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Closed degloving injuries of the toes are rare due to their short length, protection in shoes, and general lack of adornment. When these injuries occur, neurovascular compromise can lead to a loss of viability of the toe. Prompt recognition and successful reduction are necessary to maintain normal structure and function.
The outcome of surgically treated mucous cysts of the foot is poorly documented in the orthopaedic literature. This study reports on the treatment of mucous cysts of the toes by simple excision and joint debridement. This is in contrast to treatment of similar lesions in the fingers which is often treated by excision of the cyst, joint debridement, and rotational flap. Following this procedure on 15 patients (15 cysts), at a minimum of 2 years postoperatively, only one cyst had recurred at 9 months. All patients were satisfied by the cosmetic appearance of their toe. The authors reviewed the available literature on this condition and suggest that this method of treatment provides good functional and cosmetic results with a minimal rate of recurrence.
BACKGROUND: The main bony procedures used in the treatment of second hammertoe are excisional arthroplasty and arthrodesis of the proximal interphalangeal (PIP) joint. While a number of studies have reported the outcomes after PIP joint arthrodesis, there are few reports of the outcome of excisional arthroplasty of the PIP joint for the correction of second hammertoes. The purpose of this study was to evaluate the long-term outcome of PIP joint excisional arthroplasty. METHODS: Seventy-five patients (100 toes) who had excisional arthroplasty of the PIP joint for the correction of second hammertoe were reviewed at an average followup of 44 months. All patients were seen in clinic and were physically examined to assess the alignment and function of each digit. The radiographs were evaluated preoperatively. The AOFAS clinical rating scale was used preoperatively and at final followup. Patients were asked to rate their satisfaction on a scale of 0 to 10 and were asked if they would be happy to have the surgery under similar circumstances again. RESULTS: The mean preoperative AOFAS clinical rating scale was 46. At final followup this increased to 94, showing an average improvement of 48 points (p < 0.0001). The mean satisfaction on a scale of 0 to 10 (with 0 equaling complete dissatisfaction and 10 complete satisfaction) was 9.3 (SD 1.3). One patient would not have been happy to undergo outpatient surgery again, because of a change in her social circumstances. CONCLUSION: In a group of 75 patients who had PIP joint arthroplasty for the correction of second hammertoe, high levels of satisfaction were achieved. No serious complications were encountered, and revision surgery was required in just two cases. Floating toe was the most common complication encountered, and although this did decrease the level of patient satisfaction in seven patients it was not a cause of footwear irritation or pain in any patient.
Lesser toe dislocations are unusual injuries that are amenable to closed reduction in most cases. We present a case of an isolated lesser toe fracture-dislocation that required an open reduction due to soft tissue interposition.
In hammer toe correction by means of digital fusion, fixation so that the bone can unite while maintaining appropriate realignment can be a challenge. Metal fixation pins can be associated with many problems and potential complications. The author presents a method of rigid internal fixation using 2.4-mm-diameter pins fashioned out of freeze-dried allogeneic cortical bone. These devices avoid most of the risks of metal pins. Proximal interphalangeal joint arthrodesis using cortical bone pins was performed on 26 toes in 18 patients with very few complications. The author concludes that use of cortical bone pins can yield successful results in most cases. The outcomes of the fusions can be further enhanced by using flexor digitorum longus tendon transfer.
The overlapping fifth toe has often a congenital origin. It may be isolated or associated with an another pathology, congenital or acquired, but the relationship between them. Cannot be ascertained. The overlapping fifth toe is responsible for an esthetic deficit and/or a functional discomfort, it justifies a correct surgery. Twenty-one feet in 16 patients aged from 2 to 30 years (especially between 5 and 15 years) have been operated on and reviewed after a mean follow-up of 4 years. The technic associated a cutaneous dorsal Z-plasty on the cutaneous retraction a medial and dorsal capsulotomy of the metatarso-phalangeal joint, an external transfer of the fifth extensor tendon or its tenotomy and, in 10 cases, a plantar skin resection 19 results were excellent, one fair result and one failure. The condition of a stable result seems to be based on a complete and spontaneous correction of the deformity at the end of the operation.
Simultaneous metatarsophalangeal and interphalangeal dislocations of the big toe are rare injuries. Gangrene of the big toe following open dislocations was reported in a 20-year-old man.
Two patients with a deviated overlapping second toe due to rupture of the dorsal lateral metatarsophalangeal (MTP) collateral ligament and the lateral interosseous tendon were diagnosed, analyzed, and treated. Athletic activities were responsible for the tendon-ligament ruptures and the ensuing medial deviation of the second toe. Pain occurred in the second MTP joint, and a dorsal corn formed over the proximal interphalangeal joint (PIP). Reconstructive procedures included lengthening of the interosseous-lumbrical tendons and the collateral ligament on the medial side of the joint; a dorsal capsule incision; repair of the lateral collateral ligament and interosseous tendon; transfer of the flexor digitorum longus to the extensor digitorum longus; and shortening of the proximal phalanx in one patient. These soft tissue reconstructive procedures and realignment joint congruity are essential to relieve pain and prevent traumatic arthrosis. The treatment completed on the two patients resulted in relief of pain, satisfactory function, and alignment of the digits involved.
Severe mutilating injuries of the hand are rarely encountered in children. Among the reconstruction techniques, partial and total toe transfers are to be considered because these techniques fulfill the growth requirements and because good sensory results can be expected in children. A clinical series of partial or total toe transfers, performed for correction of post traumatic mutilations is presented. Clinical results and technical refinements are discussed.
We describe 31 patients in whom proximal lesions in the arterial tree were identified as probable sources of emboli causing the "blue toe" syndrome. This syndrome consists of acute digital ischemia caused by microembolization to the digital arteries from a proximal source via a patent arterial tree, as evidenced by an otherwise well-perfused foot. It is closely analogous to the transient ischemic attacks of the brain, and carries the same potential for serious tissue loss because of repeated embolic showers. The prompt delineation and eradication of the embolic source is of prime importance, in addition to restoration of arterial continuity. Along with the other well-known features of chronic severe ischemia, that is, rest pain, gangrene, etc, the "blue toe" syndrome is therefore an indication for limb salvage surgery.
A 22-year-old male awoke with right foot drop and numbness. Nerve conduction studies, sural nerve biopsy, and molecular genetic analysis were consistent with hereditary neuropathy with liability to pressure palsy (HNPP). Two months later he developed involuntary flexion/extension movements of the right toes with associated intermittent dystonic flexion of the right foot. Over the next 2 months these movements spread to the left foot and hand and myoclonus of the left trapezius and rhomboid appeared. This is the first case report of moving toes syndrome and segmental myoclonus in association with HNPP. The temporal and topographic patterns of spread of the abnormal movements suggest a central mechanism probably induced by peripheral pathology.
We report on an 8-year-old Thai girl with bilateral complete cryptophthalmos, facial asymmetry, delayed bone age, brachymesophalangy and medial deviation of the second toes, and dental anomalies. The dental anomalies consist of delayed dental development, congenital absence of the second premolars, microdontia of the deciduous molars. A fibrous band of the buccal mucosa was found. Dental anomalies are rare among patients with Fraser syndrome. They have not been reported in either isolated or other syndromic cryptophthalmos. The oral manifestations and brachymesophalangy of the second toes found in our patient may represent newly recognized findings associated with cryptophthalmos or they may represent a newly recognized syndrome.
We describe a family in whom affected persons have the following anomalies in variable combination: camptodactyly of the second and/or third toes, partial syndactyly of second and third toes, foot and lower limb asymmetry, and scoliosis. The condition seems to be an autosomal dominant trait with apparently reduced penetrance and variable expressivity.
The cytologic development of Meissner corpuscles of the mouse toe pad has been studied using light and electron microscopy, and correlated with silver impregnations of frozen sections. By 18 days of gestation, neurites are seen near the epidermis, but intraepidermal neurites are few. One day after birth, the number of intraepidermal neurites increases, and some accompanying Schwann cells extend their cytoplasmic processes penetrating the basal lamina of the epidermis. Four days after birth, Schwann cells invade the epidermis further, extending many cytoplasmic processes which are intimately associated with basal cells of epidermis. These specialized Schwann cells which contact the epidermis proper also begin to develop cytoplasmic lamellae and thus denote the onset of lamellar cell development. By eight days after birth, the developing lamellar cells become more elaborated, and their cytoplasmic processes contain caveolae and filaments, characteristic features of lamellar cells. This developmental sequence supports the concept that lamellar cells are derived from Schwann cells. Through all stages of development, neurites and Schwann cells interact closely with epidermal cells. Epidermal cells may be essential for corpuscle formation. By 20 to 25 days after birth, mouse toe pad Meissner corpuscles are cytologically mature.
OBJECTIVE: To evaluate the interobserver agreement of ultrasonographic assessment of finger and toe joints in patients with rheumatoid arthritis (RA) by 2 investigators with different medical backgrounds. METHODS: Ultrasonography and clinical examination were performed on 150 small joints of 30 patients with active RA. A General Electric LOGIQ 500 ultrasound unit with a 7-13-MHz linear array transducer was used. In each patient, 5 preselected small joints (second and third metacarpophalangeal, second proximal interphalangeal, first and second metatarsophalangeal) were examined independently on the same day by 2 ultrasound investigators (an experienced musculoskeletal radiologist and a rheumatologist with limited ultrasound training). Joint effusion, synovial thickening, bone erosions, and power Doppler signal were evaluated in accordance with an introduced 4-grade semiquantitative scoring system, on which the investigators had reached consensus prior to the study. RESULTS: Exact agreement between the 2 observers was seen in 91% of the examinations with regard to bone erosions, in 86% with regard to synovitis, in 79% with regard to joint effusions, and in 87% with regard to power Doppler signal assessments. Corresponding intraclass correlation coefficient values were 0.78, 0.81, 0.61, and 0.72, respectively, while unweighted kappa values were 0.68, 0.63, 0.48, and 0.55, respectively. Ultrasonography showed signs of inflammation in 94 joints, while clinical assessment revealed tenderness and/or swelling in 64 joints. CONCLUSION: An experienced radiologist and a rheumatologist with limited ultrasound training achieved high interobserver agreement rates for the identification of synovitis and bone erosions, using an introduced semiquantitative scoring system for ultrasonography of finger and toe joints in RA. Signs of inflammation were more frequently detected with ultrasound than with clinical examination. Ultrasonography may improve the assessment of RA patients by radiologists and rheumatologists.
Amputation of the thumb, including the basal joint, is a disabling injury that leaves limited reconstructive options. Three cases of multiple digit amputation including the thumb and basal joint are presented in which a second toe transfer was used to reconstruct the thumb. All patients have functional pinch with an average pinch strength of 27% of the opposite uninjured extremity. The average grip strength for two patients is 44% of the opposite hand. Average motion of the transfer at the MP, PIP, and DIP is 25 degrees, 37 degrees, and 9 degrees, respectively. Adduction and abduction are obtained, the degree depending on the site of proximal bony fixation. No patient has morbidity at the donor site and all are happy with their reconstruction. In selected cases we feel second toe transfer is an excellent choice to reconstruct the thumb amputated at a proximal level.
This study reports the results of 30 patients who entered a program of sensory reeducation following toe-to-thumb transfer. Results were analyzed after subdividing the patients into those whose injury had produced severe scarring (fibrotic group, N = 15) and those with clean, more distal amputations (non-fibrotic group, N = 15). Patients who were unable to complete sensory reeducation were considered as "drop-out" controls. Although the follow-up time was less than 1 year, the group receiving sensory reeducation did improve to a greater degree and more quickly than the controls, with the level of two-point discrimination recovered being better than that originally present in the toe.
Toe-to-hand transfer is a well-established reconstructive option for certain congenital hand anomalies. It is the only technique which can add growth potential to the immature skeleton. Toe transfer is best suited for constriction ring amputations, which have relatively normal proximal anatomy. Transfers should be performed early in life to avoid lack of cortical integration of the new part. Anatomic variations of both hand and foot are often encountered, which influence both operative approach and functional prognosis. Indications, techniques, and complications are reviewed.