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We describe a case of a traumatic avulsion fracture of the distal phalanx of the hallux. In the upper limb this fracture leads to a "mallet" deformity. Such an injury in the great toe has not been reported previously in the English orthopaedic literature to our knowledge. The injury was treated in a dorsal extension splint for eight weeks. At six months follow-up, a satisfactory clinical outcome was achieved.
Forefoot deformities in cerebral palsy include cavus, metatarsus adductus, hallux valgus and bunion, dorsal bunion, and toe flexion contractures. Both prevention and correction of these deformities are surgical. Some can be prevented by lengthening or tenotomy of the spastic muscle that causes the dynamic deformity which eventually becomes the fixed skeletal deformity. Fixed deformities need osteotomies and arthrodesis of the bones in addition to removing the force of the deforming muscle. Some forefoot problems are related to the mid and hind foot, e.g., hallux valgus due to spastic pes valgus. Severe cavus can develop after overzealous Achilles tendon lengthening and failure to separate forefoot from hindfoot equinus.
Congenital digitus minimus varus (overlapping of the fifth toe) is often bilateral and may result from an anatomic deformity of the extensor digitorum longus tendon. Although bifurcation of the tendinous slip to the fifth toe has been reported as an anatomical variant, in those patients affected with overlapping fifth toe, a pronounced asymmetry between the medial and lateral components may occur. Not only do the two slips to the fifth toe differ in girth, but the morphology of the separate tissues reflects a dissimilar level of organization. Surgical techniques for correction of secondary overlap should consider the possibility of altered gross and histologic anatomy of the extensor tendon when attempting to preserve function.
Nine delayed unions and nonunion of the proximal fifth metatarsal were treated with pulsed electromagnetic fields (PEMF). All fractures healed in a mean time of 4 months (range 2-8 months). Those fractures treated with both pulsed electromagnetic fields and a nonweightbearing cast healed in a mean time of 3 months (range 2-4 months). The average duration of follow-up was 39 months (range 24-60 months). There were no refractures. When compared with reported healing times and morbidity for conventional casting, medullary curettage with inlay bone, and closed axial intramedullary screw fixation, pulsed electromagnetic fields provided an effective alternative for the treatment of delayed unions and nonunion of the proximal fifth metatarsal.
Many conditions of the foot have been related to pressure maldistribution. Alteration of plantar pressure through improvements of shoe fit, orthoses, and surgery are presumed to correct pressure maldistribution. We evaluated 10 volunteers with normal, asymptomatic feet. With the use of an ultrathin in-shoe sensor, plantar pressures were measured within the shoe at the shoe/foot interface. Test conditions included three pad types: large foam, large felt, and small felt. They were evaluated in three positions: normal (at the metatarsal head base) and 5 mm proximal and 5 mm distal to the normal position. When compared with the control condition without the pad, each pad type and position caused a variable effect upon plantar pressure. On average, the small felt pad caused the greatest and most consistent decrease in pressure at the metatarsal heads (19.15%). Distal positioning tended to cause the greatest decreases in pressure for all pad types. A pad type and position was found to decrease metatarsal pad pressure in each subject. Metatarsal pads can effectively decrease plantar pressures within the shoe.
Metatarsal pads are frequently prescribed for nonoperative management of metatarsalgia due to various etiologies. When appropriately placed, they are effective in reducing pressures under the metatarsal heads on the plantar surface of the foot. Despite the positive clinical reports that have been cited, there are no quantitative studies documenting the load redistribution effects of these pads during multiple step usage within the shoe environment. The objective of this study was to assess changes in plantar pressure metrics resulting from pad use. Ten normal adult male subjects were tested during a series of 400-step trials. Pressures were recorded from eight discrete plantar locations at the hindfoot, midfoot, and forefoot regions of the insole. Significant increases in peak pressures, contact durations, and pressure-time integrals were noted at the metatarsal shaft region with pad use (P < or = .05). Statistically significant changes in metric values were not seen at the other plantar locations, although metatarsal pad use resulted in mild decreases in mean peak pressures at the first and second metatarsal heads and slight increases laterally. Contact durations decreased at all metatarsal head locations, while pressure-time integrals decreased at the first, second, third, and fourth metatarsal heads. A slight increase in pressure-time integrals was seen at the fifth metatarsal head. The redistribution of plantar pressures tended to relate not only to the dimensions of the metatarsal pads, but also to foot size, anatomic foot configuration, and pad location. Knowledge of these parameters, along with careful control of pad dimensions and placement, allows use of the metatarsal pad as an effective orthotic device for redistributing forefoot plantar pressures.
Among dancers it is widely believed that ballet dancing induces hallux valgus. Revision of radiographs of 63 active and 38 retired dancers of both sexes showed no increase in the valgus angulation of the hallux compared with that of nondancers.
This study involved the radiographic examination of 118 feet from 110 urban African female patients. Fifty-two of the 118 feet showed radiographic evidence of hallux valgus (valgus angle > 15 degrees). The parameters compared between feet with and without hallux valgus were sesamoid position, pes planus deformity, metatarsal length, and the cuneiform-metatarsal articulation. All radiographs were standardized, weightbearing anteroposterior and lateral views. The results were statistically analyzed. The findings showed no difference between the hallux valgus and control groups with respect to sesamoid position relative to the second metatarsal, incidence of pes planus, relative length of the first metatarsal, and the first metatarsal-medial cuneiform articulation.
Two surgical approaches for distal soft tissue release in the correction of hallux valgus, one using a dorsal first web space incision and the other a longitudinal medial capsulotomy incision (used also for medial eminence resection), were studied to compare and delineate the structures actually incised. Anatomic dissections were performed on six fresh-frozen amputation specimens using each of the approaches. The adequacy of release of the adductor hallucis, transverse and oblique heads, first metatarsophalangeal lateral capsule, and suspensory ligament was reviewed. Any inadvertent damage to the first metatarsal head cartilage, second metatarsophalangeal capsule, and lateral head of the flexor hallucis brevis tendon was also noted. Distal soft tissue release is thought to be an important part of hallux valgus surgery. Based on our anatomic dissections, the actual extent of the release may be inconsistent and unpredictable, and may have implications for the predictability of results after hallux valgus surgery.
BACKGROUND: After flexor tendon repair, the strength of the repair and the resistance to digital motion are important considerations in deciding when to initiate postoperative rehabilitation. Our objective was to assess these factors in a short-term in vivo canine model of flexor tendon repair. METHODS: Forty-eight dogs were randomly allocated to four groups based on the duration of postoperative follow-up (one, three, five, or seven days). In each group, two flexor digitorum profundus tendons of one forepaw were exposed. One tendon (the repair tendon) was sharply transected and repaired with a modified Kessler suture, and the other one (the sham tendon) was simply exposed without laceration. The involved paw was immobilized until the animal was killed on the designated day. Three tendons from each dog, including the repair tendon, the sham tendon, and a control tendon from a corresponding normal digit on the contralateral side, were tested. RESULTS: The mean peak total digital resistance force in the repair group was lowest at five days (p < 0.01 compared with seven days; p > 0.05 compared with one and three days). The mean peak force needed to overcome the internal gliding resistance between the repaired tendon and sheath was significantly higher than that in both the sham and control groups at all time-points (p < 0.001); however, this value was also smallest at five days. There was no significant difference in suture strength at any time-point (p > 0.05). CONCLUSIONS: When we evaluated tendon-gliding and suture strength after flexor tendon repair, the least favorable ratio of repair strength to force needed to overcome the resistance to digital motion was noted on Day 7, whereas the best combination of tendon strength and low peak resistance force was noted on Day 5.
Perception of the common cold and other discomforts was studied as a function fo age among 456 normals ranging in age from 18 to 82. Respondents completed a questionnaire which deal with the frequency and duration of their colds, their symptoms and treatments-and, finally, with the perceived severity of various discomforts. Though older Rs were found to suffer more than younger with body aches, the former had less difficulty with a variety of other physical and psychological symptoms-and also contracted relatively few colds. Older Rs treated their colds less often with Contac and Dristan, but more often by staying home and/or calling their doctor. As compared with younger Rs, older respondents perceived intestinal flu to be relatively less serious-but earache, sprained toe, indigestion, having a tooth filled, stiff neck, and hangover to be relatively more serious.
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43 children treated by flexor-to-extensor transfer for a total of 130 curly toes were retrospectively reviewed after a mean period of 8 years. According to an objective scoring system, 37 patients had a satisfactory result and 6 patients had a poor result of one or more toes. We now recommend that children with mild to moderate curly toes should be observed until the age of 6 years, by which time the majority will have had spontaneous correction. The remaining patients should be operated on at that stage because children operated on later had poor results. Attention should be paid to the surgical technique because the long flexor tendons are often bipartite.
Day-old male broilers (n = 384) were used in a 21-d trial to investigate the effect of microbial phytase on the retention and utilization of Zn. A corn-soybean isolate basal diet containing 20 ppm Zn was fed alone and supplemented with 5, 10, or 20 ppm Zn as ZnSO4.7H2O or with 150, 300, 450, or 600 U of phytase/kg of diet. Total excreta were collected during Days 18 to 20. Toe, tibia, and liver samples were taken at the end of the experiment. Adding Zn and phytase to the low Zn basal diet linearly increased BW gain and feed intake of broilers (P < 0.01). The gain to feed ratio was not changed by adding Zn but was decreased by adding phytase (P < 0.01). The amount of DM retained was linearly increased by adding Zn and phytase (P < 0.10), but DM retained as a percentage of intake was only increased by adding Zn (P < 0.05). The amount of Zn retained per bird was linearly improved by adding Zn and phytase (P < 0.01). Zinc retained as a percentage of intake was linearly decreased by adding Zn but was linearly increased by adding phytase (P < 0.10). Ash percentage of toe and tibia were not affected by adding Zn but were linearly improved by adding phytase (P < 0.10); however, the amount of ash in toe or tibia was increased by Zn (P < 0.05) and phytase (P < 0.01 for toe; not significant for tibia). The concentration and amount of Zn in toe and tibia were linearly increased by adding Zn and phytase (P < 0.001). The concentration of Zn in liver increased by adding Zn (P < 0.10) but was not significantly improved by adding phytase. The amount of Zn retained in liver was linearly improved by adding Zn and phytase (P < 0.05). Nonlinear or linear response equations of the effects of Zn and phytase levels were generated and used to calculate the Zn equivalency values. The average function of Zn equivalency values (Y, milligrams per kilogram) of microbial phytase (X, units per kilogram of diet) was developed: Y = 0.20 + 0.0082X. The results indicate that approximately 0.9 mg of Zn was released per 100 U of phytase over the range of 150 to 600 U of phytase.
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The incidence, prevalence, and severity of foot conditions increase with age. Teaching patients simple preventive techniques is crucial. Recognition, treatment, and prevention of common foot complaints--i.e., toenail problems, infections, corns and calluses, injuries, flat feet, bunions, arthritis of the toes, and toe and joint deformities--are reviewed.