The deformities of the fingers and toes

by William Anderson

Hammer toe, then, like hammer finger, must be regarded as the result of inadequate longitudinal evolution of the ligaments which limit the movement of extension at the inter-phalangeal joints, and the symptoms induced by the deformity are mainly dependent upon the formation of callosities and bursæ by contact with the opposed hard surfaces of the foot covering. This irregularity of development may be either inherited or accidental.

Treatment.—It is probably not within our power to prevent the occurrence of hammer toe, even by the greatest care in the selection of boots. For its relief when developed many plans have been adopted, the chief of which are as follow:

1. Extension by splints of various kinds in the early stages, while the contraction may be overcome by passive force. The condition is rarely seen by the surgeon in this period, but should it fall under observation the persevering use of passive extension is preferable. When the deformity is well marked, splints are painful and useless.

2. Tenotomy of the extensor tendon (Boyer). This measure, which was doubtless suggested by the visible tension of the tendon in many cases, is more likely to aggravate than to relieve the symptoms.

3. Tenotomy of the flexor tendons. This to be successful must involve also the section of the glenoid and lateral ligaments. Such an operation has been practised both by the subcutaneous and by the open methods, but it involves the risk of division of the plantar digital nerves, and the necessity for a prolonged after-treatment to prevent recurrence. It has even been advised by Petersen to treat the contraction by a transverse incision, through integuments, tendons, and ligaments, down to the articulation, but the promptitude of the method is its sole recommendation.

4. Subcutaneous division of the lateral ligaments has been performed with good results by Mr. Adams, but it has the disadvantage of requiring a long after-treatment.

5. Resection of the joint. This is unquestionably the most eligible measure, and has been successfully practised on different plans by various surgeons during the last twelve years or more, both in England and France. The articular extremities of both bones may be removed or the head of the proximal bone only, the distal bone being left intact. In either case the toe is subsequently fixed for a period of three or four weeks in an extended position. The procedure I have found most speedy and satisfactory is as follows: An incision is made on the lateral aspect of the affected articulation, following the axis of the bones and exposing the lateral ligament, while leaving intact the vascular and nervous trunks. The ligament is then divided, by a touch of the knife, and by a forcible lateral movement the head of the proximal phalanx is made to protrude through the wound, and is removed with a pair of bone nippers. The toe is straightened, the wound closed by sutures (without drainage), and dressed. Antiseptic precautions must be strictly observed, and the operation must not be performed until all inflammatory signs have been removed from the superjacent corn. The operation can be completed within two or three minutes, and, what is a far more important consideration, it involves the least possible interference with the structures of the toe. The wound heals by first intention, and after a fortnight’s rest the patient is able to walk, the toe being extended for a few weeks upon a dorsal splint of flat steel, such as was used in making the now obsolete appendages to the back of the feminine skirt. The result is all that could be desired, and the relief immediate and permanent. The same operation is applicable for the distal joint, but is less easy.

6. Amputation was, until within the last ten or twelve years, the usual resource after the failure of tenotomy of the extensor. It affords a curious comment upon the surgery of the pre-antiseptic period that the chief reason given against this operation by the early writers was its danger to life. At the present time it can rarely be needed unless, by any accident, the antisepsis of the resection operation fails and acute inflammation sets in. The objections to it are the mutilation, and the tendency to lateral distortion of the adjacent toes to fill the gap left by the lost member.

HALLUX FLEXUS.

Hallux flexus appears to have been first recognised as a separate affection only a few years ago, in 1887, and it is to Mr. Davies-Colley that we are indebted for the name and for the earliest discussion of the characters and causation of the disease. It is stated, however, by Blum that Nélaton described a “cou de cygne” of the great toe, and attributed it to the use of short boots. I have been unable to discover the reference in the works of this surgeon, but if the citation can be verified, the credit of recognising the existence and nature of the deformity will fall to him, for there is no doubt that hallux flexus is pathologically a “cou de cygne” or hammer toe. Since Mr. Davies-Colley’s introduction of the subject various contributions have been made, by Mr. Howard Marsh, Mr. Reginald Lucy, Mr. Cotterell, Mr. Ellis, and others, and I must draw especial attention to a valuable analysis of thirteen cases by my colleague, Mr. Makins, in the St. Thomas’s Hospital Reports for 1888. The complaint is by no means a rare one, for since 1887, when I began to take notes of all the cases that were brought under my observation in private and hospital practice, I have accumulated a list of thirty examples of what may be termed true “hallux flexus,” besides a number of contractions presenting a superficial resemblance to it, but resulting from arthritic lesions. I propose, as in the case of hammer toe, to separate these latter entirely from the former, because the pathological, and even the clinical, distinctions between the two classes are perfectly well marked, and it hence can only mislead to place them in the same category.