The deformities of the fingers and toes

by William Anderson

2. Forcible rectification under an anæsthetic is satisfactory for slighter cases. It may be aided if necessary by subcutaneous section of the opposing tendinous and ligamentous structures on the tibular side, and the toe is fixed for two or three weeks in plaster of Paris. The rectification should be preserved by the use of properly constructed shoes with a septum between the first and second toes, when the patient begins to walk.

3. Resection of the joint is undoubtedly the best operation in the more severe operations of hallux valgus. Involving the obliteration of an important articulation, it was feared that it might induce serious crippling, but the plan has been adopted with perfect success by Mr. Clutton[14] who, excising the cartilaginous extremities of the bones and fixing the shafts in suitable position by means of an ivory peg, has secured the best results. During the last two years I have applied the principle of the operation recommended for hammer toe. Excision of the head of the metatarsal bone is performed through a longitudinal incision over the inner side of the joint, the toe is then replaced and fixed for three weeks in a slightly extended position by means of plaster of Paris. The success of these measures is far more complete than could have been anticipated on theoretical grounds. The distal joint appears to replace almost perfectly that which is lost, and the locomotion is easy and unfatiguing. In a case of my own the patient was able to walk twenty miles a day within three months of the operation.

HALLUX VARUS.

Fig. 15.

Hallux varus. A. Before operation; B. Three years after operation. The relatively small size of the great toe in B is due to the abnormally great development of the other toes (not represented in Fig. A).

The following is a curious example of this rare condition, in association with macrodactyly. The patient, a boy aged eleven, was admitted into St. Thomas’s Hospital in March 1887, with a deformity of the right great toe, dating from infancy. The member was somewhat imperfectly developed, and projected inwards almost at right angles with the metatarsal bone. (See [Fig. 15, A.]) A slightly prominent integumental fold was present on the inner side of the metatarso-phalangeal joint, and the ligamentous and other fibrous tissues beneath this resisted the replacement of the digit in its normal line. The toe could be moved feebly by an effort of the will, but the abnormal direction of the member prevented the muscles from exercising any useful function. The smaller toes were distinctly hypertrophied, but were otherwise well formed. The boy was unable to wear a boot, and was completely crippled. The toe was apparently useless, but it was judged advisable to restore it to its natural position rather than to amputate. This was effected by subcutaneous division of the internal lateral ligament and the application of a small plaster apparatus. Fifteen days later the child left the hospital with a light metal splint fixed to the inner side of the foot and toe. Three years afterwards he presented himself for examination, and it was found that the good result was more than maintained, as the toe was not only straight, but had acquired its normal size and considerable power of movement. The boy said he was able to walk seven or eight miles without fatigue. The relative hypertrophy of the lesser toes was still obvious.

LATERAL DEVIATION OF THE LESSER TOES.

This is frequent in childhood. It was found in twenty-five children, twelve males and thirteen females, out of 800, the ages of the subjects ranging between five and fourteen. The version is usually at the first inter-phalangeal joint, but may also be present in the distal joint, and the toe much more frequently diverges towards the tibial than towards the fibular side (six to one). It may lie over or under its neighbour. The fourth toe is affected in about two-thirds of the cases, while the second, third, and fifth toes take an almost equal share in making up the remaining third. It is symmetrical in nearly two-thirds of the examples (sixteen out of twenty-five). In the early stage the joint may be straightened by passive force; but in the later, reposition is opposed by ligamentous tension, and perhaps by some alteration in the form of the bone. Like hammer toe, it occurs only during the developmental period, and there is no reason to connect it with any special defect in the shape of the shoe. In none of the examples under my own observation was it associated with hallux valgus; but a double hammer toe (third) was present in one case, and version of the fingers in three others. The children appeared to be in good health. The deformity may usually be relieved by the use of a splint, like that recommended for hammer toe; but in some cases a partial resection might be advisable.

Inversion of the little toe at the metatarso-phalangeal joint is occasionally met with. It appears always to arise during the period of active growth and is associated with shortening of the extensor tendon. Subcutaneous section of the tendon allows complete reposition, and the cure may be made permanent by temporary fixation in plaster, and subsequent attention to the feet. The origin of the condition is obscure.