The diagnosis of flat foot in the child

The term flat foot is surrounded by confusion and there is little to help the clinician to identify cases which require treatment and to avoid treating many children unnecessarily. Research for 25 years has been aimed at elucidating this problem by identifying and evaluating a series of signs and tests. These tests allow the recognition of the abnormal foot as early as possible, when efficient treatment is likely to be most effective. The results indicate that evaluation of the flat foot should be based on a combination of signs, with most emphasis on the result of the great toe extension test.     

A case of extension loss of great toe due to peroneal nerve compression by an osteochondroma of the proximal fibula

The authors present a case of extension loss of great toe caused by entrapment neuropathy of a peroneal nerve due to an osteochondroma of the proximal fibula. Plain radiographs revealed no bony abnormality around the foot or ankle, but a sessile exophytic bony growth at the proximal fibula. A positive Tinel sign in this area led us to a suspicion of compressive neuropathy of the peroneal nerve, and a subsequent electrophysiologic study confirmed the entrapment neuropathy. The peroneal nerve was decompressed by excisional biopsy. At 3 months postoperatively, normal full extension of the great toe was completely restored. The current case deserves attention in that the only clinical manifestation of peroneal nerve entrapment neuropathy by the osteochondroma at the fibular neck was extension loss of great toe.     

Abnormal extension of the big toe as a cause of ulceration in diabetic feet

Relief from external pressure and repetitive stress is a main concept in treating diabetic neuropathic ulcers. Ulcers on the tip of the big toe may be caused by abnormal extension of the big toe, which can be diagnosed only by observing the patient during barefoot walking. A flexor pad underneath the big toe eliminates the phenomenon, but in case of rigidity of the toe, extremely roomy toe boxes must be prescribed. Out of a series of 272 diabetic patients with skin lesions on the feet 18 suffered this phenomenon, in one case with bilateral ulcerations. Fifteen ulcers healed and below the knee amputation had to be carried out in 4 legs due to ischaemia.     

Relationship between Hallux Limitus and Ulceration of the Great Toe

Torque range of motion (TROM) measurements of the metatarsophalangeal joint (MTPJ) of the great toe were made to determine the relationship of joint stiffness and plantar ulceration. Subjects included 20 patients with a history of plantar ulceration of the great toe (GTU), 20 patients with a history of ulceration on the plantar surface of the foot excluding the great toe (NGTU), and 20 normal controls. Peak MTPJ extension was significantly reduced in the GTU group compared to NGTU and control groups (p < 0.0001). The slopes of the TROM and stiffness curves were significantly steeper (p < 0.0001) in the GTU group compared to the control group (p < 0.0001). Results support the hypothesis that stiffness is a factor in plantar ulceration of the great toe.J Orthop Sports Phys Ther 1988;10(5):172-176.     

Toe flexors strength and passive extension range of motion of the first metatarsophalangeal joint in individuals with plantar fasciitis

STUDY DESIGN: Cross-sectional study. OBJECTIVE: To determine if a difference exists in toe flexors strength and passive extension range of motion of the first metatarsophalangeal joint between individuals with unilateral plantar fasciitis and control subjects. BACKGROUND: Weakness of the dynamic longitudinal arch supporters and shortening of the plantar fascia have been suggested as etiologic factors for plantar fasciitis. METHOD AND MEASURES: Twenty subjects with unilateral plantar fasciitis participated in the study. Subjects had had symptoms for an average (+/-SD) of 19.9 +/- 33.2 months prior to participating in the study. Twenty control subjects matched for sex and age were also tested. Each subject was measured bilaterally for passive extension range of motion of the first metatarsophalangeal joint and peak resistance force observed during an isometric test of toe flexors strength. RESULTS: Subjects with unilateral plantar fasciitis demonstrated weaker toe flexors (P<.05) than the control subjects. A significant main effect for feet also indicated that the toe flexors for the involved feet were significantly weaker than the uninvolved feet (P<.05) of subjects with unilateral plantar fasciitis. Passive extension range of motion of the first metatarsophalangeal joint was not significantly different between the involved and the uninvolved feet for subjects with plantar fasciitis. CONCLUSION: Results for our subjects indicate that the extensibility of soft tissues influencing extension of the first metatarsophalangeal joint was not related to the presence of plantar fasciitis. Additional research is needed to determine if toe flexors weakness is a cause or a result of plantar fasciitis and if strengthening regimes for the toe flexors are effective interventions for plantar fasciitis.     

The role of the great toe in balance performance

The objective of this study was to evaluate great toe function in maintaining static and dynamic balance. Correlation among great toe length, body height, and balance performance parameters were also investigated. Thirty females (aged 22.1 ± 1.9 years) were tested in two great toe conditions: unconstrained and constrained. Balance testing was done in the following order: (1) static balance, single‐leg stance with right or left foot, eyes open or closed; (2) static balance, stance with both feet, eyes open or closed; (3) dynamic balance, left/right or forward/backward, rhythmic weight shifting; and (4) dynamic balance, target reaching test, eight targets within 90% limit of stability. Significant differences were found in sway velocity between the two toe conditions with eyes open or closed in single‐leg stance (p < 0.05). No difference was found between the two conditions while standing with both feet. For rhythmic weight shifting, significant differences in sway velocity were found in toe conditions and in weight‐shifting directions (p < 0.05). As to target reaching, significance was only noted in directional control scores. Great toe length was correlated with subject's height (r = 0.553, p < 0.05). Our results indicate that constraining the great toe deteriorated the subjects' single‐leg stance performance and worsened the directional control ability during forward/backward weight shifting. The importance of the great toe in balance may be taken into account in toe amputation or transfer in the future. © 2008 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 27: 549–554, 2009     

Turf Toe in a Taekwandoo Player: Case Report

Metatarsophalengeal joint injuries of great toe termed as ‘’turf toe” can occur in many sportive activities. However, it has not been reported before in taekwondoo players. These injuries may result in significant morbidity. Turf toe injuries, which are mainly treated with conservative methods, occasionally require surgery. In this case report, we present a surgically treated turf toe in a taekwondoo player.

Key Points

• MTP joint injury may occur when the joint is forced into hyperextension repeatedly if the exercise is being performed bare foot on hard and artificial surfaces.
• Surgery should be taken into consideration as a choice of treatment of Turf Toe.

Key Words: Turf toe, taekwondoo, treatment, surgery     

A Randomized Controlled Trial to Compare Two Techniques for Partial Digital Local Anesthetic Blocks

The administration of local anesthetic before surgery to the great toe is often associated with significant difficulties, delaying surgery and increasing risk. Anxious patients can faint, refuse injection, or withdraw the foot while an anesthetic is being delivered. Such events led us to consider whether delivering a small amount of anesthetic throughout the injection site, before the main injection, may reduce pain intensity and duration. This study was designed to test this possibility. A randomized controlled, single-blinded, parallel-grouped clinical trial was carried out with a sample of 50 patients. All study participants received each injection method (1 or 2 stage) to either the medial or lateral side of the great toe. The primary end points were pain intensity, measured by scores on a visual analogue scale and duration, recorded by the patient with a stopwatch. The 2-stage method was associated with less intense pain (reduced from moderate to mild visual analogue scale level) of a shorter duration. The differences were highly statistically significant. In the 2-stage method, it is believed that they were due to the initial infiltration of a small quantity of the anesthetic solution throughout the injection site, with the remainder being administered, after a 2-minute interval, into tissue that was predominantly anesthetized. This differs from raising a traditional bleb where a small amount of anesthetic is infiltrated into superficial tissue. The 2-stage technique is therefore recommended as the method of choice for adults.     

The aesthetic mini wrap-around technique for thumb reconstruction

In the past 12 years, 16 thumb defects at, or distal to, the interphalangeal joint were reconstructed using a great toe mini wrap-around flap. A flap including the entire nail and most of the distal phalanx of the great toe was used. Fifteen of the grafts survived. The sensory recovery of the reconstructed thumb was good as assessed by 2-point discrimination test with an average of 10 mm (range 5-15), and there were no complaints of cold intolerance. This technique results in good cosmetic appearance, and all patients were pleased with the cosmetic aspect of the thumb and there was no significant morbidity at the great toe donor site. The final decision to reconstruct a distal thumb amputation is influenced by gender, job, and age of the patients. The great toe mini wrap-around flap is an excellent reconstruction technique in selected patients.     

A systematic review of outcomes of toe-to-thumb transfers for isolated traumatic thumb amputation

Background  

Toe-to-thumb transfer is an established procedure for reconstruction of traumatic thumb amputations. The four types of toe-to-thumb transfers are the second toe, the great toe, the wrap-around great toe and the trimmed great toe transfers. The purpose of this study is to conduct a systematic review of the literature to compare outcomes amongst different methods of toe-to-thumb transfers.     

Anatomical analysis of the cause of skin necrosis of the great toe after transplantation of the great toe nail flap

Necrosis of skin on the medial side of the great toe has been a significant complication of the great toe nail flap. To investigate the reason for this, a study of the blood supply of the medial side of the great toe was carried out on 55 feet with the injection of red latex into the arteries and on 13 vascular cast specimens. It was found that, after the blood vessels from the plantar and dorsal sides of the great toe are severed during the operation, the skin of the medial side of the great toe is mainly supplied by the medial vascular network at the head of the first metatarsal bone. It is clear that the blood supply from this network may sometimes be insufficient to nourish the skin. It is suggested that the operative incision should be changed so as to increase the blood supply to the medial vascular network which may decrease the incidence of skin necrosis.     

游离坶趾腓侧皮瓣修复指腹皮肤软组织缺损

目的介绍游离坶趾腓侧皮瓣修复指腹皮肤软组织缺损的临床经验。方法对21例手指指腹皮肤软组织缺损者,采用游离坶趾腓侧皮瓣修复,并观察疗效。结果本组21例皮瓣均成活,切口均一期愈合,供足植皮成活良好。术后随访3-28个月,皮瓣色泽、质地与正常手指基本相同,皮瓣无萎缩或色素沉着,外形饱满,两点分辨觉为4-10mm,手指伸、屈功能良好。根据中华医学会手外科学会上肢部分功能评定试用标准评定,优18,良3例。供足外形及功能无影响。结论采用游离坶趾腓侧皮瓣修复指腹皮肤软组织缺损,虽然手术风险较大,但修复后能最大限度地恢复手指外形、屈伸功能,以及精细感常暑一种秸得推广酌术支     

Modified great toe wrap for thumb reconstruction

Reconstruction of the traumatically amputated thumb can be achieved with good cosmetic and functional results utilizing autogenous bone graft and a neurosensory free wrap-around flap from the great toe. The donor area of the toe is modified to create a wrap-around flap to transfer innervated glabrous skin from the medial and lateral borders of the toe. This modification includes nail and nail matrix while preserving toe length and the important plantar weight-bearing skin of the great toe. A series of three patients who have undergone thumb reconstruction utilizing this method are reported. Postoperative follow-up averages 15 months. Sensory recovery is comparable to that reported in the literature; cosmetic appearance of the thumb and nail growth are good.     

Long-term follow-up of free vascularized joint transfers to the hand in children

Toe-to-hand vascularized joint transfers in four children were reviewed 6 to 8 years after operation (average, 6.6 years). Two children had vascularized metatarsophalangeal (MTP) joints. Both children have near normal active range of motion. The transferred epiphyses have provided a major contribution to digital growth. The other two children had second toe proximal interphalangeal (PIP) joints transferred to damaged hand joints. Active PIP joint extension has been disappointing, and the overall growth contribution of the transferred epiphysis has been small. We conclude that MTP to metacarpophalangeal vascularized joint transfer can provide painless, functional, stable motion, with near normal growth potential, and the usefulness of toe PIP to hand PIP joint transfer is limited by the inability to achieve good active extension and limited growth potential.     

拇手指再造供区(足母)趾坏死的原因及预防措施

目的 对3例拇手指再造供区(足母)趾坏死的原因进行分析并提出预防措施.方法 自1998年2月至2005年2月,在我院行游离足趾移植再造拇手指中,3例供区(足母)趾部分坏死.通过分析(足母)趾血供的来源及术中采用血管阻断实验,分析供区(足母)趾部分坏死的原因,提出预防措施.结果 3例供区(足母)趾部分坏死,第1跖骨背动脉均为Ⅲ型,术中均采用足背动脉-足底深动脉-第1趾足底总动脉这一途径来切取第2趾.发现供区(足母)趾坏死时间为术后8～21 h.术中同时损伤(足母)趾腓侧趾背动脉、腓侧跖底动脉,将严重影响供区(足母)趾血液循环,术后供区包扎过紧、观察不到位,是导致供区(足母)趾坏死不可忽视的原因.结论 第1跖骨背动脉Ⅲ型,解剖足底动脉于跖底的"X"形交叉处,切取第2足趾,更易影响供区(足母)趾血运.采用吻合足底深动脉与跖底动脉或足背动脉-第2跖背动脉-趾动脉为血供切取足趾,可有效预防供区(足母)趾血运被破坏;术中、术后严密观察供区足的血运情况,及时解除(足母)趾压迫,是预防供区(足母)趾坏死的有效途径.

Abstract：

Objective To analyze the causes of necrosis of the donor great toe in 3 cases of toe-to-hand transfer and propose the proper preventive measures.Methods Among all the toe-to-hand transfers done from February 1998 to February 2005, partial necrosis of the donor great toe occurred in 3 cases.Blood supply of the transferred toe and the intraoperative vessel occlusion test was reviewed and analyzed to define causes of the necrosis, and propose preventive measures accordingly.Results The dorsal artery of the great toe was type Ⅲ in all 3 cases.Intraoperatively the second toe was harvested based on the dorsalis pedis artery, deep plantar artery, plantar artery of the first toe.Donor great toe necrosis was observed 8 to 21 hours postoperatively.Intraoperative inadvertent injury of the dorsal great toe fibular artery and fibular plantar metatarsal artery, tight dressing of the donor site after the surgery, and poor postoperative monitoring could have contributed to the toe necrosis.Conclusion Type Ⅲ of the dorsal artery of the great toe, anatomical X cross and resection of the second toe could easily affect blood supply to the donor great toe.Anastomosis of the deep plantar artery and the plantar metatarsal artery, or harvest of the toe based on the dorsalis pedis artery, second dorsal metatarsal artery,digital artery axis can effectively prevent damage of the blood flow.Intra-and post-operative close monitoring of the donor site circulation and timely decompression of the great toe were effective ways to prevent great toe necrosis.     

L'atteinte du pied au cours du rhumatisme psoriasique. À propos de 26 cas

Objective. – To describe the clinical and radiological features of foot involvement in patients with psoriatic arthritis.Methods. – We retrospectively reviewed the medical records of patients admitted between 1972 and 1999 for psoriatic arthritis with involvement of the foot. We included all patients who had peripheral and/or axial, asymmetric, chronic inflammatory joint disease meeting or not Avila's radiological criteria for psoriatic arthritis, with or without other imaging findings suggestive of psoriatic arthritis and with or without psoriasis.Results. – Twenty-six patients were included. Inflammatory heel pain was reported by 14 patients, whereas forefoot involvement was found in only seven patients. Sausage toe was present in two patients. None of the patients had Bauer's toe (combining arthritis and psoriatic skin and/or nail changes) or psoriatic onychopachydermoperiostitis of the great toe. Radiological abnormalities were found in 20 patients. Half the patients had calcaneal changes. Osteoperiostitis of the great toe was noted in two patients and mushrooming in five.Discussion. – The features of psoriatic arthritis in Morocco seem similar to those in other countries. Hindfoot involvement was present in 53% of patients. Involvement of the forefoot was rarely recorded in the charts, suggesting missed cases because of insufficient attention to the forefoot during the physical examination and availability of anteroposterior radiographs only. Oblique views (Hirtz and Chaumet) should be obtained because they give a clearer image of the distal part of the toes, which is often difficult to analyze on anteroposterior films.     

第一、二趾全背侧皮甲瓣互换的第二趾Ⅰ期塑形再造拇指

目的 探讨改进第2趾游离移植再造拇指外形的方法.方法 在切取第2趾之前,先切取其近端带蒂的全背侧皮甲瓣并留于足部.然后在游离第2趾时一同游离(足母)趾全背侧皮甲瓣,将趾全皮甲瓣与无背侧皮甲瓣的第2趾组装成为外形更近似拇指的组合足趾再造拇指.将第2趾全背侧皮甲瓣覆盖(足母)趾背侧创面,修复供区.结果 手术12例(12指)全部成活,其中8例得到6～9个月随访,再造拇指外观逼真(特别是背侧),其粗细、长度接近正常,外形及功能良好,优7例,良1例.(足母)趾的外观及功能无明显影响,行走感觉不适、有轻微疼痛者1例,但不影响行走及工作.结论 应用此方法对供区破坏较小,设计合理,患者易接受,再造的拇指背侧外观无明显差异,是一种较理想的拇指再造方法.     

多角形姆趾腓侧皮瓣塑形第二足趾中段再造拇手指

目的 探讨多角形姆趾腓侧皮瓣塑形第二足趾再造拇、手指的效果.方法 切取第二足趾的同时游离并切取四角或八角形带翼状组织瓣的姆趾腓侧皮瓣,将姆母趾腓侧皮瓣嵌入第二足趾跖侧,多角形姆趾腓侧皮瓣分别嵌入第二足趾趾腹侧的相应位置,翼状组织瓣嵌入两角之间的皮下.方果 再造10例11指全部存活,嵌入的姆趾腓侧皮瓣也全部存活.术后随访时间为3～12个月,再造拇、手指的外形较传统方法移植的第二足趾有不同程度的改善,外形与健侧的拇、手指接近.方论 多角形姆趾腓侧皮瓣嵌入第二足趾,不仅改善了第二足趾中部的狭细外形,也改善了第二足趾的屈曲畸形.     

Neglected Irreducible Dislocation of the Interphalangeal Joint of the Great Toe: A Case Report

Irreducible dorsal dislocation of the interphalangeal joint of the great toe is rare. We report a case of a 58-year-old man with an irreducible interphalangeal joint of the great toe that had been untreated for 4 years. The mechanism of this injury was thought to be a combination of axial loading with a hyperextension force when the patient hit his great toe against a pipe. Invagination of the sesamoid became a barrier for manual reduction attempted after the initial injury. The patient did not seek treatment because of the minor deformity of the affected great toe and lack of severe symptoms. One year later, symptoms eventually developed on the plantar aspect of the great toe, particularly when the patient was walking upstairs. He decided to seek treatment as pain worsened and he became more active when he changed occupations 4 years later. Manual reduction was impossible. The patient was treated with operative exploration of the joint and arthrodesis of the great toe. The operative course was uneventful. At 4 years after surgery, the patient could walk, run, and walk up and down stairs without discomfort.     

The multiple monoblock toe-to-hand transfer in digital reconstruction. a report of ten cases

Ten hands with multiple traumatic finger amputations or congenital agenesis underwent reconstruction by monoblock transfer of multiple toes. Eight patients underwent monoblock transfer of the great and second toes, one patient received the great toe and the metatarsophalangeal joint from the second toe with the same vascular pedicle, and another patient the great, second and third toes as a block. Only part of the great toe was ever taken, while the second toe was totally or partially taken. The surgical technique and the outcome are detailed in this work, with a mean postoperative follow-up of 6 years.