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Only a limited number of case reports concerning the magnetic resonance imaging appearance of lower extremity leiomyoma have been published. To the best of our knowledge, there is not any instance of toe leiomyoma reported with MRI findings. We present MRI findings of a toe leiomyoma and discuss the literature.
The characteristics of the photoplethysmography (PPG) pulse signal are body site specific, with pulses from the various peripheral sites showing differences in pulse transit time, strength and shape, and variation of each over time. The aim of this study was to determine the similarity in the right-left pulse characteristics for a group of normal subjects with pulses obtained simultaneously from six peripheral sites (cars, thumbs and big toes). A multi-site photoplethysmography pulse measurement and analysis system is described and comprised six sets of pulse probes and amplifiers, arranged and electronically matched in pairs for the right and left side comparisons. Two sets of data were collected: firstly a set of validation data to test the electronic matching of right left channels, and secondly a set of physiological data for pulses from 40 normal subjects. The right-to-left side similarity in pulse waveform shape at the three segmental levels (ears, thumbs and toes) was assessed using two types of analysis: root mean square error (RMSE) providing a measure of differences, and cross correlation analysis providing a measure of the degree of similarity. Very low levels of RMSE and correlation coefficients close to unity were obtained for the system validation data, demonstrating good right-left channel matching. The RMSE was an order of magnitude lower than that calculated for the normative physiological data, where median RMSE levels were between 0.053 and 0.060 relative to a peak-to-peak pulse amplitude of unity. The median correlation coefficients were greater than 0.98 for all three segmental levels studied, with the maximum values approaching those of the validation data. We have shown that pulses from the right and left sides of normal subjects are highly correlated at each segmental level. We have obtained a normative range of pulse data, with which specific (vascular) patient groups can be compared.
Samples of skin surface bacteria from 28 healthy subjects plated directly on to selective and non-selective media revealed that the proportion of aerobic coryneforms and furazolidone-resistant Gram-positive cocci (FURECs) resistant to erythromycin was significantly greater in the fourth toe cleft than in the axilla (P < 0.05). There were more erythromycin-resistant bacteria than tetracycline-resistant bacteria at both sites (P = 0.001 for the toe cleft; P < 0.01 for the axilla). In total, 160 distinct isolates were obtained, of which 42 were FURECs and 118 were aerobic coryneforms. Of these, 153 (96%) were resistant to erythromycin and 66 (41%) to tetracycline. All except seven of the tetracycline-resistant strains were also resistant to erythromycin. The resistant isolates belonged to a variety of species. CDC group ANF corynebacteria were most numerous and composed 31% of all isolates. The majority (76%) of FURECs were identified as Micrococcus luteus. MIC determinations on selected strains revealed that tetracycline-resistant FURECs were sensitive to doxycycline and minocycline, as were most tetracycline-resistant coryneforms. Nine coryneform isolates were cross-resistant to all three tetracyclines. Only a minority of erythromycin-resistant FURECs (21%) demonstrated a macrolide-lincosamide-streptogramin type B (MLS)-resistant phenotype with inducible or constitutive cross-resistance to clindamycin and the type B streptogramin, pristinamycin IA. Twenty-nine erythromycin-resistant FURECs had a novel phenotype distinct from MLS and macrolide-streptogramin type B resistance. In contrast, most coryneforms (79%) were MLS resistant. Among the remainder, two unusual erythromycin resistance phenotypes were apparent, both of which differed from the unusual phenotype in FURECs. This study has revealed that the non-staphylococcal aerobic flora of skin contains a considerable reservoir of tetracycline and erythromycin resistance determinants. The three unusual macrolide resistance phenotypes may be associated with novel resistance mechanisms.
Two hundred consecutive in-patients with rheumatoid arthritis were examined for pain or deformity of the feet, and of the great toe in particular. Some abnormality occured in 196 feet and the deformities observed are presented. The symptoms that arise from these deformities are mainly derived from ill-fitting shoes, and the need for suitable foot-wear is emphasized. Two hitherto un-named entities are described namely Hallux tortus and chisel toe, since they give rise to their own shoe-fitting problems.
Merkel cell tumor (MCT) typically occurs on the head or neck of elderly patients. A case is presented of a teenage girl with an MCT on her toe. The diagnosis was made 5 years after an ingrown nail on the toe was avulsed. During the interim 5 years, the periungual skin looked like granulation tissue and thus no biopsy was performed. This case of MCT is unique in three aspects: (a) extraordinarily young age, (b) atypical site, and (c) deceptive clinical appearance. Awareness of the possible occurrence of MCT in younger patients and in unusual locations will facilitate earlier diagnosis.
A case of a sclerosing variant of osteosarcoma of a toe phalanx is reported in a 28-year-old man. This represents the first reported case of osteosarcoma of any kind at this site. This is based on a review of 4,214 cases of conventional osteosarcoma. The reason for the extraordinary rarity in toe or hand phalanges is unknown although osteosarcoma is the second most common primary tumor of bone. Since the neoplasm had minimal signs of cytologic anaplasia, it was originally mistaken for and treated as an osteoid osteoma. The lesion recurred and extended into soft tissues. Reevaluation revealed the tumor to be an osteosarcoma, sclerosing variant with "normalization" of nuclei. The lesions that this tumor should be distinguished from are osteoid osteoma and osteoblastoma.
A second toe to hand transfer is described for thumb reconstruction which includes the extensor digitorum brevis as a simultaneous opponensplasty. This procedure was effective in a young man injured in a bomb explosion that completely destroyed the first ray. The second toe was dissected in continuity with the extensor digitorum brevis muscle, its nerve was anastomosed to the motor branch of the median nerve. Thus a one-stage operation allowed a complete reconstruction of the first ray proximally to the trapezium. Recovery at 2 years is good, and the muscle transfer can be demonstrated to work.
Dermatofibrosarcoma protuberans is an unusual soft-tissue tumor with a propensity for local recurrence and occasional metastatic spread. Given its indolent course, it may be mistaken for atypical scarring or a keloid growth. Most lesions are trunkal or on the proximal extremities with digital lesions being extremely rare. There is only one previous reference of the tumor arising on a toe. Early diagnosis and prompt wide local resection of this entity are required to prevent a local recurrence, which would necessitate a wider, more debilitating resection. The management of a patient with a dermatofibrosarcoma protuberans of the second toe is presented along with a review of the literature.
Posttraumatic fingertip reconstruction with a free toe pulp neurovascular flap, first described in 1979, has not been frequently reported. We present our results with 8 free transfers of the toe pulp and demonstrate the successful restoration of a well-padded and sensitive fingertip. All patients, studied with a follow-up of up to 20 months, recovered a discriminative sensibility of the thumb and main fingers, with a stationary two-point discrimination test between 5 and 12 mm and a moving two-point discrimination test between 4 and 8 mm. In spite of the good results obtained, we believe this procedure must be chosen only in certain circumstances. We present the indications and the contraindications for this digital reconstruction.
After the loss of four fingers at the metacarpal level, triple toe transfer from the same foot was performed in the dominant hand of an art worker who needed three ulnar digits to work with the intact thumb. The toes of the left foot could not be used because of a previous injury. Long-term follow-up at 3 years showed good results in terms of function. He regained dexterity for calligraphy, notably the brush calligraphy and painting that are important in his job. The donor site was treated very carefully to prevent complications. There was minimal donor site morbidity. He still can walk very well and runs fast. Gait analysis of the donor foot is presented. This was a unique situation, and satisfactory results were obtained through the cooperation of the patient as well as detailed analysis before surgery.
One hundred three microvascular toe-to-hand transfers were performed on 66 pediatric patients with congenital and posttraumatic deformities. Techniques for dissection and transfer of individual and composite toes were elaborated, and adjunctive procedures were added when indicated.
A family with Saethre-Chotzen syndrome with or without polydactyly of the great toes is presented. Saethre-Chotzen syndrome with polydactyly of the great toes has been reported as Robinow-Sorauf syndrome. Both syndromes were observed in this family. This suggests that Saethre-Chotzen syndrome and Robinow-Sorauf syndrome fall within the same clinical spectrum, and the cause is a pleiotropic effect, which is variously expressed.
A multiplanar distraction device was used in a 65-year-old woman for correction of multiplanar deformities of her right big toe. These deformities were caused by long-standing scar contracture after a crushing injury to the right foot. Without the necessity of other complicated procedures, the dorsal contracture and lateral deviation were corrected from 43 deg to 0 deg and from 22 deg to 0 deg respectively 3 weeks postoperatively. Kirschner wires were inserted temporarily for prevention of recurrence after removal of the frame, and were removed 6 weeks later. In follow-up after 8 months, the position of the big toe was stable and without recurrence of contracture. Application of the multiplanar distraction device simplified the surgical procedure to achieve this correction.
The blue toe syndrome is characterized by tissue ischemia secondary to cholesterol crystal or atherothrombotic embolization leading to occlusion of small vessels. Embolization occurs typically from an ulcerated atherosclerotic plaque located in the aorto-iliac-femoral arterial system. Clinical presentation can range from a cyanotic toe to a diffuse multiorgan systemic disease that can mimic other systemic illness. Mortality can be higher than 70% depending on the scope of the illness. Embolization can occur spontaneously or from a variety of insults such as invasive vascular procedures, anticoagulation, or thrombolytic therapy. Angiography, duplex ultrasonography, computerized tomographic scanning, and magnetic resonance imaging have been used to image the offending lesions, with angiography considered the "gold standard" despite its inherent risks. Recently, transesophageal echocardiography has been shown to be a helpful tool in imaging the thoracic aorta and delineating in great detail the anatomy of the aortic atheroma. At present, surgery remains the most viable treatment option. However, we look to the future for large randomized trials to help predict embolization and thus the proper medical therapy.
Severe hypofibrinogenemia was found in an Algerian woman who, since the age of 37 years, suffered three different episodes of ischemic necrosis of the toes and fingers leading to amputation of the toes and surgical removal of necrotic tissue (necretomy). No anti-fibrinogen antibody was present. The deficiency appeared to be due to severe congenital hypofibrinogenemia since the fibrinogen level remained at the same low level over a long period, without any abnormality of other coagulation proteins. The thrombotic events may be explained by the increased thrombin generation observed in the patient's plasma, due to the lack of thrombin adsorption onto a fibrin net.
Painful legs and moving toes is a rare syndrome with controversial physiopathology. We report two cases that were relieved by applying transcutaneous vibratory simulation. The pain relief was objectively evaluated using the nociceptive flexion reflex of the lower limb (RIII reflex). In these patients, we found a deficiency in circulating adenosine levels, which was not found in other chronic painful syndromes (sciatic pain). Based on these observations, we successfully treated patients with painful legs and moving toes by the administration of ATP. The deficit in blood adenosine may be an explanation of the physiopathology of this syndrome.
A new method has been introduced to form a functional great toe following amputation. This method has several advantages, especially its simple one-stage operation, which uses a local plantar flap. Results are good from the esthetic and functional point of view. It may be used for traumatic and congenital defects of the great toe. Three cases are presented with illustrations.
This article discusses toe-to-hand transplantation. The purpose of this article is to familiarize nurses with this procedure. In many cases, the actions taken initially and postoperatively may have a direct effect on the success or failure of the surgery. Two different procedures are discussed. The first procedure is replantation or revascularization of amputated digits in which time is of the essence and is usually performed right after the initial injury. The second procedure is the toe-to-hand transfer, which is an elective procedure in which there is less emphasis on time. This procedure occurs a few months after the initial accident.