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Three male patients, each receiving microvascular tissue transfer of the second toe to the thumb of their dominant hand, underwent a formal program of sensory reeducation immediately following the transfer. A high degree of functional sensation is reported.
Combined transplantation of 1) a residual proximal phalanx flap of the thumb with a fascial pedicle, 2) a reversed island flap based on the posterior interosseous artery, and 3) a free second toe was successfully used to reconstruct the radial half of the hand in a patient who had experienced loss of the second metacarpal bone and index finger, a defect to the shaft of the third metacarpal bone, and dry gangrene of the thumb, two-thirds of the radial dorsal skin and the first web space of the left hand. The reconstructive result was satisfactory and took advantage of each tissue flap. The operation was relatively simple and was completed in one stage. We believe the procedure provided good recovery of function and appearance at an appropriate cost.
The second metatarsal is routinely excised to facilitate closure of the defect created by the harvest of a second toe transfer. However, if the deep transverse metatarsal ligament is not disrupted by the harvest, it seems unnecessarily destructive to remove the metatarsal. A small arterialized venous flap provides a logical solution to the problem of wound closure in this circumstance. This paper describes such a reconstruction, discusses the reasons for its selection and the long term outcome, which has been very satisfactory.
The authors describe three cases of familial acrocephalosyndactyly (ACS) in two boys (9 and 3 years of age) and in their 7.5-year old sister. In addition, irregularities in skull and limbs were found in the 46-year old father as well as in two other children, i.e., two girls, 14 and 4 years of age. The mother (46 years-old) and the remaining four 4 boys (12-, 9-, and 7-years-old), as well as the youngest child, a son, 1-year-old) did not show any deviations. The diagnosis of the Saethre-Chotzen syndrome in six members of one family was based on the finding of a typical skull deformation (oxybrachycephalia), low hairline, flattened nasofrontal angle, lateral deviation of the nasal septum, facial dysmorphy, prolapse of upper eyelids, antimongoloid placement of palpebral fissures, protruding eyes, hypertelorism, dysmorphy of auricles, imperfect hearing, highly arched palate, improper dentition, and characteristic skin syndactyly of hands and feet. In addition, deformed chest, weight and height deficiency, significant mental retardation, as well as, in the boys, true cryptorchidism were found. Radiological examination showed, in all affected members of the family, intensified digitate impressions within the whole fornix of the skull, large and deep sella turcica, underdeveloped frontal bone and upper jaw bone, untypical syndactyly of hands and feet, and the partial bifid of distal phalanges of the great toes, not described previously in the Saethre-Chotzen syndrome. In the differential diagnosis, other forms of ACS, i.e., Apert, Vogt, Pfeiffer, Summitt, and Herrmann-Opitz syndromes, were not found. Manifestation of the described symptoms transferred autosomally, dominantly, and with a similar degree of expression in 6 of 11 members of one family, leads us to think that they are the consequence of a fresh mutation revealed in the father.
Since 1975 the usual treatment of hallux valgus and hallux rigidus at the Medical High School, Lübeck, has been arthrodesis of the metatarophalangeal joint of the great toe. We report 48 operations performed between 1975 and 1977 on 35 patients with a follow-up of 3-32 months. The operative technique, using the "dynamic compression plate" is described in detail. The patient's assessment and the clinical and radiological situations were recorded. There were only three poor results. Thus, arthrodesis of the metatarsophalangeal joint is considered to be a reliable therapeutic method in hallux valgus, with minimal post-operative complications. It compares well with other operations, including Keller's arthroplasty.
For the athlete a stress fracture of the great toe sesamoid is an injury of fundamental significance. As radiographic findings and bone scintigraphy are not specific, these fractures have the longest delay between first symptoms and definitive diagnosis. Apart from magnetic resonance imaging, the only accurate investigation for early diagnosis is the longitudinal bone scan.
A hereditary malformation of the metatarsophalangeal joints, called here "tear drop" deformity, and a cut off appearance of the distal phalanges of the toes is described in a family with double translocation t (7; 12), t (2; 6) heterozygosity. A bracydactyly E was also found. These disorders seemed unrelated to the chromosomal aberration.
Thirty-six finger and toe nails were analyzed for ABO(H) blood group substances by the modified absorption elution method. The blood groups from nails were successfully determined in all the samples.
This case is the first to depict a stress fracture of the great toe sesamoid bone using magnetic resonance imaging. We used a 3" surface coil to produce high resolution images of the sesamoid.
A retrospective study of 136 men undergoing forefoot amputation was done to test the hypothesis that preoperative toe pressure (TP) could predict the likelihood of wound healing. Demographic data included age, smoking history, diabetes mellitus (DM), hypertension, hyperlipidemia, and coronary artery disease. Clinical data included infection, preoperative arterial Doppler data, TP, wound disposition, concomitant revascularization (REV), and healing outcome. Among diabetics, no primary amputation healed with a preoperative TP < 38 mm Hg. Among REV diabetics, no healing occurred with a TP < 40 mm Hg after bypass, but no failures occurred either with a TP > 68 mm Hg or an increase in TP > or = 30 mm Hg after bypass. Nondiabetic patients exhibited no threshold TP values. Univariate analysis revealed that DM and REV were significantly different in the healed (N = 83) vs. nonhealed (N = 53) populations (p = 0.027 and 0.034). In healed patients mean TP (71.8 +/- 3.5 mm Hg SEM) was significantly higher than in nonhealed patients (45.1 +/- 4.3 mm Hg SEM, p = 0.000). Logistic regression analysis identified age > 60 years (p = 0.03), DM (p = 0.003), preoperative TP (p < 0.001), and REV (p < 0.001) as significant independent predictors of forefoot amputation healing. Healing probability was calculated and plotted vs. TP for subpopulations based on age, DM, and REV status for both primary forefoot amputation and amputation concomitant with bypass. In this study population, therefore, preoperative TP appeared to be a useful clinical tool for predicting the healing potential of both primary forefoot amputations and amputations plus concomitant bypass for any given patient.
We report a case of acute fracture of both sesamoids of the great toe in an athlete. The fractures healed uneventfully after non-surgical treatment.
OBJECTIVE: To present four related patients with progressive pseudorheumatoid dysplasia (PPsRD) each with distinctive history, unique phenotype and some peculiar radiographic findings. RESULTS AND CONCLUSIONS: The history was characterised by weather-dependent articular pain. The unique phenotypic features were hypoplasia/dysplasia of one or two toes. Peculiar radiographic findings were hypoplasia of the 3rd and 4th metatarsals, platyspondyly with rectangular shape of the lumbar spinal canal, progressive narrowing of the joint spaces and early synovial chondromatosis. Finally, the condition was inherited as a dominant trait. This constellation of abnormalities constitutes a distinct form of PPsRD. PPsRD must be differentiated from other bone dysplasias, specifically spondyloepiphyseal dysplasias, autosomal dominant spondylarthropathy, juvenile rheumatoid arthritis and osteoarthritis.
Gangrene of digits is a very rare manifestation of Wegener's granulomatosis (WG). We report a case of a 29-year-old woman with nonspecific symptoms like fever, weight loss, arthralgia, arthritis and high systemic inflammatory signs. On the grounds of a presumed infection the patient was treated with antibiotics which showed no effect. Within short she complained of pain and paresthesia of the right foot with a rapid lividity. Angiography demonstrated multiples stenoses and multisegmental occlusions of the lower leg arteries. Together with renal and pulmonal symptoms a WG was suspected, the diagnosis being confirmed by kidney biopsy and positive cANCAs. A few months after starting a combined therapy with cyclophosphamide and corticosteroids the patient showed a partial remission with a residual toe gangrene. Comparing the five worldwide reported cases with digital gangrene and our presentation there is a concordance of all in the occurrence of an extremely high disease activity together with a glomerulonephritis. The findings of p-ANCAs in our patient and positive Hbs antigen in another case of WG with digital gangrene suggests a relation to panarteriitis nodosa, where gangren is more common.
Fractures of the growth plate are unique to childhood. The risk of growth disturbances depends on the type of fracture, its location, the age of the patient, the vascularization to the epiphysis, the state of the surrounding soft tissues, and whether the injury is open or closed. Epiphyseal fractures of the foot are uncommon, and only rarely are the phalanges involved. We report a Salter-Harris type II injury in the fifth toe. The patient, a 3-year-old girl, was successfully managed conservatively with no sequelae.
Six patients with unilateral blue toe syndrome presented a diagnostic dilemma with regard to the source of embolization: central aortic versus peripheral. Two patients had moderately severe aortoiliac atherosclerosis associated with focal stenoses in the superficial femoral arteries, and four patients had mild aortoiliac disease associated with localized plaques confined to either the superficial femoral or popliteal arteries. In all patients, it was elected to explore the peripheral lesions first. At operation, ulcerated plaques or focal stenoses were found, and all lesions had adherent white thrombi on their surfaces. All patients were treated either by localized thromboendarterectomy or short reversed saphenous vein grafting. There was no morbidity or mortality. Recurrent embolization did not occur during a follow-up of 8 to 24 months. Distal atherosclerotic lesions should be sought to explain distal embolization before more complex aortoiliac disease is incriminated. In the presence of concomitant aortoiliac disease, it is mandatory to directly explore the peripheral lesion, open the artery, and carefully examine the lesion in situ. Thrombus adherent to the surface of an ulcerated plaque is evidence of an embolizing source. This approach is associated with minimal morbidity and may be curative. If these findings are not present, it would be appropriate to proceed with staged correction of aortoiliac disease.
Nine toe pulp flaps based on the first dorsal metatarsal artery for reconstruction of thumb and index pulp loss are reviewed. The method is capable of giving excellent results, and particular indications are noted.
A technique for reducing congenital gigantism of the toes which has been used successfully in four patients is described.
Reconstruction of a large post-excisional defect of the oral commissure by free transfer of the great/second toe web is reported. A comparison with other methods of repair is briefly made.