CONTRACTIONS OF THE TOES
The whole of the morbid conditions described in connection with the
fingers are probably represented in the toes, and the classification
adopted in the former case may be applied with but slight modification to
the latter.
CONTRACTIONS DEPENDENT UPON PATHOLOGICAL LESIONS IN THE CUTANEOUS AND
FASCIAL STRUCTURES.
Lesions of the sole corresponding to Dupuytren’s disease in the hand are
extremely rare, on account of the protection afforded by the shoe and
the thickness of the plantar pad, and although cases have been mentioned
by Mr. Adams and other surgeons, I believe none has yet been shown or
discussed at any medical society. The following example deserves record:
The patient, a gardener, aged fifty-seven, was admitted to St.
Thomas’s Hospital in May last with contraction of both hands.
He stated that he first noticed a slight contraction beginning
in the ring finger of the left hand twelve years ago; in the
course of a year or two the disease extended to the little
finger, and afterwards to the middle finger. Four years since
a similar affection appeared in the right hand, and shortly
before admission he observed a superficial nodule on the sole
of each foot. He had never suffered from gout or rheumatism,
and had always enjoyed good health; the family history was
negative. On examination the third, fourth, and fifth fingers
were found contracted in both hands; the fourth and fifth
fingers of the left hand being strongly bent at the first and
second joints, and brought into contact with the palm, while on
the right side the lesions were similar in character but less
advanced. In each sole a flat subcutaneous nodule could be felt
adherent to the plantar fascia and slightly to the integument
over the head of the second metatarsal bone, but there was
no puckering of the skin, and the position of the toes was
quite unaffected. The contracted cords in both hands were
divided by multiple subcutaneous incisions, and the fingers
were extended by plaster-of-Paris splints. The nodule upon the
right sole was excised, and found to consist of white fibrous
tissue, longitudinally striated, and adherent to the fascia,
but could be detached from it without difficulty. Under the
microscope the appearances presented were identical with those
in the early stage of Dupuytren’s contraction, and there is no
doubt that the foot nodule was pathologically the same as the
contracted tissue in the hands. The operations upon the hands
and feet were successful.
CONTRACTIONS DUE TO DEVELOPMENTAL IRREGULARITIES IN THE ARTICULAR
STRUCTURES.
This group includes the conditions known as hammer toe, hallux flexus,
and some of the lateral versions of the toes.
HAMMER TOE.
This complaint may be described as a permanent flexion from the straight
line at either or both of the inter-phalangeal joints, without paralysis
of muscles, unattended with any primary degenerative or inflammatory
disease of the articular structures, and essentially confined in origin
to the period of active growth. Some precision of definition is necessary
to exclude similar deformities of wholly different pathological nature.
Hammer toe was known long before it became the subject of scientific
observation. According to Dr. Cohen,[8] the first printed description
was that by a French surgeon named Laforest, in a volume published in
1782, and entitled “L’Art de Soigner les Pieds”; but Laforest was the
successor of one Rousselot, who thirteen years earlier wrote a book to
which he gave the formidable name of “La Toilette les Pieds, ou Traité
de la Guérison des Cors, Verrues, et autres Affections de la Peau, et
Dissertation abrégé sur le Traitement et la Guérison des Cancers.” In
this essay a flexion of the toes attributed to the use of short shoes is
alluded to with sufficient clearness to make it probable that Laforest
had succeeded to the ideas as well as to the practice of his predecessor.
The first account, however, with any pretensions to science, was that
given by Boyer in 1822.[9] Since that time the subject has been discussed
repeatedly in France, and within the last few years has been brought
forward twice in England, at the Clinical Society in 1887, and at the
Medical Society in 1889.
The deformity is found in both sexes, but appears to be somewhat more
frequent in the male (three to two). The influence of _age_ is very
strongly marked. The condition invariably begins within the developmental
period, and may show itself at any time between birth and adult life, but
most frequently attracts the notice of the patient for the first time
during the third quinquennial period. Amongst a number of incipient cases
seen at Hanwell not more than one-tenth were under twelve years of age,
the little toe being usually the seat of the earlier manifestations. It
is said to be occasionally congenital. So far as my own observations go,
neither class, occupation, nor constitutional condition, appears to have
any share in its production.
It has long been a popular as well as a medical opinion that the
deformity is handed down by inheritance. Even Laforest, who contests
the belief, says, “Je m’entends souvent dire que l’on est né avec un
doigt ainsi; que c’est un doigt de famille.” Boyer asserted that it was
frequently inherited, and Blum and others have adduced examples in
support of this view. In a paper read before the Clinical Society in
1887, I referred to a history in four cases out of twenty-two which had
the same bearing; and other striking examples have since been brought
forward by Mr. Adams. In fact, some evidence of the influence of the
hereditary principle may be traced in at least a fourth of the examples
that come under notice, and is particularly frequent and clear amongst
patients of the educated classes.
F.* M.*
| |
+--------+--------+ |
| | | |
F. F. F.* M.*
\----v----/
|
+--------+--------+--------+--------+--------+--------+
| | | | | | |
F. F.* M. M. F.* M. F.*
|
+--------+--------+
| | |
F. M.* F.*
* The Asterisk indicates the members of the family who suffered from
hammer toe. M. and F. signify sex.
The subjoined pedigree of a family in which the affection has arisen,
illustrates the descent through four generations. It was noted that the
children attacked were those who presented most resemblance in feature
and temperament to the grandfather. The deformity usually appeared about
the age of four, and was confined to the second toe. “Double-jointed”
thumbs were also an inheritance in the family. In another example
the condition developed in five children out of eleven. Here too
there was a history of “double-jointedness” in the fingers and thumb,
extending through three generations; and an aunt on the male side was
also the subject of hammer finger. This association of hammer toe with
other developmental irregularities is significant enough to deserve
attention. In addition to the instances mentioned, there are amongst
the seventy-three surgical cases on my list three accompanied by hallux
flexus, and one with retraction of both little toes; and there is little
doubt that coincidences of a like kind would more frequently be found
were it always possible to ascertain the facts by inquiry.
_Seat of attack._—In surgical cases the toe most commonly affected is the
second. In my list of 73 patients who had applied for treatment, this
digit was affected in all but four, while the third was attacked in five,
the fourth in one, and the fifth in three cases. In one instance the
affection of the third toe was symmetrical, each afforded only a single
example; but if all cases of contraction of the joint for 30° or more be
counted without reference to symptoms, the condition is far more frequent
in the little toe than in the others. Thus in an examination of a series
of 800 children under sixteen years of age the little toe was found to
be involved in forty-one cases, nearly all of which were double, while
the second toe was affected in six only, and the third toe in five. It
may be noted also that the projection of the extremity of the second toe
beyond that of the first—a condition regarded as a type by the ancient
sculptors—was present in only three instances. This is confirmed by
Professor Flower, who failed to find a single instance in many hundreds
of children.
The deformity is bilateral and symmetrical in nearly a third of the
cases, in the rest having a slight preference for the right side,
in the proportion of five to four. It is usually localised in the
first inter-phalangeal articulation, but occasionally implicates both
inter-phalangeal joints, or the distal joint only.
_Symptoms._—The stages of the deformity in a typical case may be
described as follows: In the _first_ period, which is rarely seen by
the surgeon, the toe is slightly extended at the metatarso-phalangeal
articulation, and flexed at the proximal inter-phalangeal joint. By
passive movement the flexed joint may often, but not always, be extended;
but the range of motion, even in the early stage, is found to be less
than that of the neighbouring or opposite toe. The distal joint is
usually unaffected, and may be held straight or slightly flexed, but
occasionally it undergoes contraction, either alone or in association
with the proximal articulation. There is no evidence at this or any
subsequent time of inflammation in or around the joint structures, except
in association with corns or bursæ. How long this period may last it is
difficult to say, as it may altogether escape the notice of the patient.
In the _second_ stage the flexion of the inter-phalangeal joint becomes
more pronounced, and the secondary extension at the metatarso-phalangeal
joint increases _pari passu_. At this period the affected articulation
is fixed for all movement of extension, but the power of flexion within
the limits left to it remains unimpaired; in other words, the angle may
be diminished, but not widened, and the toe, although contracted, is
neither ankylosed nor paralysed. In exceptional instances the flexion may
be overcome by strong passive force, and a distinct trigger-like action
established, the middle phalanx becoming extended and flexed again with
a movement very comparable to that which takes place during the opening
and shutting of the blade of a pocket-knife. As secondary results of the
contraction of the proximal inter-phalangeal joint the patient is subject
to certain inconveniences which may give rise to much suffering, and are
usually the immediate cause of his appeal to the surgeon. The chief of
these are a bursal formation, which is very liable to inflammation, over
the angle of flexion, and two associated callosities, one above the head
of the retracted phalanx, the other beneath the head of the metatarsal
bone, both consequent upon the pressure exercised by the boot. (See
Fig. 10.) A third callosity may develop over the tip of the toe, and
the soft parts over the terminal joint may become somewhat swollen, so
that the digit presents a clubbed appearance. The degree of interference
with functions and comfort varies greatly in different cases, partly in
relation to the degree of the contraction and partly to the sensibility
of the patient. In some persons a hammer toe of a marked kind will cause
so little trouble that no medical advice is sought—this is especially the
case when the contraction is limited to the little toe; in others the
suffering is so great that the patient begs the surgeon to remove the
offending member with the knife, and remains absolutely crippled until an
operation is practised for his relief. When the deformity affects more
than a single digit, an interval varying from a few months to five or six
years may elapse before the second attack appears. As a rule, it is the
corresponding toe on the opposite foot that suffers, but occasionally a
neighbour is selected; or even the distal joint of the same or another
toe.
[Illustration: FIG. 10.
A. Diagram showing position of bones in hammer toe, involving the
proximal joint; 1. Metatarsal bone; 2. Head of first phalanx; slight
groove corresponding to position of dorsal border of base of second
phalanx; 3,4, and 5. Callosities due to boot pressure; 6. Bursa over
contracted joint; 7, 8. Shoe. The arrow indicates the direction in
which the pressure of the upper leather tends to force downwards the
head of the metatarsal bone towards the sole. B. Dissection of first
inter-phalangeal joint in hammer toe; C. The same preparation after
section of plantar fibres of lateral ligaments.]
_Morbid anatomy and pathology._—The earlier opinions upon the pathology
of hammer toe were very conflicting. Gosselin, who dissected a specimen,
was unable to find any lesion. Fano, in 1855, mentions as the chief
defect a cartilaginous nucleus in the extensor tendon. Blum described a
luxation of the first phalangeal joint, with a thickening of the whole
capsule, and maintained that the contraction of the toe was due to a
peri-arthritis set up by the inflammation resulting from corns—a curious
example of “hysteron proteron.” Blandin attributed the affection to a
shortening of the plantar fascia; Boyer to a retraction of the extensor
tendons; Roche and Sanson to a contraction of the flexor tendons, and
other surgeons to a paralysis of the interossei, but no attempt was made
to separate true hammer toe from the arthritic and traumatic deformities
which simulate it. It is now beyond doubt that the essential seat of
the contraction is in the joint itself. The specimen represented in B,
C, Fig. 10, is one prepared by myself in 1882 from a toe which had been
amputated by a colleague. It showed that the deformity was not affected
by section of the tendons, but that it yielded immediately upon division
of the plantar fibres of the lateral ligaments where they blended with
the glenoid plate. This observation, which has been confirmed by a
dissection of Mr. Walsham’s, was not published until 1887, and it was
by Mr. Shattock, who, working independently, had found the same lesion,
that the condition was first made known at the Clinical Society in the
same year. The preparation illustrating his paper is now in the museum
of St. Thomas’s Hospital, as well as a second dissection demonstrating
the absence of disease in the interossei. The results of these and later
investigations may now be stated.
(1) There are no essential alterations of muscle or tendon except those
secondary to the contraction of the joint—namely, an undue tension
and prominence of the extensor tendon over the metatarso-phalangeal
articulation, and an adaptive deficiency of length in the flexors,
which are prevented by the permanently bent state of the articulation
from keeping pace in growth with the osseous structures. (2) The skin
and fasciæ in like manner are unaffected or only undergo a secondary
shortening on the flexor side in severe and long-standing cases. (3)
The articular surfaces generally show no change beyond atrophy of that
portion of the cartilage of the head of the proximal bone, which is
permanently excluded from contact with the distal bone in consequence of
the imperfect range of extension of the joint. In some cases, however, a
distinct transverse groove is present on the head of the proximal phalanx
at the point where it comes in contact with the dorsal border of the
base of the distal bone during the attempt at extension, and behind this
groove the bone may be heaped up into a little ridge. It is the existence
of this irregularity that explains the trigger phenomenon previously
alluded to. (4) The ligaments present no structural change, but an
important quantitative defect is always found in the plantar fibres of
the lateral ligaments, which are so short that they check prematurely the
movement of extension of the joint.
The real origin of the articular defect has been the source of much
argument. At all times, whatever may have been the opinion as to
the exact morbid anatomy of the condition, there has been a strong
disposition to blame the shoemaker, or rather the fashion that dictated
the arbitrary form the shoe was to assume, as the prime cause of the
disease. There is, of course, no question that the mistaken ideal of
elegance which finds expression in the demand for tight and pointed
boots has been the cause of much misery and deformity, and it appears
only natural to assume that the artificial crowding together of the toes
might force one of the members to assume a position of retraction, in
order to make room for the rest, and the digit so drawn up might after
a time become permanently fixed in its abnormal attitude. This view is
well expressed by Mr. Ellis,[10] but the study of a number of cases of
hammer toe furnishes strong reason for doubting this fatally plausible
hypothesis. The deformity may be seen in early infancy, before any rigid
foot covering has been adopted; and a precisely analogous condition is
known to exist in the fingers, which are not subjected to any artificial
restraints. Moreover, in the great majority of the feet affected with
hammer toe there is a complete freedom from the deformities which are
known to result from overcrowding of the digits, and there is seldom
anything in the history of the cases to indicate the past use of improper
boots.
It has been said that hammer toe is unknown in countries where boots
are not worn; but the subject has yet to be studied in those parts of
the world on a scale that sanctions generalisation. Moreover, as hammer
toe is painful only in consequence of the friction and pressure induced
by the foot-covering, its existence would be unlikely to attract much
attention in a bootless race. During my own residence of six years in
Japan I never met with an example, and my friend Surgeon-General Takaki
writes to me that his observations, covering a period of fifteen years,
are equally negative; but it must be noted that it is the rising and
boot-wearing generation that has been especially brought under our
notice, and the conclusions to be drawn from our experience tend as much
to contradict the view that boots are an immediate cause of hammer toe,
as to support the belief that the Japanese are exempt from the defect.
There is little doubt, however, that the use of shoes is to some extent,
and in a remote sense, a predisponent to this and to other analogous
deformities, for it is certain that a rigid leather foot-covering, even
when shaped according to the most scientific principles, must necessarily
impede the free action of the toes, and so interfere with the processes
of nutrition and development; but I am equally confident that few,
if any, of the examples of hammer toe that have come within my own
experience could be traced to any special defect in the form of the shoe.
Out of the whole number only six confessed to having worn tight boots.
In the rest, neither history nor inspection indicated any fault of the
kind, and the feet in the great majority were perfectly well formed in
all other respects, and bore no marks of injurious compression. In a case
of inherited hammer toe in which the proximal joint of the second digit
of the right foot was straightened by operation, the boots worn before
and after the operation were made upon sound anatomical principles; but
nevertheless the patient came two years later with a contraction of the
distal joint of the same toe and of the middle toe of the opposite foot,
and a lateral distortion of the fourth toe.
The pathological explanation I believe to be that advanced to account
for the occurrence of hammer finder. The examination of a large number
of healthy feet will reveal physiological variations in the condition
of the inter-phalangeal joints exactly comparable with those noted in
the hands. The second phalanx may in some persons be super-extended 30°
beyond the axial line of the proximal bone, while in other instances the
movement is arrested by tension of the plantar fibres of the lateral
ligaments before this line has been attained;[11] and in the distal joint
even greater variation may be found. There is, in fact, a physiological
tendency to hammer toe in large numbers of people who never actually
suffer any inconvenience from it, and it is in the exaggeration of this
physiological irregularity that we have to seek the pathology of the
surgical hammer toe. The tendency ceases at adult life, because the
ligamentous and bony structures of the articulation have then assumed
their permanent condition, and any later deformity simulating it can only
occur as a result of a totally different set of conditions.
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.
Hallux flexus may be defined as a progressive diminution of the normal
range of extension at the metatarso-phalangeal, or, more rarely, at
the inter-phalangeal joint of the great toe. It is unassociated with
any disease of the bones, cartilages, or synovial membrane of the
articulation, and originates only during the period of active growth.
It is, in fact, a “hammer great toe,” and it will be found strictly
analogous to the disease just described, occurring under the same
conditions and affecting the corresponding articulations.[12] The name
proposed by Mr. Davies-Colley has been objected to on more grounds
than one. In the first place, there is perhaps a lack of soundness in
the pedigree of the word “hallux.” It is a rather modern addition to
anatomical nomenclature, and its sanction in classical literature is
very dubious. In Plautus there is an expression “hallex viri,” implying
a little man, a “thumbling,” and the words “hallex,” “allex,” and
“hallux” have been used by other writers with a somewhat questionable
signification for the great toe. A purist might indeed be justified in
opposing the adoption of either “hallex” or “hallux,” and especially the
latter; but the convenience attached to a distinctive name for the great
toe in place of that of “pollex,” which is applied also to the thumb,
is so great that we are not tempted to be hypercritical on philological
grounds. A more serious objection has been raised against the adjective
“flexus,” because in the majority of cases the toe is not actually in
the position of flexion; but the term “flexion” may be applied in the
sense of movement as well as in that of position; and although the great
toe in hallux flexus may not reach the position of flexion, it has
passed through the motion of flexion before it has attained the line of
direction in which it is found in the disease.
_Symptoms._—In a typical case of hallux flexus the patient, usually
a boy near the age of puberty, suffers some little pain about the
metatarso-phalangeal articulation of the great toe in walking, at the
moment when the weight of the body falls chiefly upon this joint. Rest
affords complete relief, and the structures about the articulation
show no signs of inflammation. As time goes on the pain increases and
becomes associated with a sense of rigidity of the toe, and the power
of full extension becomes lost. The diminution of the range of movement
is very gradual, and usually it is not until the proximal phalanx can
no longer be extended beyond a line corresponding to the prolonged
axis of the metatarsal bone that the condition is brought before the
surgeon, but in more extreme examples the toe becomes actually bent below
this axis, so that it forms with the metatarsal bone an obtuse angle
with plantar opening. The foot is now seriously crippled. Over-use in
walking induces much suffering, and any attempt at passive extension
is extremely painful, while flexion still remains unimpaired. The head
of the metatarsal bone thrown into prominence by the unwonted position
of the proximal phalanx looks abnormally large. In some cases a reflex
hyperæmia of the tissues surrounding the joint may be induced by forced
exercise; but there is rarely, if ever, any effusion within the capsule.
The patient finds walking more and more difficult, and to avoid pressure
upon the contracted articulation limps on the outer edge of the foot; but
this gives little relief, and at last he is compelled to rest. In the
more severe cases the patient consults the surgeon; in the slighter forms
he puts up with the inconvenience, and we may assume that he recovers
without professional assistance, for the condition is very seldom found
after the attainment of full adult life.
An analysis of my series of thirty cases shows that the deformity is
much more frequent in boys the number including only three girls. (In
the series of thirteen cases recorded by Mr. Makins the proportion
of males to females was eleven to two). It was bilateral in one case
only, right-sided in nineteen cases, left in ten, and affected the
metatarso-phalangeal articulation in every instance, except two in
which the distal joint was involved. (Fig. 11.) In only three cases
did the flexion pass the prolonged axis of the metatarsal bone, the
angle reached in the worst example being 150°; in the rest the toe
during full extension was either in a line with the metatarsal bone,
or formed with the latter a very obtuse angle, 170° to 160°, with the
opening towards the dorsal aspect. The ages at which the symptoms were
first noticed ranged from twelve to eighteen, in the greater number
lying between fourteen and sixteen. The associated deformities were:
excessive length of toe in two cases, this amounting to a distinct giant
growth in one, hammer toe (second) in one, hallux valgus (slight) in
three, flat-foot in four, and slight varus in one. In the other cases
the feet were perfectly normal in shape. The duration of the disease
before the patient came under treatment varied from three months to four
years. Occupation appeared to exercise little influence; the subjects
were mostly schoolboys, labourers, and errand boys, but there was no
reason to believe that there had been any unusual strain upon the powers
of endurance, except in two instances. In two cases the condition was
attributed to the use of short boots, but in the others no complaint was
made as to the foot covering, and that in wear at the time of attendance
was as unobjectionable as the materials and plan of the modern boot will
allow. Constitutionally, the patients were, for the most part, a little
below the average in physique; one (a girl) was tuberculous, and one was
a child of rheumatic parents, but none had suffered from rheumatism.
The result of inquiries with respect to inherited tendencies was less
striking than in the case of hammer toe. In one instance the father had
double hammer toe, in another a brother had suffered from hallux flexus
at the age of sixteen, and became cured without medical intervention
in the course of three years; but in the majority no satisfactory
information on the point could be obtained.
[Illustration: FIG. 11.
Hallux flexus of the distal joint.]
_Progress._—There can be little doubt that the natural tendency of the
complaint is to subside under the mechanical influence of ordinary
exercise, and hence, although the deformity is fairly common in youth,
it is rarely found in fully developed adults, except where the distal
joint is affected. In one case of this kind the contraction began about
puberty, and was still present at the age of fifty-two, but the defect
never interfered materially with locomotion. It is possible that some
of the ordinary cases terminate, as suggested by Mr. Davies-Colley, by
conversion into hallux valgus, but my inquiries have failed to confirm
this.
_Pathology._—The origin of the condition may be explained in the same
manner as that of hammer finger and hammer toe. There is a physiological
variation in the range of movement permitted in the articulations of
the great toe similar to that demonstrated in the fingers and lesser
toes, and in examining a number of healthy feet it will be found that
the position of extreme super-extension at the metatarso-phalangeal
joint may lie at any point between 30° and 110° beyond the prolonged
axis of the metatarsal bone; but if the movement of extension be checked
at less than 30°, the symptoms of hallux flexus supervene. The chief
distinctive feature in the anatomy of the joint lies in the substitution
of two sesamoid bones, with their tendons and connecting tissue, for the
glenoid plate developed in all the other articulations, and it is those
structures that receive the distal attachment of the plantar fibres of
the lateral ligaments. (Figs. 12 and 13.) The function of the lateral
ligaments, however, remains the same as in the other toes, and the range
of the movement of extension is governed by the development of their
plantar fibres.
[Illustration: FIG. 12.
Bones and ligaments in hallux flexus. 1. Lateral ligament of
metatarso-phalangeal joint; inferior fibres attached to sesamoid bone; 2.
Lateral ligament of inter-phalangeal joint; inferior fibres blending with
glenoid plate.]
[Illustration: FIG. 13.
Hallux flexus of the distal joint.]
The opportunities of examining the morbid anatomy of the complaint are
necessarily very few. Mr. Davies-Colley’s specimen proves that the
structures restraining the movement of extension correspond to those
concerned in the production of hammer toe, those fibres of the lateral
ligaments which blend with the osseo-tendinous structures replacing the
glenoid plate; and the cause of the deformity in both cases appears to
be an irregularity of nutrition by which the ligamentous fibres undergo
imperfect longitudinal development, and consequently induce premature
arrest of the movement of extension. This developmental defect is
probably unconnected with any special error in the form of the shoe.
Like hammer toe, the deformity occurs at the age most prone to nutritive
disturbance; but hallux flexus tends to undergo cure without the help of
the surgeon, because the weight of the body serves as an extending force,
which sooner or later proves stronger than the resistance opposed; while
in hammer toe the lesser digit is not essential to locomotion, and its
retraction at the metatarso-phalangeal joint frees the inter-phalangeal
joint from all necessity for action, and favours the permanency of the
vicious position.
Hallux flexus of the distal joint must be distinguished from the
paralytic hallux retractus which simulates it (see p. 127).
_Treatment._—Bearing in mind the fact that true hallux flexus has a
natural tendency to recovery, it is obvious that the graver surgical
operations can seldom be called for. In the case of hammer toe a
resection of the articulation may be undertaken without hesitation,
because the deformity is more likely to become aggravated than relieved
by lapse of time, and because the function of the digit is not sensibly
interfered with by obliteration of the joint; but the destruction of
the metatarso-phalangeal joint of the great toe entails a permanent
alteration of gait. The treatment I have adopted in the milder cases
is to instruct the patient to perform a regulated series of passive
movements of the toe by the use of his hands, aiding the process by
massage of the lower and inner side of the foot, and as the tenderness
passes away to practise walking on tiptoe until the normal degree of
extension is restored. In more severe examples I have extended the joint
forcibly under an anæsthetic, afterwards fixing it in the super-extended
position in a plaster splint for three weeks. The result of this plan
has been so satisfactory that I have found it unnecessary to do more,
but should it fail, we have the choice of several plans: (1) Section of
the lateral ligaments, subcutaneously or by means of an open wound. (2)
Excision of the head of the metatarsal bone, an operation necessarily
involving obliteration of the joint and a shifting of the point of
support to the distal joint, which is less well fitted to discharge the
office. It might, however, be permissible in certain cases. (3) Excision
of the proximal half of the first phalanx. This has been successfully
effected by Mr. Davies-Colley. (4) Osteotomy of the metatarsal bone above
the head, with excision of a dorsal wedge proportioned to allow the toe
to be placed in a position of slight super-extension, the articulation
being preserved intact.
It is improbable that any of these more severe measures will be required
if the method of forcible reposition be well carried out.
HALLUX VALGUS.
This, the most common of all digital deformities, may be defined as an
eversion of the great toe at the metatarso-phalangeal joint, and in some
instances of the phalangeal joint also, with alterations, adaptive or
causative, in the bony and ligamentous apparatus of the articulation. It
is often accompanied by deformities of the other toes and by flat foot.
In its milder forms it must be regarded as a simple malposition caused
by the use of boots constructed on the principle of median symmetry; and
as this fault is more common in the shoes made for women than in those
worn by men, the distortion is far more frequent in the latter sex. In
a large number of patients examined by Dr. Robinson and myself in the
female wards of the Mile End Infirmary, over ten per cent. were found
to be affected in greater or less degree; while in the male wards the
proportion did not exceed three per cent. It is a noteworthy fact that
the deformity is comparatively rare in the period before puberty. I was
able to find only three examples, and these of a very slight kind, among
800 children under the age of sixteen; while incipient hammer toes and
hammer fingers were present in considerable numbers. This early immunity
is probably due to the fact that the vanity which leads the adolescent
to sacrifice comfort to a false elegance has not awakened in the child.
The more severe cases of hallux valgus in which the toe is so far everted
as to form an angle of from 120° to 90° with the metatarsal bone are
comparatively rare, the total number amongst 2600 persons amounting to no
more than thirty (twelve male and eighteen female). It is with these that
we are especially concerned, and it is probable that they are closely
related in origin to hallux flexus.
_Morbid anatomy._—On examining a well-marked hallux valgus it is seen
that the facetted surface of the head of the metatarsal bone has been
extended considerably over the external aspect, the prominent inner side
of the head lies beneath the stretched joint capsule, the sesamoid bones
are displaced outwards from their normal grooves, the internal lateral
ligament is greatly elongated and considerably thickened, the external
ligament undergoes an inversely proportionate shortening and opposes the
reposition of the displaced phalanx (Fig. 14); and the cartilage over the
portion of the joint surface, removed from its normal contact with the
opposed bones, presents marked degenerative changes. The integumentary
structures over the projecting head of the metatarsal bone are affected
in the same way as those over the angle of flexion in hammer toe, as a
consequence of friction by contact with the shoe leather; callosities and
bursal formations, often of great size, are found, and inflammation of
the abnormal bursa may give rise to great suffering.
[Illustration: FIG. 14.
Hallux valgus. From a preparation at St. Thomas’s Hospital.
A. _Dorsal aspect._—1. Metatarsal bone; 2. Elongated and thickened
internal lateral ligament, a large bursa lay over this; 3. First phalanx;
4. Shortened external lateral ligament; 5. Displaced external sesamoid
bone.
B. _Plantar aspect._—1. Metatarsal bone; 2. Degenerating cartilage over
disused sesamoid furrow; 3. Displaced internal sesamoid bone; 4. Section
of thickened capsule (the structure had here assumed the character of a
glenoid ligament); 5. First phalanx; 6. Displaced external sesamoid bone.]
Although the great majority of cases of hallux valgus are undoubtedly
provoked by ill-shaped boots, it is probable that some, and especially
those of a very aggravated type, are, like hallux flexus and hammer
toe, dependent essentially upon causes not obviously connected with any
vice in the foot covering. It is at least certain that some examples of
extreme deformity are confined to one foot, the opposite member being of
normal shape—a fact that strongly negatives the boot theory; and there
are also bilateral cases in which the form of the distortion and the
history given by the patients and friends make it equally difficult to
accept the common explanation. In one instance recently under my notice
the first, second, and third toes of the left foot were carried outwards
over the fourth, producing a deformity of a strongly marked kind, while
the right foot was perfectly well formed, and the patient, an intelligent
woman, insisted that “the toes went wrong by themselves while she was
growing up,” and that her shoes had nothing to do with it. In some cases
the conditions may be traced to paralytic or spastic affections, and if
we accept the developmental theory with respect to hammer toe and hallux
flexus, we may assume that hallux valgus occasionally arises in the same
way.
_Treatment._—Hallux valgus, like hammer toe, is often rather a question
of æsthetics than of pain or inconvenience, and the patients are only
moved to see the surgeon by a natural desire to get rid of a deformity;
but in many cases the inflammatory complications occuring in connection
with the associated “bunion,” or the interference with the neighbouring
toes, upon whose territory the larger digit is encroaching, may give rise
to actual and even intolerable suffering. In the milder examples the
use of a well-shaped boot, and a stocking made with a separate pocket
for the great toe, as recommended by Mr. Ellis, will be sufficient to
allow the rectification of the defect, and to these elementary measures
may be superadded Bigg’s bunion spring, which can be obtained from most
instrument makers, or a vertical septum may be introduced into the boot
in the normal position of the cleft between the first and second toes. In
the more severe cases these plans of treatment are insufficient, and we
then have the choice of several alternatives.
1. Section of the neck of the metatarsal bone with excision of a
cuneiform segment from the tibial side has been performed successfully
by Mr. A. E. Barker.[13] This allows the articulation, together with
the entire toe, to be restored to the straight line, but the abnormal
disposition of the articular surfaces and ligaments remains uncorrected,
and there is reason to fear that trouble would arise later.
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.
[Illustration: 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.
ARTHRITIC DEFORMITIES OF THE TOES.
_Arthritic hammer toe_ may be due to rheumatoid arthritis, gout,
rheumatism, or traumatic inflammation. The variety dependent upon
rheumatoid arthritis is the most common of these, and the most likely
to be brought under the eye of the surgeon. Its characteristics are
as follows: 1. It is not limited to the developmental period, and may
occur at any age in association with the causative disease, but it
is most frequently met with after middle life. 2. The deformity is
usually present in many or all of the toes and in both feet, and may
be associated with lateral (fibular) displacement of the digits, and
with bony outgrowths at the margin of the affected articulations. The
movements of the joints are much more impaired than in true hammer
toe, owing to changes in the cartilage; and fibrous ankylosis is often
present. 3. Manifestations of the causative disease may be found in other
parts of the body.
In the great toe the direction of the distortion appears to depend upon
the size and position of the osteophytic developments at the margin of
the affected articulation. Most commonly the position simulated is that
of hallux valgus, more rarely that of hallux flexus, and we may also find
a condition in which the distal phalanx is bent upwards, so that the
nail approaches or even touches the dorsal surface of the first phalanx.
(See Fig. 16, A.) This is a painful deformity and calls for treatment. I
have not yet seen an arthritic hallux varus. It is probably rare, because
the form of the boot opposes the divergence of the toe in the inward
direction.
[Illustration: FIG. 16.
Rheumatoid arthritis. Retracted hallux with arthritic hammer toes.
A. Before operation; B. After operation. The dotted outline in A
indicates the position of the flap made to expose the diseased joint.
From casts at St. Thomas’s Hospital.]
It is unnecessary here to say anything as to the nature and course
of the general disease. As a rule the case falls into the hands of
the physician, and the surgeon is rarely asked to intervene. It must
be pointed out, however, that the contractions may cause severe
inconvenience, and that despite the intractable nature of the complaint
the reaction of the patient to surgical operation is favourable, recovery
being nearly as speedy as in true hammer toe. I have on two occasions
operated with the result of considerable relief to suffering, and without
any surgical casualty. In one instance eight toes underwent operation at
a single sitting, and the wounds all healed by immediate union.
In gouty contractions of the toes the history of the sudden and painful
inflammatory attacks preceding the deformity, the almost constant
implication of the first metatarso-phalangeal joint, and the presence
of other indications of gout leave no question as to the nature of the
disease. In this affection the surgeon can rarely be called upon to
interfere. The distortions of the great toe are generally associated with
eversion—a valgus—and complete ankylosis may supervene. Contractions
in association with acute rheumatism or acute rheumatoid arthritis are
comparatively rare. Lastly, certain arthritic affections of neuropathic
origin may produce ankylosis of the joints, sometimes in association with
rapid atrophy of the muscular and integumentary structures, as in a case
shown by the author at the Medical Society in 1893 (_Trans._, vol. xvii.
p. 104).
PARALYTIC CONTRACTIONS OF THE TOES.
Deformities of this kind may be met with in association with various
diseases of the nervous system. The most common condition is a hammer
deformity of the lesser toes, with retraction at the metatarso-phalangeal
joint, and an exaggeration of the plantar arch (paralytic cavus). This
is probably due to paralysis of the interossei in nearly all cases.
Occasionally a single toe is affected. In the great toe it may arise
from paralysis either of the short flexors or of the tibialis anticus
(as pointed out by Mr. Davies-Colley), and is associated with retraction
of the first phalanx and flexion of the second. In the smaller toes
the digits assume a position like that of the clawed finger in ulnar
paralysis, with extension of the proximal and flexion of the middle and
distal phalanges, but, unlike in true hammer toe, there is distinct
evidence of paralysis, and the capacity of the flexed joints for passive
extension is usually retained for long periods. In these cases where the
unopposed extensor leads to very inconvenient retraction of the first
phalanx the tendon may be divided, and Mr. Davies-Colley suggests that
the proximal cut end should be fixed to the metatarsal bone in order
to preserve its utility as a dorsal flexor of the ankle. The return of
the deformity must be prevented by the subsequent use of splints and
manipulation.