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THE DEFORMITIES OF THE FINGERS AND TOES
THE DEFORMITIES OF THE FINGERS AND TOES
THE DEFORMITIES OF THE FINGERS AND TOES BY WILLIAM ANDERSON, F.R.C.S. SURGEON TO ST. THOMAS’S HOSPITAL; EXAMINER IN SURGERY AT THE UNIVERSITY OF LONDON, AND ROYAL COLLEGE OF SURGEONS OF ENGLAND; PROFESSOR OF ANATOMY IN THE ROYAL ACADEMY OF ARTS, ETC.; FORMERLY HUNTERIAN PROFESSOR OF SURGERY AND PATHOLOGY IN THE ROYAL COLLEGE OF SURGEONS LONDON J. & A. CHURCHILL 7 GREAT MARLBOROUGH STREET 1897...
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PREFACE
PREFACE
The following pages are developed from a course of Hunterian Lectures delivered by the Author in the theatre of the Royal College of Surgeons, in 1891. The matter has been revised and brought up to date, and augmented by a section upon the congenital deformities of the hands and feet. WILLIAM ANDERSON. 2 Harley Street, W. March 1897....
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THE DEFORMITIES OF THE FINGERS AND TOES
THE DEFORMITIES OF THE FINGERS AND TOES
The section of surgical disease treated in the following pages is unambitious in its scope, but it is, nevertheless, one that deserves the attention of every surgeon and pathologist, because it comprises a group of ailments which are the source of much pain and crippling, and because it offers many problems of causation that are still unsolved. It is true that none of these affections threaten life, but in medicine, as in law, it is often the value of the principle involved rather than the magni
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CONTRACTIONS INVOLVING THE DIGITAL AND PALMAR FASCIÆ.
CONTRACTIONS INVOLVING THE DIGITAL AND PALMAR FASCIÆ.
The clinical features of the disease called Dupuytren’s “contraction of the palmar fascia” were well known before the true seat of the morbid process was surmised; but the Greek and Arab writers, and their European followers down to the end of the last century, make no reference to it. The first accessible descriptions are those of Sir Astley Cooper in his “Treatise on Fractures and Dislocations” published in 1822, and of Boyer in the eleventh and last volume of his “Maladies Chirurgicales,” iss
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CONTRACTION OF THE FINGERS DUE TO DEVELOPMENTAL IRREGULARITIES IN THE BONY AND LIGAMENTOUS ELEMENTS OF THE ARTICULATIONS.
CONTRACTION OF THE FINGERS DUE TO DEVELOPMENTAL IRREGULARITIES IN THE BONY AND LIGAMENTOUS ELEMENTS OF THE ARTICULATIONS.
There are certain affections of the fingers which have hitherto attracted little notice, but are interesting on account of their relationship to deformities of much greater frequency in the lower extremity. These are conditions of abnormal flexion and of lateral deviation of the phalanges at the inter-phalangeal articulations, the first of which corresponds exactly to the well-known deformity of the foot called “hammer toe.” Fig. 6. “Hammer Finger.” “ Hammer finger ” ( Fig. 6 ) is not a rare com
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CONTRACTIONS ARISING FROM INTERRUPTED EVOLUTION OF THE FLEXORS OF THE FINGERS, WITHOUT PARALYTIC OR SPASTIC COMPLICATIONS.
CONTRACTIONS ARISING FROM INTERRUPTED EVOLUTION OF THE FLEXORS OF THE FINGERS, WITHOUT PARALYTIC OR SPASTIC COMPLICATIONS.
This condition necessarily belongs to the pre-adult stage of development. It is characterised by persistent flexion of one or more digits, without any articular abnormality, and unassociated with spasm or paralysis, but the contraction is of a different kind from that found in hammer finger and hammer toe. The degree of flexion varies with the position of the hand, and when the wrist is strongly bent forwards the fingers may be extended, perhaps completely, but extension of the wrist is accompan
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CONTRACTIONS DUE TO UNBALANCED ACTION OF THE FLEXOR MUSCLES AFTER RUPTURE, DIVISION, OR DESTRUCTION OF THE EXTENSOR TENDON.
CONTRACTIONS DUE TO UNBALANCED ACTION OF THE FLEXOR MUSCLES AFTER RUPTURE, DIVISION, OR DESTRUCTION OF THE EXTENSOR TENDON.
These accidents are not uncommon in ordinary hospital experience. The effect of such a solution of continuity over the back of the hand is to leave the first phalanx in a state of flexion, while the second and third phalanges may be voluntarily straightened without difficulty, especially if the metacarpo-phalangeal joint be passively fixed in the position of extension. The reason for this of course is that the common extensor, by virtue of its ligamenta dorsalia and its connection with the apone
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CONTRACTIONS ARISING FROM NUTRITIVE CHANGES IN THE MOTOR APPARATUS.
CONTRACTIONS ARISING FROM NUTRITIVE CHANGES IN THE MOTOR APPARATUS.
There are at least three well-known forms of pathological change in the motor apparatus of the forearm (independent of the ordinary paralytic or spastic conditions due to nerve lesions) that may give rise to contractions of the fingers. These are—the ischæmic paralysis of Volckmann, inflammatory processes in the muscular sheaths, and gummatous formations, or more rarely other tumour growths in the muscles. ( a ) The affection described by Volckmann as muscular paralysis of ischæmic origin is now
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CONTRACTION OF THE FINGERS DEPENDENT UPON A TENDO-VAGINITIS OF THE BURSAL SHEATH OF THE FLEXOR TENDONS.
CONTRACTION OF THE FINGERS DEPENDENT UPON A TENDO-VAGINITIS OF THE BURSAL SHEATH OF THE FLEXOR TENDONS.
The following notes of an example of this somewhat rare condition under my observation may be of interest: The patient, a girl, aged twenty, attended St. Thomas’s Hospital for a swelling of the front of the right wrist, with contraction of the fingers and complete loss of use of the hand. She stated that the contraction appeared six days before without apparent cause. On examination a large swelling was found, extending upwards for about an inch and a half above the anterior annular ligament, an
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CONTRACTIONS DEPENDENT UPON INFLAMMATORY AND DEGENERATIVE CHANGES IN THE ARTICULAR STRUCTURES.
CONTRACTIONS DEPENDENT UPON INFLAMMATORY AND DEGENERATIVE CHANGES IN THE ARTICULAR STRUCTURES.
The deformities induced by gout, rheumatism, and rheumatoid arthritis fall more directly within the domain of the physician, while those due to tuberculous or traumatic lesions are of more immediate concern to the surgeon, but the characters which distinguish the various conditions from each other are of interest for every practitioner. The chief points bearing upon diagnosis are as follows: In the gouty form the personal and family history of the patient, the acute and painful nature of the loc
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CONTRACTIONS OF PARALYTIC AND SPASTIC ORIGIN FOLLOWING LOCAL INJURY.
CONTRACTIONS OF PARALYTIC AND SPASTIC ORIGIN FOLLOWING LOCAL INJURY.
A complete account of the various conditions falling under this denomination would require an entire course of lectures, and it is hence necessary to confine our attention to those forms which belong to the surgeon rather than to the physician. Spastic conditions following local injury are very rare. An example was brought before the Medical Society by Dr. Beevor [6] in April 1888, in which a contusion of the right hand in a boy of fifteen was followed five days later by permanent contraction of
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CONGENITAL AND INFANTILE CONTRACTIONS.
CONGENITAL AND INFANTILE CONTRACTIONS.
These are usually of paralytic origin, but include a proportion of cases of true hammer finger. The common form is that already described by Mr. William Adams (Medical Society, December 1890), in which the inter-phalangeal joints of one or more fingers (most frequently the fifth) are flexed, and the integument on the palmar aspect forms a longitudinal fold, which becomes tense when an attempt is made to straighten the digit; the metacarpo-phalangeal joint is super-extended. At first the finger m
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TRIGGER FINGER.
TRIGGER FINGER.
The description of this curious affection has been left until the last because its true nature is still an unsolved problem, and it is hence difficult to place it in any of the groups already described. It is indeed rather a pathological curiosity than an important item in surgical disease, and many surgeons of long experience have never met with a single example. Of the mechanism of its causation we know almost nothing, of its ultimate tendencies we know little more, and its morbid anatomy is a
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CONTRACTIONS DEPENDENT UPON PATHOLOGICAL LESIONS IN THE CUTANEOUS AND FASCIAL STRUCTURES.
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 h
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CONTRACTIONS DUE TO DEVELOPMENTAL IRREGULARITIES IN THE ARTICULAR STRUCTURES.
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....
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HAMMER TOE.
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 scientifi
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HALLUX FLEXUS.
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, th
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HALLUX VALGUS.
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; a
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HALLUX VARUS.
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 develop
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LATERAL DEVIATION OF THE LESSER TOES.
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 sec
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ARTHRITIC DEFORMITIES OF THE TOES.
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 al
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PARALYTIC CONTRACTIONS OF THE TOES.
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 point
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MAKRODACTYLY.
MAKRODACTYLY.
The earliest examples of “congenital hypertrophy” recorded in this country were those of Dr. Reid, published in the London and Edinburgh Monthly Journal of Medical Science for March 1843, but before this date a characteristic case of makrodactyly had been carefully described by von Klein, [15] and other instances had been brought forward by Beck [16] and Wagner. [17] Reid’s paper was followed by a valuable article by Curling, [18] and contributions by Ideler, [19] Adams, [20] Devouges, [21] Chas
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SUPERNUMERARY FINGERS AND TOES.
SUPERNUMERARY FINGERS AND TOES.
The occasional occurrence of supernumerary fingers and toes is well known. As a rule the extra digit is a mere pediculated appendage bearing a nail and a more or less perfect representative of the ungual phalanx; in other cases, however, it is complete and well formed, and furnished with a metacarpal or metatarsal bone of its own, or sharing the proximal bone with a neighbouring finger or toe. In rare instances the digits may undergo still further numeral increase even to a complete duplication
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SYNDACTYLY.
SYNDACTYLY.
The absence of one or more of the normal clefts between the fingers or toes is a common congenital deformity, and, like most of the other inherited defects of the parts, is often transmitted by descent, and associated with other malformations. Syndactyly presents all varieties in extent and degree. Most frequently two neighbouring digits are joined together by a web of integument involving the whole or a portion of their length, but in some instances the connecting material is much thicker, and
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ECTRODACTYLY.
ECTRODACTYLY.
Simple congenital ectrodactyly, like the loss of a larger segment of an extremity, may arise either by intra-uterine traumatism or defective development. Amputation by an amniotic band or a coil of umbilical cord probably explains the majority of the cases, as well as the congenital constrictions sometimes found in the limbs or digits of the newborn child, but the occasional appearance of fingers or toes at the end of a congenital stump can only be accounted for on the hypothesis of a temporary
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BRACHYDACTYLY.
BRACHYDACTYLY.
Undue shortness of the fingers or toes may occur either as a congenital or as an acquired defect. The congenital form, due to imperfect formation of any or all of the bony elements of a digit (including the metacarpal bone), is insusceptible of treatment except by amputation, should that step be justified by the inconvenience or deformity attached to the defective member. Acquired brachydactyly may arise in several ways. Occasionally it is to be traced to an arrest of development either due to a
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