury of the distal thumb who underwent partial great toe-to-hand transfer at the authors' institute over an 11-year period were reviewed. Based on the amputation level of the distal thumb, the authors classified the injuries into three groups. Operative techniques used were osteo-onychocutaneous flap with partial or whole toenail from the great toe and partial great toe transfer with arthrodesis of the interphalangeal joint. Overall results were evaluated in terms of success rate, incidence of emergency reexploration, and number and type of secondary operation. Static two-point discrimination, range of motion, pinch strength, and subjective satisfaction were also evaluated. RESULTS: The success rate of immediate partial great toe-to-hand transfer was 100 percent. The incidence of inflammation and the reexploration rate were not significantly different from those in previously reported articles. In 35 cases where postoperative follow-up was possible, static two-point discrimination, total active range of motion, and pinch strength were generally excellent and the majority of the patients were satisfied with the final outcome. CONCLUSION: Immediate reconstruction with partial great toe transfer is an excellent option for reconstruction of composite defects of the distal thumb, not only for aesthetic reasons but also for functional purposes.

Adolescent↗
PubMed1986

Autonomic neuropathy and toe circulation. A prospective study.

Ankle and toe pressure ratios and toe temperature reactions to cold followed by indirect heating were evaluated in 23 diabetic patients with and without autonomic neuropathy (AN) in a first and in a second follow-up study after 5-7 years. In the first study, despite normal blood pressure ratios, AN patients, all with parasympathetic neuropathy, showed a markedly delayed increase in toe temperature after cooling followed by indirect heating. In the second study, most AN patients showed sympathetic neuropathy and had higher toe temperatures before cooling than those without AN. Parasympathetic neuropathy leads to increased sensitivity to cold in toe vessels and sympathetic neuropathy to vasodilation and increased toe temperatures.

Adult↗
PubMed1995

Detection of movements imposed on human hip, knee, ankle and toe joints.

1. The angular displacements necessary for 70% correct detection were determined in normal subjects at the hip, knee and ankle joints, and the interphalangeal joint of the big toe. Angular velocities between 0.1 and 50 deg s-1 were tested. The hip and knee joints were tested in slight flexion and the ankle and toe joints were tested in the mid-range of the normal excursion. The joints were carefully supported for testing and the muscles acting at the joints were relaxed. 2. When detection thresholds and velocities were assessed in terms of angular displacements and angular velocities, proprioceptive performances at the hip, knee and ankle joints were superior to that at the toe joint. 3. When detection levels and displacement velocities were expressed in terms of linear displacements and velocities at the tip of the extended toe for all four joints, instead of in angular terms, the ankle gave the best performance and the hip and knee the worst. 4. The detection level and velocity data were expressed also in terms of proportional changes in the fascicle lengths of muscles operating these joints. Analysis in these terms showed that performance was similar at the hip, knee and ankle joints, but that performance for the toe was much poorer than for the other joints. 5. These results for the hip, knee and ankle are similar to those previously measured for the elbow and distal interphlangeal joint of the finger, and are consistent with the theory that muscle fascicle length is the variable of significance to the central nervous system. However, the proprioceptive performance at the big toe is notably poorer than all other joints studied and analysed in terms of this variable.

Adult↗
PubMed1996

Contractile properties of single motor units in human toe extensors assessed by intraneural motor axon stimulation.

1. Single motor axons innervating human toe extensor muscles were selectively stimulated through a tungsten microelectrode inserted percutaneously into the peroneal nerve. Twitch and tetanic forces were measured from a strain gauge over the proximal phalanx of the toe generating the greatest force. Twitch data were obtained from 19 single motor units in nine subjects: 8 motor units supplied extensor hallucis longus (EHL), 5 motor units supplied extensor digitorum longus (EDL), and 6 motor units supplied extensor digitorum brevis (EDB). Unpotentiated twitch forces ranged from 6.3 to 78.1 mN (20.0 +/- 4.0 mN, mean +/- SE), with the distribution highly skewed toward small forces. Twitch contraction and half-relaxation times were 74.8 +/- 3.9 and 78.6 +/- 6.0 ms, respectively. Compared with motor units in human thenar muscles, those in human toe extensor muscles were stronger but slower. However, as in thenar motor units, twitch force and contraction time were not related. 2. Force-frequency relationships were determined for 13 units (5 EDL, 5 EHL, 3 EDB) by stimulating each unit with short trains (1.0-5.0 s) of constant frequency (2-100 Hz). Peak force was related to stimulus frequency in a sigmoid fashion. The steep region of the curve extended from 5.5 +/- 0.7 (SE) Hz to 16.3 +/- 1.1 Hz for all units, and the stimulus frequency required to generate half-maximal force (9.6 +/- 0.6 Hz) was close to the center of the steep range. This frequency, which was inversely related to twitch contraction time, was lower than the frequency required to develop half-maximal force of human thenar motor units (12 +/- 4 Hz, mean +/- SD). The slopes of the regression lines relating force to frequency, computed over the steep range for each unit, were also lower for the toe extensors (3.7 +/- 0.7 mN/Hz) than for the thenar muscles (6 +/- 1 mN/Hz). 3. Maximal tetanic forces ranged from 29.9 to 188.1 mN (89.0 +/- 16.5 mN, mean +/- SE), and were generated at stimulus frequencies from 15 to 100 Hz (median 50 Hz). The stimulation frequency required for fused tetani (absence of noticeable force fluctuation) was generally less than that required for maximum tetanic force. The mean twitch-tetanus ratio, calculated for unpotentiated twitches, was 0.22 +/- 0.02 (range 0.15-0.41). This ratio was higher than for human thenar motor units (0.14 +/- 0.06, mean +/- SE). After twitch potentiation of 10 units, the mean twitch-tetanus ratio increased to 0.28 +/- 0.04. 4. The effects of preceding each stimulus train with a short interstimulus interval (10 ms) on force production at each frequency were examined in nine motor units. Peak forces at the onset of each contraction were higher when such an "initial doublet" preceded stimulus trains of < or = 20 Hz, but the mean force at the end of each stimulus train was not significantly affected at any frequency. 5. Eight units were stimulated with a train that increased in frequency continuously from 2 to 80 Hz, and then decreased symmetrically. This pattern resulted in peak forces that were higher on the descending limb of the stimulus train, the force-frequency relationship tracing a hysteresis loop. Hysteresis was exhibited because damping in the neuromuscular system causes the mechanical output of muscle to lag behind neural input. Thus, in non-steady-state conditions (as in most forms of natural activity), somewhat higher firing rates may be required to attain a particular level of force; once attained, force output will be transiently unresponsive to diminution of firing rate. 6. We conclude that there are differences in the contractile properties of single motor units in human toe extensor muscles (involved in posture and locomotion) and thenar muscles (involved in prehension and manipulation). Twitch-tetanus ratios were greater for motor units in the toe extensors, and this property accounted for the lower force sensitivity of these units to increases in frequency. (ABSTRACT TRUNCATED)

Adult↗
PubMed1985

Transcutaneous oxygen recovery and toe pulse reappearance time in the assessment of peripheral vascular disease.

The accuracy of measurements of transcutaneous oxygen tension (Ptco2) in the diagnosis of peripheral vascular disease (PVD) may be significantly increased by stressing limb circulation with the use of temporary ischemia. The purpose of this study was to compare the transcutaneous oxygen recovery half-time (TORT) and the toe pulse reappearance time (PRT/2) in a series of patients with symptomatic PVD before and after vascular reconstruction. The TORT was defined as the time required to recover half of the decrease in the limb/chest Ptco2 ratio caused by temporary limb ischemia, and is conceptually comparable to the toe PRT/2, the time required to recover half of the control toe pulse amplitude. Measurement of TORT was found to be more feasible (100% vs 58%) and to have a greater diagnostic yield (100% vs 92%) than that of the toe PRT/2. When measured on the dorsum of the foot, TORT values were found to correlate well with the severity of symptoms of PVD; toe PRT/2 values did not correlate with severity of symptoms. Patients who underwent successful vascular reconstruction had significant improvement in their calf and foot TORT values after surgery (p less than .005 and .0005, respectively); postoperative values were similar to those obtained in normal subjects. Toe PRT/2 values usually improved postoperatively, but in many patients postoperative values overlapped with values that were considered abnormal. There was no overlap of TORT values in normal subjects with those in patients with symptomatic PVD. The measurement of TORT may be clinically useful for screening patients with suspected PVD and for assessing quantitatively the results of conservative and surgical therapy.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed2003

Purple toes syndrome associated with warfarin therapy in a patient with antiphospholipid syndrome.

Purple toes syndrome is an extremely uncommon, nonhemorrhagic, cutaneous complication associated with warfarin therapy. It is characterized by the sudden appearance of bilateral, painful, purple lesions on the toes and sides of the feet that blanch with pressure. The syndrome usually develops 3-8 weeks after the start of warfarin therapy. A 47-year-old man with a history of purple toes syndrome that resolved after discontinuing warfarin--prescribed for a deep vein thrombosis (DVT) in his right lower leg--experienced an acute, proximal DVT in his other leg. Warfarin again was prescribed; 1 week later, purple toes syndrome developed in that extremity. Warfarin therapy again was discontinued, and intravenous unfractionated heparin was started; the patient's clinical picture indicated a possible pulmonary embolism, and laboratory analysis suggested antiphospholipid syndrome. The patient's toe pain resolved, but the purple discoloration persisted. Follow-up laboratory analysis confirmed antiphospholipid syndrome, and warfarin was restarted with close monitoring. No further complications occurred with long-term therapy. Although a rare complication of therapy, clinicians should monitor for the development of purple toes syndrome in patients taking warfarin.

Anticoagulants↗